Migraine Successfully Treated with a Milk-Gluten-Sugar-Free Diet: A Case Report

Abstract

Objective:

To describe a patient's clinical case with migraine who improved with a milk-gluten-sugar-free diet.

Clinical Features:

A patient with migraine for 25 years has had episodic pain 1–2 days long, in addition to photophobia and phonophobia. She was treated with analgesics, topiramate, and antidepressants, with no improvement in her condition.

Intervention and outcome:

She was treated with a milk-gluten-sugar-free diet and improved in about 3 weeks.

Conclusion:

This is a case report of a patient with migraine treated with a milk-gluten-sugar-free diet who had a remarkable clinical response.

Introduction

Migraine is a widespread recurrent chronic condition and affects ∼12% of the population. It is characterized by recurrent episodes of pain in the head segment, preceded or not by an aura, nausea, vomiting, photophobia, or phonophobia. ¹ It is the third most common medical condition in the world, according to the World Health Organization. ²

The disease is commonly treated with analgesics (paracetamol), nonsteroidal anti-inflammatory drugs, and triptans. For the prevention of crises, medications such as beta-blockers, antidepressants, and topiramate are used; however, the adverse effects of these medications are often described, limiting the indication. ³ Even with these drugs, therapeutic failures can occur in 57%, considering treatment with candesartan and 60% with propranolol.^4,5 Preventive migraine medication is considered an effective treatment when the drug can reduce the frequency of migraine attacks by ∼50% for up to 3 months. Proven preventive drugs for migraines are beta-blockers, valproate, and topiramate. ³

In addition, new drugs such as monoclonal antibodies targeting CGRP or its receptor and also two gepants are proved to be effective for preventive management of migraine. ⁵

In contrast, the treatment of primary headache using nonpharmacological approaches in young patients promoted a significant reduction in the frequency of painful crises of ∼34%–78% about the period before treatment. This rate of resolving pain crises using meditation, cognitive behavioral therapy, and transcranial magnetic stimulation was similar to the clinical result obtained in the treatment using pharmacological compounds. ⁶

In this sense, the search for alternative and complementary methods for the treatment of migraines is natural. Thus, several studies have already demonstrated the effectiveness of acupuncture, meditation, manual therapy, ⁷ and other complementary therapies, such as aerobic exercise, Yoga, and nutraceutical options as well.^7,8

This article intends to describe a patient with a migraine diagnosis who was subsequently treated with a milk-gluten-sugar-free diet.

Case Report

A 41-year-old female patient with a migraine history since she was 16, diagnosed by two different neurologists, and she fulfilled the International Classification of Headache Disorders, ⁹ characterized by recurrent episodes of unilateral cranial pain lasting from 1 to 2 days, accompanied by photophobia and phonophobia, the migraine intensity worsened during menstruation. She had a magnetic resonance of the brain and cervical spine with normal results. She sought clinical nutritional monitoring for alternative and complementary migraine treatment. She has already been treated with analgesics (paracetamol), several nonsteroidal anti-inflammatories (ibuprofen, naproxen, and diclofenac).

Currently, she was regularly using preventive treatment with amitriptyline 25 mg and topiramate 50 mg/day for >2 years. Her frequency of headache was one or twice a week, about 6–8 episodes per month in the past 5 months. She has a history of insomnia, physical inactivity, asthma, anxiety, and depression, using escitalopram 20 mg/day. She denied food allergies, medications, or substances, as well as previous gastrointestinal symptoms. In the first visit, her weight was 98 kg, height 1.72 cm, body mass index of 33.1 kg/height ² , and blood pressure 120 × 80 mmHg. Beck's anxiety questionnaire of 21 (normal range [nr]: <8) and Beck's depression of 14 points (nr: <10) and pain intensity assessment on the pain visual analog scale (VAS) of 8.0.

Laboratory tests were requested to initiate a milk-gluten-sugar-free diet, with sucrose restriction. Upon return, after 3 weeks, the patient reported that she had markedly improved the intensity of the migraine and its frequency, having had only one episode in the past week. At the consultation, VAS showed zero pain, reported improved sleep, and had a weight loss of 2 kg. The patient reported significant improvement in migraine attacks in subsequent visits, with topiramate and amitriptyline being gradually reduced and then tapered off. She felt well-being in this period, referring to the frequency of a monthly low-intensity migraine crisis related to menstruation.

It was observed that 6 months after clinical and nutritional monitoring, she improved her dietary pattern, with a significant increase in the intake of foods containing vitamins and selenium. Besides, she reduced the number of calories consumed daily. The examinations showed 25-OH-vitamin D 20.8 ng/mL (nr: >30 ng/mL), C-reactive protein of 2.0 mg/dL (nr: <3mg/dL), normal thyrotrophic stimulating hormone of 3.54 IU/mL, and normal blood biochemistry. On two occasions, coeliac disease-related antibodies, immunoglobulin A (IgA) and immunoglobulin G (IgG) anti-transglutaminase, anti-gliadin, and anti-endomysium, were all negative. Lactose tolerance test and immunoglobulin E (IgE) for cow's milk protein were also absent.

She had a positive anti-thyroglobulin antibody 4.5 (nr: <4.0 U/mL) and anti-thyroperoxidase of 767 (nr: <60U/mL). Patient denied any sign or symptom of celiac disease (CD). Owing to the cost and health insurance problems, the patient cannot perform the examination using the enzyme-linked immunosorbent assay method for screening IgG for multiple foods. Selenium 200 mcg/day was started to improve thyroid antibodies and vitamin D replacement at a dosage of 50,000 IU/week, and the patient was instructed to maintain prophylactic measures for pain, mainly diet. After 1 year, the patient has a migraine attack once a month with lower intensity than previous ones and feeling well.

Discussion

This article is the first case report of a patient with migraine who was successfully treated with a milk-gluten-sugar-free diet. Some foods in our diet can catalyze migraine attacks in susceptible people. For example, many citrus fruits, tea, coffee, pork, chocolate, cow's milk, nuts, vegetables, and cola drinks have been associated with migraines.

However, the high IgE positivity is not different from that found in the normal population. Moreover, several food substances (e.g., tyramine, phenylalanine, phenolic flavonoids, alcohol, caffeine, and food additives such as sodium nitrate, monosodium glutamate, and aspartame) may be the cause of vascular tone alterations and consequent migraine. In this line, different dietary approaches have been suggested for subjects with migraines, ¹⁰ but nowadays it is not clear if any diet can be used to improve migraine management.

A randomized trial evaluated the effects of a low glycemic index diet hypocaloric diet in 350 migraineurs than the prophylactic medications group. Interestingly, after 1 and 3 months, the frequency of attacks was significantly reduced in both groups. Moreover, headache intensity was decreased at both 30 and 90 days in the drug group and only at 90 days in the diet group. ¹¹ This study confirms the efficacy of the sugar-free diet used in our patient.

Regarding milk, some reports indicate that foods such as chocolate, cheese, cow's milk, eggs, and red wine may trigger migraine headaches. ¹² A study including 39 children with migraine headaches compared with 167 healthy children demonstrated that 4 (12%) of these 39 children had IgE against cow's milk. ¹³ Unfortunately, due to health insurance, our patient could not perform food tolerance tests.

Concerning the gluten-free diet for migraines, it is a controversial field. Some authors suggest that people with migraines and any other symptoms that suggest CD should be screened for CD-related antibodies, mainly IgA anti-tissue transglutaminase and IgA, with a sensitivity of 98% and specificity of 95%. ¹⁴ A critical study that evaluated 883 children with headaches and performed a screening for CD. The authors found 11 children (1.2%) with CD, and 7 children were diagnosed with CD before the neurological evaluation. In their study, the prevalence of CD was 2.04% versus 1.2% of the general population. ¹⁴ This study confirmed a relationship between CD and migraines.

More so, a study showed that 95% of CD patients who followed GFD had a marked reduction in a migraine within days to a week.^15,16 In migraine patients without CD, this topic is still controversial. Future case reports and randomized trials evaluating GFD in migraineurs are desired.

Our patient could not know what kind of diet is responsible for that since the gluten-milk-sugar-free diet was initiated with all these components together. Furthermore, with the attempt to restart these foods, migraine relapsed. So, probably, a combination of these elements takes part in the pathophysiology of our patient.

In summary, the authors describe in this article a 35-year-old migraine patient who was quickly treated successfully after the exclusion of milk, gluten, and sugar from her diet.