If you’ve considered changing what you eat in the hopes of preventing migraine attacks, you’re in good company. Many people subtract certain foods from their diets that they believe to be migraine triggers. Others look for a comprehensive, migraine-specific approach to diet, of which several have been proposed over the years.
One diet that’s been the subject of a number of studies and reports in professional journals, as described in a June 2020 article in Nutrients, is the ketogenic diet — or keto diet, for short.
The keto diet calls for people to get about 70 to 80 percent of their daily calories from fats, by consuming foods such as eggs, grass-fed meat, full-fat dairy products, and nuts, and smaller percentages of calories from protein and carbohydrate. Low-carbohydrate vegetables, such as kale, broccoli, asparagus, mushrooms, and zucchini, are recommended for their nutrient and fiber content, while foods that are high in carbohydrate, such as fruit, grains, sugar, and other caloric sweeteners, must generally be avoided.
There is evidence that the ketogenic diet can have such short-term benefits as weight loss, lowered insulin resistance, and reduction of high blood pressure, cholesterol, and triglycerides, according to the Harvard T.H. Chan School of Public Health. But severely limiting carbohydrates can also come with health consequences; side effects including hunger, fatigue, constipation, headaches, and “brain fog” are common.
But can the keto diet help you manage migraine? Some experts believe that fueling your body and brain with more healthy fats and less carbohydrate could help reduce headaches and migraine pain, while others are more cautious about recommending low-carbohydrate diets.
1. A Ketogenic Diet Causes the Body to Produce Ketones
Simply put, a ketogenic diet is a diet that produces ketone bodies, according to Angel L. Moreno, NP, at the UCLA Goldberg Migraine Program in Los Angeles, who spoke on the keto diet and migraine in 2019 at the annual Migraine World Summit.
“Ketones are [acids that are released into the bloodstream] when we start burning for fat for fuel, when there is no readily available sugar or glucose from carbohydrates. Most people never form [measurable] ketones, because they usually eat too high of a carbohydrate load to ever allow the body to switch over to a different fuel source,” he says.
While many cells in the body, particularly brain cells, prefer glucose as an energy source, the body can also use ketones as an alternative energy source if glucose is not available.
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2. The Keto Diet Has Been Shown to Stop Seizures in Those With Epilepsy
In the early 1900’s, researchers found that starvation was an effective way to stop seizures in people with epilepsy, with seizures typically improving after two to three days, according to a history of the ketogenic diet published in Epilepsia. Soon after, researchers began successfully treating some patients with the ketogenic diet and other carbohydrate-restricting diets, including the Atkins diet and the modified Atkins diet.
Migraine and epilepsy have a lot of overlapping mechanisms, says Moreno. “We use antiepileptic medications for some people who have migraine, including Depakote (divalproex sodium), Topamax (topiramate), and Neurontin (gabapentin) — these are all anti-epileptic medications,” he says.
3. Ketones Nourish Cells Differently From Glucose
The causes of migraine are multifactorial, with one potential factor relating to metabolism, says Moreno.
“This means the ability for the body to extract energy from the food that eat, the water we drink, the air that we breathe — all of that has to be metabolized so that the brain can use it as a fuel source. If there’s ever a deficit of energy that’s being delivered to the central nervous system, one theory is that it can cause irritation in the nerves and then trigger migraine,” he says.
Stress can trigger migraine as well, because when we’re stressed, our metabolic demand increases, says Moreno. “Our heart beats faster, our blood rushes from our core to our extremities to either run or fight. There’s a lot of metabolic demand,” he says.
If we’re burning carbohydrate as our only fuel source, the carbohydrate has to break down into glucose, which then gets transported into cells via the insulin transport process, he explains. “Insulin takes the glucose and moves it from the outside of the cell to the inside of the cell, where it can be used for fuel,” says Moreno.
The problem is that there is evidence that right before and during migraine our cells become insulin-resistant — or less sensitive to the effects of insulin — for a period of time, he says.
“If we’re solely dependent on carbohydrates and glucose and other kinds of sugars, then we’re out of luck; our cells aren’t going to get nourished. But if we also have ketones in our system, ketones have three different pathways to passively go into cells and nourish them, versus only one path for glucose to go into cells,” he says.
The path for glucose is solely dependent on insulin, and so if you develop any kind of resistance to that insulin, that’s a problem, says Moreno. “If you’re resistant, you can be swimming in all the glucose in the world, but you’re not going get it into where you need it.”
4. Studies Link the Keto Diet to Fewer Migraine Attacks
Several small studies or case reports have described positive results when the subjects followed a ketogenic diet, but the cumulative number of participants has been very low.
A somewhat larger pilot study with 96 participants, published in the European Journal of Neurology, compared overweight women with migraine who followed a very-low-calorie keto diet for one month, followed by a standard, low-calorie diet for five months, with a similar group of women who followed a standard, low-calorie diet for six months. The study found that the keto diet was more effective at bringing about improvement.
In the first month of the trial, the keto group adhered to a restrictive diet of 800 calories and only 30 grams of carbohydrate per day. Their attack frequency dropped from 2.9 to 0.71, number of days with headaches went from 5.11 to 0.91, and acute treatment taken dropped from 4.91 doses to 0.51 doses per month.
After the keto diet was stopped, all of those measurements temporarily worsened, but then the group continued to improve through the end of the study.
In the standard-diet group, significant decreases in the number of days with headache and in medication use were observed only starting in month 3, and in attack frequency at month 6.
5. Just Reducing Carbohydrate in the Diet May Be Beneficial
There’s evidence that the metabolic breakdown of carbohydrate is proinflammatory, and inflammation is associated with migraine, says Moreno. “The standard American diet can cause a lot of metabolic harm to our bodies; some people need to be on a lower-carb or ketogenic diet to heal from eating an unhealthy diet.”
Moreno often recommends a low-carb diet rather than a keto diet. “I don’t know that everyone needs to go into ketosis and stay in ketosis 24/7. I don’t think that’s how humans are meant to function,” he says. “It’s been my experience that a lot of people get benefits just by reducing carbohydrates.”
Moreno recommends following a diet of whole foods and real ingredients, which could include diets such as the Whole30, Paleo, or the South Beach Diet. “A low-carb diet starts out at about 100 grams of carbohydrates a day,” he says.
It’s also important to note that not all carbs are created equal, he notes. “If you eat a bowl of pasta, that’s going to cause more inflammation than eating a bowl of veggies,” he says.
A study published in January 2018 in Agri: The Journal of the Turkish Society of Algology found that a low-glycemic diet reduced the number of migraine attacks and headache intensity in 147 people with migraine without aura.
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6. Keto and Low-Carb Diets May Not Be a Good Choice for Everyone
Headache experts are divided on whether the benefits of the keto diet outweigh the downsides. Although there is some evidence that using a ketogenic type diet can positively influence migraine, it’s not necessarily strong evidence, according to Elizabeth Leroux, MD, headache clinic director at Montreal University Health Center in Canada in her presentation at the 2020 Migraine World Summit.
“The other problem is that the ketogenic diet is not necessarily safe for everyone, and it may have consequences on your health,” says Dr. Leroux.
A keto diet can also be hard to stay on, she points out. If you have migraine and want to improve your diet, Leroux recommends trying something like the Mediterranean diet, which is healthier than the average diet but less strict than the keto diet.
“Why not try a step that is a little bit easier and less extreme, and see how that works for you first, because it will be way easier to sustain not only for you, but also for your family,” she says.
7. Get Help From a Professional if You Want to Try the Keto Diet
If you’re considering restricting carbohydrate in your diet or following a full-fledged keto diet, it’s a good idea to work with your doctor or a dietitian to make sure you continue to get the right amount of nutrients and essential vitamins and minerals, including salt, says Morena.
“One of the pitfalls I often see when people undertake a low-carb, ketogenic diet is not eating enough salt or replacing enough electrolytes,” he says.
8. Seek Out Social Support to Stay Inspired and Reap Wellness Benefits
If you make the decision to make lifestyle changes in an effort to improve migraine, seek out the support of friends, family, or an in-person or online community, he suggests. “Find ways to stay inspired; staying inspired can lead to a lot of wellness benefits,” he says.
“Migraine doesn’t kill you, but it steals your life while you’re alive. It forces you into a dark room and isolates you from social connections. Because of pain, migraine can keep you from realizing your ultimate potential,” says Moreno.
It can be hard to cut carbs, because so many things that are high in carbs taste so good, but there can be a price to pay for what tastes good, he says. “I think feeling good is better than anything that tastes really good. Being able to wake up and not have pain, or going about your day without a migraine attack — there are a lot of benefits there,” says Moreno.