“Eating Chocolate does NOT Trigger Your Migraine Attacks!”

Over the last 2 decades of practicing neurology, I have seen a dramatic increase in our understanding of the mechanism and phenomenology of migraine attacks which in turn has led to some amazing new treatments.  The first step toward having a better handle on migraine occurred before I started practicing when neurologists finally understood that migraine is not a primarily vascular disorder, but rather neurological.  An old term for migraine was “vascular headaches.”  The old concept postulated that migraine aura occurs during a time of decreased blood flow to the brain, hence the stroke-like neurological symptoms of vision disturbance, paresthesia (numbness and tingling), and dysarthria and aphasia (speech and language disturbance).  The old theory held that the migraine headache occurs during the increased blood flow phase causing the throbbing and pain and pressure.  In fact, blood flow changes do occur, but they are secondary to the neurological changes that occur in the brain during migraine with and without aura attacks. 

More recently, aided by the advent of functional imaging such as functional MRI and PET scanning, a whole additional phase of the migraine attack has been recognized, the premonitory phase.  This phase may come hours to days before a migraine aura or headache.  Symptoms include fatigue and changes in mood, yawning, thirst, cravings, urinary frequency, and light and sound sensitivity.  A patient recently told me that everything looks brighter with more vivid colors before a migraine headache begins, and she has come to recognize and act on this awareness.  For example, she may hydrate, do some neck stretches, have a snack or meal, and work to de-stress. 

I typically feel very tired before a migraine headache.  Sometimes on a walk with my husband I may feel sudden overwhelming fatigue, and I have been known to say, “I don’t think I can make it home.”  And I am pretty certain my speech is a little dysarthric (slurred) when I say it.  During the pandemic I have come to recognize a different premonitory symptom for me:  euphoria.  It took me a long time to figure this out.  Initially I was just enjoying the experience of feeling briefly on top of the world.  However, I finally noticed that not long after each episode, I would crash and burn.  I talk to myself a lot, both inside my head and out loud.  I now realize that if I am talking to myself in hyperbole and feeling as if nothing is insurmountable and even feeling a “buzz” sans alcohol, bad things are soon to happen.  I follow my patient’s lead and do anything and everything I can to head it off.  Since I am a rare breed of migraine sufferer who is a Tylenol super-responder (most migraine patients tell me that Tylenol for them is like “eating tic tacs.”), I also take two Tylenol when I feel these symptoms.  These efforts do help head off more severe migraine attacks.

Cravings are also prevalent during the premonitory phase of migraine.  Many patients, me included, have long believed that chocolate is a trigger for their migraine attacks.  If my nurse sees me getting chocolate from her office stash, she will say, “Uh oh.  Take your Tylenol.”  We have always assumed that the chocolate is going to trigger a migraine attack.  Instead, functional imaging suggests that changes in the brain heralding a migraine headache are already occurring in patients with migraine when they feel the urge to indulge in their favorite chocolate snack.  This lesson is music to the ears of all those chocoholics with migraine out there:  Eating Chocolate does NOT Trigger your Migraine Attacks!  However, if you are a migraine sufferer and find yourself craving chocolate, take notice, and step up your self-care program STAT!