Ketogenic Diets and Migraines: What’s the Current Evidence?

If you’ve read my previous article on the ketogenic diet for beginners, you may be wondering the rationale for an article on the current evidence on using the ketogenic diet (KD) for migraines. Didn’t that article state that initiating a ketogenic diet can lead to certain adverse effects, including headaches?

While it is true that one of the common side effects of the “keto flu” is headaches, this symptom tends to be transitory. Though it might seem counterintuitive, some people claim that the ketogenic diet has lessened or diminished their migraines over time, generally after that initial period where they were becoming acclimated to the diet. If you’re wondering whether there is currently any scientific evidence to back these interesting anecdotes regarding the ketogenic diet and migraines, today’s article should interest you.

In this article:

• What are the different subtypes of migraine?
• Conventional nutrition approaches for migraine mitigation
• Is there evidence for the use of ketogenic diets as a migraine therapy?
• Final thoughts: Is this treatment right for you?

Even if you are not personally a migraine sufferer, it is highly likely that you know someone who experiences migraines, since this condition impacts 18% of American women and 6% of American men. Migraine also has a genetic component, with 90% of sufferers having a family history of the condition. If you are ready to learn more about the nutrition interventions that may help improve migraines, keep reading.

What are the different subtypes of migraine?

Though people tend to use the basic term “migraine” to refer to any severe headache, there are actually several distinct subtypes of migraine, a condition that is considered to be a neurological disorder. What follows are some of the most common types of migraines (information adapted from the American Migraine Foundation website):

• Migraine with aura: Aura is a set of visual and sensory changes that may come before or accompany the head pain of a migraine, and typically lasts for 10-30 minutes. About 25% of those with migraine have this subtype.
• Migraine without aura: This type of migraine lacks the warning signs (such as aura) that other types of migraine may have. Light and sound sensitivity, pain on a single side of the head, and nausea and vomiting are common symptoms of this subtype.
• Silent migraine: A person with silent migraine may experience an aura, nausea, and the other symptoms of migraine except for head pain. Those with silent migraines are more prone to have other types of migraines too. Hemiplegic migraine may also involve little head pain, but the symptoms may feel more like a stroke and can last anywhere from a few hours to a few days.
• Retinal migraine: An unusual type of migraine that causes loss of vision in one eye, retinal migraines are most common in young adult women and may indicate an underlying serious medical condition. Consult with your physician immediately if you experience this type of migraine, and know that the vision loss will typically fully resolve.
• Chronic migraine: If your migraine pain lasts for more than half of the days in the month, it is classified as a chronic migraine. Patients with chronic migraine typically use acute headache medications to help manage the pain and other symptoms, which can vary in severity from day today.
• Ice pick headache: Highly intense and painful headache that typically lasts 5-30 seconds. The pain is felt on the side of the head between the eye and ear.
• Cluster headache: This type of headache is often perceived as a burning pain covering a large area around the temples, eyes, and possibly towards the back of the head. Symptoms can include facial flushing, nasal congestion, and tearing eyes. Most patients are ages 20-50; 80% of sufferers are male.

It is important to know which type of migraine(s) you are having because the studies on ketogenic diets for migraines typically focus on particular subtypes. It is possible that the ketogenic diet may be efficacious as nutrition therapy for only certain types of migraines, but there is currently not enough information on this topic to say for sure.

Some of these types of headaches can occur as a result of or alongside a diverse array of conditions such as allergies, aneurysm, arthritis, caffeine withdrawal, eyestrain, fever, hangovers, high blood pressure, hunger, TMJ, and tumors. Always check with your physician to rule out any underlying medical issues that may be triggering migraines.

Conventional nutrition approaches for migraine mitigation

There are certain foods that are more likely to be implicated in migraine. Eliminating these foods from the diet and then reintroducing them one by one in a challenging phase is a recommended first step in identifying foods that may be a migraine trigger. Also keep in mind that some migraines are triggered by factors such as lack of sleep, hormone irregularities, stress, anxiety, and other factors that may not be diet-related at all.

Some common foods that trigger migraines are also limited on a ketogenic diet, but you will not have the opportunity to learn whether specific foods are causing the problems if you jump into a ketogenic diet as the first step. Consider following this conventional migraine nutrition advice first, and trying other therapies that have potential but limited evidence (such as the ketogenic diet) only if medication and the following suggestions are not bringing relief.

The foods that may precipitate a migraine vary by individual. The following list of foods that are most likely to trigger a migraine has been adapted from the text Nutrition & Diagnosis-Related Care:

• Alcohol
• Foods and beverages containing caffeine (unfortunately both caffeine intake and caffeine withdrawal is implicated in migraine)
• Aged and fermented cheeses, as well as other fermented foods
• Certain fruits (some citrus fruits, bananas, figs, and raisins)
• Gluten-containing foods (there is a link between celiac disease and migraine; do not give up gluten-containing foods before being tested for celiac disease)
• Foods that are high in histamine (this includes spinach, tomatoes, eggplants, and many foods that fit other categories in this list, particularly fermented foods)
• Frozen foods (some individuals are sensitive to frozen foods, such as ice cream)
• Foods containing monosodium glutamate (MSG)
• Tree nuts, peanuts, soy
• Processed meats
• Sulfite-containing foods (e.g., dried fruit, shrimp, some packaged potato products)
• Foods that are high in tyramine (this includes many foods mentioned above, such as alcohol and chocolate, and also may include leftovers)
• Certain vegetables (onions, lima beans, pea pods)

Consider keeping a food diary to help pinpoint which foods are most likely to be migraine triggers, and focus on just these foods for an elimination and challenge trial, particularly if other items on the above list do not seem to be bothering you. Though some of the above foods are significantly reduced or eliminated on a ketogenic diet, others are encouraged. 

Is there evidence for the use of ketogenic diets as a migraine therapy?

As mentioned in the Keto 101 article, the most robust evidence for the use of the ketogenic diet is for certain patients with epilepsy, type 2 diabetes, and those looking for weight loss. A 2017 article confirms that “randomized controlled studies are needed to confirm the usefulness of KD in migraine and to investigate its optimal duration, repeatability, feasibility.” There is not enough evidence in humans available at this point to make universal recommendations of this diet therapy as a treatment for migraines.

A 2018 study tested a 12-week modified Atkins ketogenic diet (averaging 15 grams of carbohydrates per day) on 18 patients with cluster headaches that did not respond to drug therapy. Urinary ketones were measured, to assure patients remained in a state of ketosis. Of the 18 patients, 15 responded to diet therapy, with 11 experiencing a full resolution of their headaches. 

Though the above article is quite compelling, the authors admit that the observational study design is the main limitation of their work. Different methodology (double-blind versus placebo) would help to ascertain how much of the above improvement was due to the placebo effect and be better be able to compare diet treatment improvement to spontaneous improvements that are not diet-related.

A 2015 study tested the efficacy of a very-low-calorie ketogenic diet in 96 overweight women who suffer from migraines (both with and without aura). The women were assigned to one of two groups based on nutritional preferences and blindly received treatment. The first group received one month of a very-low-calorie ketogenic diet (800 calories and about 30 grams of carbohydrate per day) followed by five months of a standard low-calorie diet (1200-1500 calories per day), while the second group spent all six months on the standard low-calorie diet.

This study design helped investigators determine whether any migraine mitigation found could be primarily attributed to the ketogenic diet or to weight loss. Though weight loss was linked to headache amelioration, those following the ketogenic diet had a significant improvement in symptoms compared to the standard diet group. In addition, all clinical variables worsened in the ketogenic diet group after being switched to the standard diet, though migraine symptoms never completely returned to baseline.

Though the results of the above study appear to be promising, conclusive results cannot be made due to the inability to fully control for confounding factors since participants were not randomized into their diet groups. Also, since only overweight women were studied, these results cannot necessarily be generalized to the entire population of those with migraine.

If you are interested in this topic, I recommend keeping an eye on this randomized, double-blind crossover trial which will be comparing the use of exogenous ketones to placebo in the preventative treatment of migraine (both with and without aura). The study protocol was just published in 2019, so no results are available yet. This trial is expected to be completed in January 2020, with results published sometime thereafter, so stay tuned.

It is important to note that this study is looking at the impact of mild nutritional ketosis on migraines due to supplementation with beta-hydroxybutyrate (βHB) in mineral salt form, and not the impact due to following a ketogenic diet. If the results of this clinical trial show the βHB to be both safe and effective, this could become a novel therapeutic option for migraine patients who would prefer to avoid the complication of following a restricted diet that is very high in fat.

The role of ketone bodies in migraine is not fully understood, but it is hypothesized that mechanisms involved may include the dampening of a neuroinflammatory phenomenon and the enhancement of energy metabolism in the mitochondria. However, the mechanisms underlying the efficacy of the ketogenic diet in refractory epilepsy are also not fully understood, but this has not prevented its use as a medical nutrition therapy.

Final thoughts: Is this treatment right for you?

Diet is not the only factor that may trigger a migraine, so it is important to take an overall approach to wellness if you are a migraine sufferer. Regular sleeping patterns, healthy weight management, smoking cessation, regular mealtimes, and consistent exercise are all just as important as diet in the management of migraine. 

Health care practitioners need to remain open to the potential of novel nutrition therapies with an emerging evidence base, particularly in regards to treating refractory medical conditions. It can be comfortable to dismiss solutions that do not fit the conventional treatment protocol, but in doing so, we may be overlooking tools that can help people.

If you are interested in trying a ketogenic diet for your migraines, don’t forget to talk to your physician about it first. Also, ensure that you are taking inadequate fluid and electrolytes when initiating the diet. This precaution will not only help to reduce or eliminate headaches associated with the “keto flu,” consuming enough fluid to stay well-hydrated can also lessen the risk of kidney stones.