Migraine and lifestyle: what does the science say

Source: Jeleefstijlalsmedicijn

Author: Jaap Versfelt, Medical reviewer: drs. Wardell Amerika, neurologist.

Key messages from the article Migraine and lifestyle: what does the science say

Reading time 15 minutes

1. Definition Migraine is a neurological condition with multiple phases involving a hereditary sensitivity to stimuli.
2. Prevalence In the Netherlands, 293,400 people with migraine were known to their general practitioner in 2023. The actual number of people with migraine is higher: 14 to 15 percent of all adults.
3. Cause The best explanation for migraine is that a large facial nerve (the trigeminal nerve) becomes too active. This releases substances such as CGRP (a neurotransmitter), which cause headache and other migraine symptoms.
4. Risk factors Genetic predisposition, lifestyle, and triggers such as hormonal fluctuations, stress, and diet influence migraine.
5. Medication limitations Medications can suppress symptoms or reduce attacks, but often have side effects and no curative effect.
6. Triggers Avoiding triggers can be difficult partly because there are individual differences, due to misinterpretation of warning signs, and psychological factors.
7. Nutrition There are indications that the ketogenic diet, DASH diet, and omega-3 fatty acids can reduce migraine attacks.
8. Sleep Poor sleep increases the chance of a migraine attack, while a regular sleep pattern and good sleep hygiene can reduce the frequency of attacks.
9. Exercise Moderate-intensity exercise can have a positive effect on migraine, although the effect may be smaller than that of interventions targeting other lifestyle factors.
10. Stress Stress is an important trigger and can be reduced with therapies such as cognitive behavioral therapy, biofeedback therapy, and relaxation techniques.
11. Conclusion Lifestyle adjustments in the areas of nutrition, sleep, exercise, and stress management can significantly reduce migraine attacks.

1. What is migraine

Migraine is a disabling brain disease characterized by multiple phases: warning phase, aura, headache, and recovery phase. Migraine has a hereditary sensitivity to stimuli (‘triggers’). An excess of triggers can lead to a migraine attack. Migraine can be accompanied by headache, but that is not always the case.

2. How often does migraine occur

In 2023, an estimated 293,400 people with migraine were known to their general practitioner (that is 2 percent of the Dutch population). Approximately 124,000 people report new migraine complaints to their general practitioner each year. This number of new diagnoses has remained virtually constant over the past ten years (VzInfo).

These figures are almost certainly an underestimate of the actual number of people with migraine in the Netherlands. Worldwide, it is estimated that 14 to 15 percent of all adults have migraine (Steiner, 2023). Many people do not go to the doctor but accept migraine as a fact, not as a condition that can be treated.

3. Causes of migraine

The most accepted theory about how migraine develops is the trigeminovascular hypothesis. This states that people with migraine are more sensitive to stimuli because certain nerves in the head (the trigeminal nerves) become overactive. This makes the nerves respond faster to substances that affect blood vessels, such as CGRP, an important chemical involved in migraine (Neri, 2023).

4. Risk factors for migraine

Migraine is influenced by a combination of genetic factors, lifestyle, and specific triggers. These risk factors determine not only the sensitivity to migraine but can also influence the frequency and severity of attacks.

4.1 Genetic factors

Migraine occurs three to four times more often in women than in men, indicating the influence of hormonal and genetic factors (Hersenstichting). Additionally, migraine often runs in families, suggesting that genetic predisposition plays an important role. People with a family member who suffers from migraine have an increased risk of developing migraine themselves. Researchers have identified specific genetic variants that increase the risk of migraine, especially in the form associated with aura.

4.2 Lifestyle

Lifestyle factors play a major role in migraine and can affect both the frequency and severity of attacks:

• Obesity Obesity (BMI ≥ 30) is associated with an almost two times greater chance of migraine (Bigal, 2006).
• Exercise A low level of physical activity is associated with a higher frequency of migraine attacks (Bond, 2015).
• Sleep Sleep disorders, poor sleep quality, and too short or too long sleep duration are recognized as causes of headache (Sullivan, 2019).
• Stress A stressful life is linked to migraine. Anxiety disorders and depression are more common in people with migraine (Agbetou, 2022).
• Substance use Alcohol can be a trigger for migraine attacks. Smoking can also contribute to migraine attacks (Agbetou, 2022).

4.3 Triggers

Triggers are external or internal factors that can trigger a migraine attack. The most common triggers are menstrual cycle changes, weather changes, fasting, air pressure, and ‘relaxation’ after a stressful period. Odors such as perfume and chemical substances as well as bright light can increase sensitivity (Marmura, 2018).

5. Limitations of pharmacological treatments

Unfortunately, there is still no treatment that can cure migraine. Medications cannot remove the sensitivity to stimuli that trigger an attack, but they can contribute to reducing the frequency, severity, and impact of migraine attacks. There are two important approaches: acute treatment and preventive treatment (Shamliyan, 2013):

• Acute treatment During a migraine attack, medications can be used to suppress symptoms such as headache and nausea or even break through a migraine attack. For this, paracetamol or NSAIDs such as ibuprofen and diclofenac are often started. When these are not effective enough, treatment with triptans can be considered.
• Preventive treatment In addition to directly addressing migraine attacks, attempts can be made to reduce the frequency and severity of migraine attacks. This can be done with ‘maintenance medication’. Commonly used maintenance medications include propranolol and metoprolol (beta blockers), candesartan (angiotensin II receptor blocker), topiramate, and valproic acid (anti-epileptics). Additionally, botox treatments and injections with CGRP inhibitors can improve migraine. Research shows that although these agents can be effective, their use can also cause side effects. Examples include fatigue, weight changes, and memory problems. Sometimes these side effects are so bothersome that patients stop treatment.

6. Why working on triggers can be difficult

Targeting triggers as a way to prevent migraine appeals to both patients and healthcare providers. Given the limited effectiveness of medications, this is logical. However, identifying triggers for migraine attacks is complicated, which means avoiding them is not always effective. There are several reasons for this (Marmura, 2018):

• Variability and complexity Triggers differ significantly per person. What triggers a migraine attack in one patient may have no effect on another. Moreover, what leads to migraine in a person one time may not do so the next time. Additionally, a single trigger is rarely sufficient to trigger a migraine attack. Often it is a combination of factors, such as stress and hormonal changes. This complexity makes it difficult to identify triggers.
• Warning signs are not triggers Warning signs such as fatigue, mood swings, or food cravings can occur hours to days before a migraine attack actually begins. These symptoms are often confused with triggers, while they are in fact already the beginning of a migraine attack.
• Psychological factors The expectation or fear that a certain trigger will cause an attack (for example a bright light or certain smell) can actually lead to a migraine attack, the so-called nocebo effect.

Due to these three factors, identifying triggers is often not easy. Using migraine diaries can help with this. What perhaps works even better is focusing on healthy lifestyle choices to address the causes of migraine.

7. Lifestyle pillar 1: migraine and nutrition

Various dietary patterns have been studied for their effect on migraine. Some of them are possibly effective, such as the ketogenic diet, the DASH diet (Ruiz, 2025, Nguyen, 2024), and a diet rich in omega-3 fatty acids from fish. However, the evidence for this is limited, and more research is needed to draw definitive conclusions.

7.1 Ketogenic diet

With the ketogenic diet, the amount of carbohydrates is limited to a maximum of 20 to 50 grams per day. Carbohydrates come from sugars (from for example cookies and soft drinks) and starch (such as from potatoes, bread, and rice). The diet is called the ketogenic diet because with strong carbohydrate restriction, the body starts producing ketones. When glucose (blood sugar) from carbohydrates is less available, the brain uses ketones as an energy source.

In a 2023 review study, ten studies on the effect of the ketogenic diet were examined (Neri, 2023). The study shows that a ketogenic diet may offer benefits in treating migraine. There appears to be a reduction in the frequency of migraine attacks, with some studies reporting a decrease of at least 50 percent in the number of attacks in 58 to 83 percent of patients. The authors of the review note that only three of these ten studies were randomized. Randomized research (randomized controlled trials or RCTs) constitute the strongest level of evidence.

More recently, two more studies have been conducted:

• Caprio, 2023. This RCT showed that a ketogenic diet (less than 50 grams of carbohydrates per day) is more effective than a Mediterranean diet in reducing the number of attacks: minus 6 versus minus 2 migraine days per month.
• Olivito, 2024. This cohort study showed that a ketogenic diet (in this case: less than 25 grams of carbohydrates per day) reduced the number of attacks from 17 to 3 per month and reduced the severity of these attacks from 8 to 4 (on a scale of zero to ten).

About the why of how the ketogenic diet works, researchers must still speculate. Research shows that the brain has difficulty producing enough energy during a migraine attack. The ketogenic diet ensures that the brain switches from glucose as fuel to ketones, which can resolve this energy deficit (Neri, 2023).

In practice, it does not even seem necessary to restrict carbohydrates as strictly as a ketogenic diet prescribes. By eliminating rice, bread, pasta, and pizzas, much benefit can already be achieved.

7.2 DASH diet

The DASH diet (dietary approaches to stop hypertension) was originally developed to lower high blood pressure, but could also have a beneficial effect on migraine. The diet is rich in vegetables, fruits, whole grain products, low-fat dairy, nuts, and legumes, while limiting the intake of salt, saturated fats, and processed foods. This means the diet contains a lot of potassium, magnesium, and calcium---minerals that play a role in regulating nerve signals and vasodilation, two processes involved in migraine attacks.

A randomized study examined the effect of the DASH diet on migraine (Arab, 2021). After twelve weeks, participants in the DASH group had an average of three fewer migraine days per month, while in the control group it was only 1.4 days. The severity of the attacks also decreased significantly in the DASH group (a decrease of 1.76 points on a scale of 10), while the decrease in the control group was less pronounced (0.59 points).

7.3 Dietary pattern rich in omega-3 fatty acids from fish

The Western diet contains many industrially produced seed oils (such as sunflower oil) and few of the omega-3 fatty acids EPA and DHA. Such fatty acids are abundant in fatty fish such as salmon and mackerel.

In a randomized study, a group of people with migraine ate a diet with more omega-3 fatty acids (Ramsden, 2021). After 16 weeks, they had about two fewer migraine days per month. The number of hours with moderate to severe headache also decreased by 0.8 hours per day. The researchers suspect that this effect comes from omega-3 fatty acids helping to reduce inflammation and pain responses in the brain.

8. Lifestyle pillar 2: migraine and sleep

Sleep plays a crucial role in the onset and reduction of migraine attacks. Poor sleep quality, an irregular sleep pattern, and sleep disorders such as insomnia or sleep apnea are well-known risk factors for migraine attacks.

8.1 Effects of sleep interventions on migraine

Research on sleep interventions shows impressive results:

• Headache frequency Studies show that sleep interventions can significantly reduce the frequency of headache days (Sullivan, 2019). In one study, the number of headache days decreased from an average of 22.7 to 11.6 days per month (Smitherma, 2016). Other studies also showed a major improvement.
• Headache intensity Although some studies report significant decreases in pain intensity, results here are more variable.

8.2 Sleep hygiene: the foundation for a good night’s rest

Sleep hygiene includes adjustments that improve sleep quality. Think of tips such as:

• Get out of bed at about the same time every day, even if you are not well-rested. Do this on weekends too. Also go to bed at about the same time every day. Make sure you are in bed for a maximum of 8 hours.
• Do not drink coffee, black or green tea, iced tea, cola, energy drinks, or other drinks containing caffeine in the 6 hours before going to sleep.
• Do not drink alcohol to fall asleep. Alcohol makes the quality of your sleep worse.
• Put away your phone, tablet, or computer 1 or 2 hours before you go to sleep.
  The light from your screen keeps you awake.

There are more tips like these. A good overview of sleep hygiene tips can be found on thuisarts.nl. For severe sleep problems, a referral to a sleep exercise therapist can help.

9. Lifestyle pillar 3: migraine and exercise

There is some evidence that moderate-intensity exercise can reduce the number of migraine days. The effect appears relatively small (an average of 0.6 days less per month). About the intensity of pain and the duration of attacks, researchers cannot draw clear conclusions (Lemmens, 2019).

It is also not yet clear what kind of exercise is best for people with migraine. Various types of exercise have been studied, for example walking, cycling, cross-training, jogging, and combinations thereof. What does appear from the literature is that this kind of moderate-intensity exercise works better than high intensity training (HIT) or strength training.

In short, following the Dutch exercise guideline can be sensible: at least 150 minutes per week of moderate intensity exertion, spread over multiple days.

10. Lifestyle factor 4: migraine and stress

Stress is one of the most reported triggers for migraine. A targeted approach to stress can help reduce migraine symptoms.

10.1 Evidence for the importance of stress reduction

Various studies show that stress reduction is effective for migraine. Therapies such as cognitive behavioral therapy (Harris, 2015), biofeedback, and relaxation techniques, have been proven to reduce the number of migraine days and decrease the severity of attacks (Ailani, 2021).
With biofeedback, the patient consciously controls body functions such as breathing, heart rate, or muscle tension to reduce stress, pain, or other complaints. Researchers on biofeedback show that people with migraine experience approximately 60 percent improvement in their symptoms (Nestoriuc, 2008).

These interventions are safe and a valuable addition, especially for patients who are sensitive to stress-related triggers.

10.2 Stress sources and approach

The approach to stress depends on the specific source and situation. Here are some common stress sources and ways to address them:

• Grief processing Migraine can be described as a form of ‘living loss’. People can go through different stages of grief, such as anger, frustration, or denial. If people are in grief about migraine for a long time, it can lead to chronic stress. Learning to accept migraine as part of life can help relieve the psychological burden.
• Anxiety disorders Fear of a migraine attack can lead to a vicious cycle of anxiety and migraine attacks. Treatment for anxiety such as cognitive behavioral therapy or ACT can help break this cycle.
• Unconscious stress Some people experience stress without realizing it themselves. Biofeedback therapy can help gain more awareness of physical tensions and learn how to reduce them.

There are also specific approaches for other situations (stress at work, trauma, etc.). In addition to these specific approaches, regular relaxation exercises, such as breathing exercises, can also help reduce stress. See for example Care 4 Migraine for practical tips. It is recommended to do these exercises twice a day.

11. Conclusion

Migraine is a complex condition where genetic factors, triggers, and lifestyle play a major role. Because pharmacological treatments are often limited in their effectiveness, and finding triggers proves difficult in practice, adjusting lifestyle can be a good alternative or additional treatment.

By making the right lifestyle choices in the areas of nutrition, sleep, exercise, and stress management, the frequency and severity of migraine attacks can be significantly reduced.

Research on the effect of nutrition shows a possible beneficial effect of the ketogenic diet, DASH diet, and a dietary pattern rich in omega-3 fatty acids.

Additionally, improving sleep habits can have a strong effect on migraine. Physical exercise can also help. For people with stress-related triggers, certain therapies and daily relaxation exercises can work well.

Making these lifestyle adjustments can be an effective and sustainable way to increase control over migraine. So start today and discover what a healthy lifestyle can mean for you.

Scientific sources for this article

• Agbetou, M., & Adoukonou, T. (2022). Lifestyle modifications for migraine management. Frontiers in Neurology, 13, 719467. https://doi.org/10.3389/fneur.2022.719467\ • Ailani, J., Burch, R. C., & Robbins, M. S. (2021). The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache, 61(7), 1021—1039. https://doi.org/10.1111/head.14153\ • Arab, A., Khorvash, F., Kazemi, M., Heidari, Z., & Askari, G. (2021). Effects of the Dietary Approaches to Stop Hypertension (DASH) diet on clinical, quality of life and mental health outcomes in women with migraine: A randomised controlled trial. British Journal of Nutrition, 128(1), 124—133. https://doi.org/10.1017/S000711452100444X\ • Bigal, M. E., & Lipton, R. B. (2006). Obesity is a risk factor for transformed migraine but not chronic tension-type headache. Neurology, 67(2), 252—257. https://doi.org/10.1212/01.wnl.0000225052.35019.f9\ • Bond, D. S., Thomas, J. G., O’Leary, K. C., Lipton, R. B., Peterlin, B. L., Roth, J., Rathier, L., & Wing, R. R. (2015). Objectively measured physical activity in obese women with and without migraine. Cephalalgia, 35(10), 886—893. https://doi.org/10.1177/0333102414562970\ • Caprio, M., Moriconi, E., Camajani, E., Feraco, A., Marzolla, V., Vitiello, L., Proietti, S., Armani, A., Gorini, S., Mammi, C., Egeo, G., Aurilia, C., Fiorentini, G., Tomino, C., & Barbanti, P. (2023). Very-low-calorie ketogenic diet vs hypocaloric balanced diet in the prevention of high-frequency episodic migraine: The EMIKETO randomized, controlled trial. Journal of Translational Medicine, 21(1), 692. https://doi.org/10.1186/s12967-023-04561-1\ • Harris, P., Loveman, E., Clegg, A., Easton, S., & Berry, N. (2015). Systematic review of cognitive behavioural therapy for the management of headaches and migraines in adults. British Journal of Pain, 9(4), 213—224. https://doi.org/10.1177/2049463715578291\ • Lemmens, J., De Pauw, J., Van Soom, T., Michiels, S., Versijpt, J., van Breda, E., Castien, R., & De Hertogh, W. (2019). The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: A systematic literature review and meta-analysis. The Journal of Headache and Pain, 20(1), 16. https://doi.org/10.1186/s10194-019-0961-8\ • Marmura, M. J. (2018). Triggers, protectors, and predictors in episodic migraine. Current Pain and Headache Reports, 22(12), 81. https://doi.org/10.1007/s11916-018-0734-0\ • Neri, L. de C. L., Ferraris, C., Catalano, G., Guglielmetti, M., Pasca, L., Pezzotti, E., Carpani, A., & Tagliabue, A. (2023). Ketosis and migraine: A systematic review of the literature and meta-analysis. Frontiers in Nutrition, 10, 1204700. https://doi.org/10.3389/fnut.2023.1204700\ • Nestoriuc, Y., Martin, A., Rief, W., & Andrasik, F. (2008). Biofeedback treatment for headache disorders: A comprehensive efficacy review. Applied Psychophysiology and Biofeedback, 33(3), 125—140. https://doi.org/10.1007/s10484-008-9060-3\ • Nguyen, K. V., & Schytz, H. W. (2024). The evidence for diet as a treatment in migraine---A review. Nutrients, 16(19), 3415. https://doi.org/10.3390/nu16193415\ • Olivito, I., Simona, F., Tarsitano, A., Pagliuso, M., Tarantino, C., De Lorenzo, A., Alò, R., Avolio, E., & Facciolo, R. M. (2024). Mediterranean ketogenic diet accounts for reduced pain frequency and intensity in patients with chronic migraine: A pilot study. Clinical Nutrition, 43(8), 1781—1787. https://doi.org/10.1016/j.clnu.2024.06.015\ • Ramsden, C. E., Zamora, D., Faurot, K. R., MacIntosh, B., Horowitz, M., Keyes, G. S., Yuan, Z.-X., Miller, V., Lynch, C., Honvoh, G., Park, J., Levy, R., Domenichiello, A. F., Johnston, A., Majchrzak-Hong, S., Hibbeln, J. R., Barrow, D. A., Loewke, J., Davis, J. M., … Mann, J. D. (2021). 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Veelgestelde vragen

Can you treat migraine naturally without medication?

Yes, lifestyle adjustments can significantly reduce migraine attacks. Research shows that adjustments in diet, sleep, exercise, and stress management can be effective in reducing both the frequency and severity of migraine attacks. This approach addresses the underlying causes rather than just the symptoms.

Which diets are effective against migraine?

Various dietary patterns show promising results for migraine. The ketogenic diet (with less than 50 grams of carbohydrates per day) was found to halve migraine attacks in 58 to 83 percent of study participants. The DASH diet (rich in vegetables, fruits, and minerals) resulted in a reduction of 3 migraine days per month. Additionally, a diet rich in omega-3 fatty acids from fish showed a reduction of approximately 2 days of migraine per month.

What is the connection between sleep and migraine?

Sleep plays a crucial role in migraine. Poor sleep quality, irregular sleep patterns, and sleep disorders increase the risk of migraine attacks. Research shows that sleep interventions can significantly reduce the number of headache days, in one study from an average of 22.7 to 11.6 days per month. A regular sleep pattern and good sleep hygiene are essential.

How can I reduce stress to prevent migraine attacks?

Stress is one of the most reported triggers for migraine. Effective methods for stress reduction include cognitive behavioral therapy, biofeedback, and relaxation techniques. With biofeedback, people with migraine experience approximately 60 percent improvement in their symptoms. Regular relaxation exercises such as breathing exercises, performed twice daily, can also help reduce stress.

Does exercise affect migraine?

Yes, there is scientific evidence that moderate-intensity exercise can slightly reduce the number of migraine days, on average by 0.6 days per month. Moderate-intensity exercise such as walking, cycling, and jogging appears more effective than high intensity training (HIT) or strength training. Following the Dutch exercise guideline (at least 150 minutes per week of moderate intensity exertion, spread over multiple days) is recommended.

Is the ketogenic diet effective against migraine?

The ketogenic diet shows promising results for migraine. Research shows that a ketogenic diet (with less than 50 grams of carbohydrates per day) led to a reduction of 6 versus 2 migraine days per month. Another study showed a decrease from 17 to 3 attacks per month, with a reduction in severity from 8 to 4 on a scale of 10. The diet possibly works because the brain switches from glucose to ketones as an energy source.

How can I recognize and avoid migraine triggers?

Identifying triggers is complex because they differ per person and often occur in combination. Moreover, warning signs (such as fatigue or mood swings) are often confused with triggers. Keeping a migraine diary can help identify patterns. Instead of focusing only on avoiding specific triggers, it is more effective to focus on a healthy lifestyle that reduces the underlying sensitivity to migraine.

Which lifestyle adjustments are most effective for migraine?

The most effective lifestyle adjustments focus on four pillars: nutrition (such as the ketogenic diet, DASH diet, or omega-3-rich diet), sleep (a regular sleep pattern and good sleep hygiene), exercise (150 minutes of moderate-intensity exertion per week), and stress management (cognitive behavioral therapy, biofeedback, or relaxation techniques). The combination of these adjustments can significantly reduce both the frequency and severity of migraine attacks.