Migraine exacerbation during Ramadan fasting

Frequency of migraine and its associated triggers and relievers among medical students of Lahore: a cross-sectional study

Introduction

Headache is a widely prevalent illness that negatively impacts people's lives, leaving them functionally incapable of performing regular everyday tasks. The global burden of headache is 40%, of which migraine accounts for 47%.

Objective

This study aims to determine the frequency of migraine among medical students of Lahore and its characteristics, associated triggers, and relievers among medical students.

Methodology

A cross-sectional study was conducted in medical colleges after obtaining ethical approval. Migraine was diagnosed using the criteria provided in the International Classification of Headache Disorders, Third Edition (ICHD-3), and data on triggers, relief, and demographics were collected. The information is analyzed using SPSS 22.

Result

The data were collected from 522 medical students. The average age of the students was 21.3 ± 2.0 SD (in years). About 146 (28.0%) of the medical students have migraine according to ICHD-3 criteria and were diagnosed initially. Gender was insignificantly associated with migraine (P-value=0.32). Students with psoriasis, hypertension, and polycystic ovarian syndrome were statistically significantly related to migraines with a P-value=0.002. Dehydration is the most frequent aggravator, and adequate sleep is the most frequent reliever of migraine.

Conclusion

The findings show a high frequency of migraine. They are similar in both genders, depicting that stressful lifestyles, inadequate sleep patterns, and bizarre dietary habits make them more prone to migraine episodes. So, further, detailed studies should be done on evaluating triggers and relievers of migraine and their interrelations with migraine so we can focus on preventive strategies, diagnosis, and treatment of migraine.

Sex as a Biological Factor in the Changes in Disease Patients During Ramadan Intermittent Fasting: A Systematic Review

Background

During Ramadan, many patients with diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy choose to fast even against their doctor's advice. The impact of this intermittent fasting on health and disease could be different in men and women. The aim of this study was to determine the effect of sex as a factor in diseases outcomes of patients who opt to fast during Ramadan.

Main Body

The articles included in this study reported data on six diseases: diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy. A systematic search was performed on PubMed and Scopus for observational and clinical studies mentioning Ramadan, diabetes, renal, cardiovascular, gastrointestinal diseases, headaches, and epilepsy in both men and women. Data was extracted by two independent reviewers using a standardized data-collection form. From 381 original articles, 38 studies were selected, including 25,023 patients of which 44.4% were women. Sex-based differences were reported by 18 studies for several variables such as body mass index, blood glucose, the frequency of hypoglycemia, renal colic, mortality, thrombosis, and gastrointestinal diseases in patients fasting during Ramadan. Most of the differences between men and women were reported both in the baseline period before Ramadan and during Ramadan. Indeed, during the period outside Ramadan, the frequency of renal colic, cardiovascular, gastrointestinal diseases, were higher in men; while body mass index, Thrombosis, and headache were higher in women. In the remaining 21 studies, it was reported that the sex factor was not associated with the effect of Ramadan fasting in the frequency and other outcomes of these diseases.

Conclusion

Currently, small attention is paid to sex as a determinant factor in patients while fasting during Ramadan. There appeared to be differences in the frequency and incidence of diseases in men and women during Ramadan. Closer attention to sex differences regarding the frequency and the progression of the diseases during fasting may help to improve patient care, especially to benefit those patients willing to fast during Ramadan.

The potential impact of nutritional intake on symptoms severity in patients with comorbid migraine and irritable bowel syndrome

Background

Specific dietary recommendations for migraine patients with comorbid irritable bowel syndrome (IBS) are lacking. This work aimed to study the severity scores of such two common pain-related disorders in relation to various macronutrients and micronutrients intake.

Methods

A cross-sectional study was conducted on patients with concomitant migraine and IBS. The frequency and intensity of migraine attacks and the severity of IBS were evaluated. Data on dietary intake were collected using food frequency questionnaires and 24-hour dietary recall.

Results

One-hundred patients with a median age of 36 years participated. The severity scores for migraine and IBS were positively correlated with fat and copper and negatively correlated with fiber and zinc intake. Copper intake was an independent predictor of the severity of both migraine and IBS (P 0.033, < 0.001). Patients with episodic migraine (n = 69) had a significantly higher frequency of cooked, fresh vegetables, and wheat bran bread intake (P 0.009, 0.004, 0.021) and lower frequency of hydrogenated oils intake (P 0.046), in comparison to patients with chronic migraine (n = 31). Patients with moderate intensity of migraine (n = 37) had a significantly higher frequency of herbal drinks intake (P 0.014) than patients with a severe intensity of migraine (n = 63). Patients with mild (n = 13) and moderate IBS (n = 41) had a significantly higher frequency of wheat bran bread and sen bread intake (P 0.003, 0.022) than patients with severe IBS (n = 46).

Conclusion

Patients with comorbid migraine and IBS are advised to adhere to a diet low in fat and copper and rich in fiber and zinc.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02723-0.

Glucose-Related Traits and Risk of Migraine—A Potential Mechanism and Treatment Consideration

Migraine and glucose-related (glycaemic) traits (fasting glucose, fasting insulin, and type 2 diabetes) are common and complex comorbid disorders that cause major economic and social burdens on patients and their families. Studies on the relationship between migraine and glucose-related traits have yielded inconsistent results. The purpose of this review is to synthesise and discuss the information from the available literature on the relationship between fasting glucose, fasting insulin, and type 2 diabetes (T2D) with migraine. Publications on migraine and fasting glucose, migraine and fasting insulin, and migraine and T2D were identified from a PubMed and Google Scholar database search and reviewed for this article. Multiple publications have suggested that the comorbidity of migraine and glucose-related traits may have a similar complex pathogenic mechanism, including impaired glucose homeostasis, insulin resistance, reduced cerebrovascular reactivity, abnormal brain metabolism, shared genetic factors, neurotransmitters, and sex hormones. Furthermore, several studies have found a bi-directional link between migraine with insulin resistance and T2D. There is strong evidence for a biological association between migraine headache and glucose-related traits, and burgeoning evidence for shared genetic influences. Therefore, genetic research into these comorbid traits has the potential to identify new biomarkers and therapeutic targets and provide biological insight into their relationships. We encourage healthcare professionals to consider the co-occurrence of migraine with glucose-related traits in the evaluation and treatment of their patients.

Lifestyle Modifications for Migraine Management

Migraine is a disabling disease that inflicts a heavy burden on individuals who suffer from it. Significant advances are being made in understanding the pathophysiology and treatment of the disease. The role of lifestyle modifications has become increasingly predominant. We reviewed the current and available data on the role of a healthy lifestyle in the management of migraine. Physical activity, management of obesity, a healthy diet, and a better lifestyle, such as adequate sleep and avoidance of drug abuse, significantly contribute to reducing the frequency and severity of attacks. It is important to consider these factors in the overall management strategies for migraine sufferers.

Changes in migraine characteristics over 30 days of Ramadan fasting: A prospective study

OBJECTIVE

To study Ramadan's effect on migraine from the start to the end of the month and the tolerability of patients with migraine to fasting.

BACKGROUND

Fasting is a well-known trigger for migraine. Whether this effect on migraine is the same throughout the whole month, or whether it varies from the first to the last days of the month, has not been studied yet.

METHODS

A prospective cohort observational study was carried out on persons with migraine who fasted from 24 April to 23 May during Ramadan 2020. Each patient was asked to fill out their headache diary starting from Shaaban (the month before Ramadan) to the end of Ramadan. The Ramadan diary was divided by 10 days each, by which the patient was asked to accurately describe their migraine attacks in terms of frequency, duration, and intensity by using the Visual Analog Scale. Migraine attacks during the first day of fasting were assessed separately.

RESULTS

A total of 292 known persons with migraine from Egypt completed the study. Their median age was 33 years; 72/292 (24.7%) were male, and 220/292 (75.3%) were female. About 126/236 (53.4%) of the patients had migraine attacks on Ramadan's first day, most of them during fasting. The frequency of migraine attacks was significantly increased in Ramadan (median 4, interquartile range [IQR] 2-7) compared with Shaaban (median 3, IQR 1-6), p = 0.009. The number of attacks was significantly reduced in both the second (median 1, IQR 0-2.25) and the third 10 days of Ramadan (median 1, IQR 1-3) compared with the first 10 days (median 3, IQR 1-5) (p < 0.001 for each).

CONCLUSION

Ramadan's potential exacerbating effect on the frequency of migraine attacks should be discussed with patients with migraine. This effect appears to be limited to the first 10 days of Ramadan and then subsides with successive days of fasting.

Was it something I ate? Understanding the bidirectional interaction of migraine and appetite neural circuits

Migraine attacks can involve changes of appetite: while fasting or skipping meals are often reported triggers in susceptible individuals, hunger or food craving are reported in the premonitory phase. Over the last decade, there has been a growing interest and recognition of the importance of studying these overlapping fields of neuroscience, which has led to novel findings. The data suggest additional studies are needed to unravel key neurobiological mechanisms underlying the bidirectional interaction between migraine and appetite. Herein, we review information about the metabolic migraine phenotype and explore migraine therapeutic targets that have a strong input on appetite neuronal circuits, including the calcitonin gene-related peptide (CGRP), the pituitary adenylate cyclase-activating polypeptide (PACAP) and the orexins. Furthermore, we focus on potential therapeutic peptide targets that are involved in regulation of feeding and play a role in migraine pathophysiology, such as neuropeptide Y, insulin, glucagon and leptin. We then examine the orexigenic - anorexigenic circuit feedback loop and explore glucose metabolism disturbances. Additionally, it is proposed a different perspective on the most reported feeding-related trigger - skipping meals - as well as a link between contrasting feeding behaviors (skipping meals vs food craving). Our review aims to increase awareness of migraine through the lens of appetite neurobiology in order to improve our understanding of the earlier phase of migraine, encourage better studies and cross-disciplinary collaborations, and provide novel migraine-specific therapeutic opportunities.

Worsening of migraine headache with fasting Ramadan

BACKGROUND

Fasting is known as a trigger for migraines. Muslims fast 1 month every luminal year. We aimed to study the impact of The Holy month of Ramadan on migraine headaches.

METHODS

This retrospective study included patients diagnosed with migraines according to The International Classification of Headache Disorders, 3rd edition (ICDH-3). Both genders, aged between 18 and 65 years were included. The impact of Ramadan fasting and changing habits during the month of Ramadan was studied. The frequency and the severity of migraine attacks, and the number of analgesic days during Ramadan were compared to those during Shaban, the immediately preceding month to Ramadan. The number of breaking fasting due to migraines was reported.

RESULTS

This study identified 293 with migraine with mean age and mean disease duration 37.09 ± 9.36, 12.34 ± 9.27 years respectively. Most of them were females (89.1%). Most of our cohort had changed sleep and food habits during Ramadan (93.2%). The majority of them were dehydrated (89.8%). Most of the patients completed fasting the whole month of Ramadan. A minority (1.7) could not tolerate fasting the whole Ramadan due to intolerable migraine headaches and 36.5% broke their fasting for some days during Ramadan. Most of our cohort (82.3%) continue on the same management plan for migraines during Ramadan. During the month of Ramadan, the patients had a significant increase in migraine days of 10.42 ± 7.98 compared with 6.90 ± 6.55 migraine days during the previous month (p < 0.001). Also, days of analgesic use (11.32 ± 10.46 versus 6.11 ± 6.69; P < 0.001) and migraine severity (7.46 ± 2.39 versus 6.84 ± 2.25; P < 0.001) were significantly increased during Ramadan compared with Shaban. In multivariate analysis, change in sleep and feeding habits together with non-modification of the treatment plan before Ramadan significantly predict breaking fasting due to worsening of migraine headache (p value = 0.041, p value = 0.025; respectively). The majority of our cohort (75.4%) reported that migraines interfered with their daily activities due to fasting during Ramadan.

CONCLUSION

Change in sleep and food habits along with dehydration make Migraine frequency and severity worse during Ramadan fasting. Physicians should educate migraine patients who fast to manage their headaches and habits before starting fasting.

Dehydration and Headache

PURPOSE OF REVIEW

We define dehydration and its relationship to pain physiology including both primary and secondary headache disorders.

RECENT FINDINGS

Intravenous fluids administered for acute migraine attacks in an emergency department setting have not been shown to improve pain outcomes. However, increased intravascular volume before diagnostic lumbar puncture may reduce the frequency of post-lumbar puncture headache from iatrogenic spinal fluid leak. Maintenance of euhydration can help treat orthostatic and "coat-hanger" headache due to autonomic disorders. Similarly, prevention of fluid losses can mitigate secondary headaches provoked by dehydration such as cerebral venous thrombosis or pituitary apoplexy. Dehydration alone may cause headache, but oftentimes exacerbates underlying medical conditions such as primary headache disorders or other conditions dependent on fluid balance.

Postprandial fasting related headache during Ramadan in Saudi Arabia: A cross-sectional study

BACKGROUND

Headache disorders are classified as primary or secondary; however, among the secondary headaches, those attributed to food ingestion are not well understood. Therefore, we conducted this study to describe and characterize a new headache entity that occurred during the holy month of Ramadan. This headache occurred within 4 h of breaking the fast.

METHODS

This is a nationwide descriptive community-based cross-sectional study conducted during the last 10 days of Ramadan, based on a random sample of adults living in Saudi Arabia. The demographic data, headache symptomatology, nature and distribution of the pain, possible triggering and relieving factors, and patient management programs were analyzed.

RESULTS

Completed questionnaires were obtained from 16,031 participants. Of those, 3147 (19.6%) reported headaches after breaking the fast in Ramadan. In 84.1% of cases, there was no previous diagnosis of headache or migraine. The characteristics of these postprandial fasting-related headaches mostly was episodic in nature (72%). The nature of the headache was variable, mostly heaviness or tightness (53.9%). Triggering factors included ingestion of fried food in (45%) and coffee (26.3%). Lying down and sleeping was found to be an important relieving factor (61%).

CONCLUSION

A new headache entity is being described. Appears to be quite common, occurs less than 2 h following the first meal, and is mostly of the heaviness and tension type.

Pediatric emergency department utilisation during Ramadan: a retrospective cross-sectional study

OBJECTIVE

To investigate the impact of Ramadan on patient characteristics, diagnoses and metrics in the paediatric emergency department (PED).

DESIGN

Retrospective cross-sectional study.

SETTING

PED of a tertiary care centre in Lebanon.

PATIENTS

All paediatric patients.

EXPOSURE

Ramadan (June 2016 and 2017) versus the months before and after Ramadan (non-Ramadan).

MAIN OUTCOME MEASURES

Patient and illness characteristics and PED metrics including peak patient load; presentation timings; length of stay; and times to order tests, receive samples and report results.

RESULTS

We included 5711 patients with mean age of 6.1±5.3 years and 55.4% males. The number of daily visits was 28.3±6.5 during Ramadan versus 31.5±7.3 during non-Ramadan (p=0.004). The peak time of visits ranged from 18:00 to 22:00 during non-Ramadan versus from 22:00 to 02:00 during Ramadan. During Ramadan, there were significantly more gastrointestinal (GI) and trauma-related complaints (39.0% vs 35.4%, p=0.01 and 2.9% vs 1.8%, p=0.005). The Ramadan group had faster work efficiency measures such as times to order tests (21.1±21.3 vs 24.3±28.1 min, p<0.0001) and to collect samples (50.7±44.5 vs 54.8±42.6 min, p=0.03).

CONCLUSIONS

Ramadan changes presentation patterns, with fewer daily visits and a later peak time of visits. Ramadan also affects illness presentation patterns with more GI and trauma cases. Fasting times during Ramadan did not affect staff work efficiency. These findings could help EDs structure their staffing to optimise resource allocation during Ramadan.

Sudden Caffeine Withdrawal Triggers Migraine-A Randomized Controlled Trial

Objective: Assessing the effects of caffeine withdrawal on migraine.

Background: The effects of caffeine withdrawal on migraineurs are at large unknown.

Methods: This was a randomized, double-blind, crossover study (NCT03022838), designed to enroll 80 adults with episodic migraine and a daily consumption of 300–800 mg caffeine. Participants substituted their estimated dietary caffeine with either placebo capsules or capsulated caffeine tablets for 5 weeks before switching the comparators for 5 more weeks.

Results: The study was terminated due to low recruitment. Ten subjects with a mean age of 46.3 ± 9.9 years, BMI of 24.9 ± 3.7, and a mean blood pressure of 134/83 ± 17/12 mmHg were enrolled. The average consumption of caffeine per day was 539 ± 196.3 mg. The average monthly headache days and migraine attack frequency at baseline was 11.5 ± 4.9 and 5.2 ± 1.2, respectively. At baseline Pittsburgh Sleep Quality Index was 5.8 ± 2.5 and HIT-6 was 62.8 ± 3.9. There were no differences in these or in parameters from actigraphy during the caffeine period compared with the placebo period. One subject withdrew just after entering the study. In the remaining nine, withdrawal triggered severe migraine attacks in seven, causing one more drop-out, and a typical caffeine withdrawal syndrome in two. Caffeine continuation did not trigger migraines, but one attack occurred in the wake of caffeine reintroduction.

Conclusions: The study failed to answer how caffeine withdrawal affects migraineurs over time, but showed that abrupt withdrawal of caffeine is a potent trigger for migraine attacks.

What is Needed for Evidence-Based Dietary Recommendations for Migraine: A Call to Action for Nutrition and Microbiome Research

BACKGROUND

The gastrointestinal symptoms of migraine attacks have invited numerous dietary hypotheses for migraine etiology through the centuries. Substantial efforts have been dedicated to identifying dietary interventions for migraine attack prevention, with limited success. Meanwhile, mounting evidence suggests that the reverse relationship may also exist - that the biological mechanisms of migraine may influence dietary intake. More likely, the truth involves some combination of both, where the disease influences food intake, and the foods eaten impact the manifestations of the disease. In addition, the gut's microbiota is increasingly suspected to influence the migraine brain via the gut-brain axis, though these hypotheses remain largely unsubstantiated.

OBJECTIVE

This paper presents an overview of the strength of existing evidence for food-based dietary interventions for migraine, noting that there is frequently evidence to suggest that a dietary risk factor for migraine exists but no evidence for how to best intervene; in fact, our intuitive assumptions on interventions are being challenged with new evidence. We then look to the future for promising avenues of research, notably the gut microbiome.

CONCLUSION

The evidence supports a call to action for high-quality dietary and microbiome research in migraine, both to substantiate hypothesized relationships and build the evidence base regarding nutrition's potential impact on migraine attack prevention and treatment.

The Role of Diet and Nutrition in Migraine Triggers and Treatment: A Systematic Literature Review

Background

Migraine is a disabling primary headache disorder often associated with triggers. Diet‐related triggers are a common cause of migraine and certain diets have been reported to decrease the frequency of migraine attacks if dietary triggers or patterns are adjusted.

Objective

The systematic literature review was conducted to qualitatively summarize evidence from the published literature regarding the role of diet patterns, diet‐related triggers, and diet interventions in people with migraine.

Methods

A literature search was carried out on diet patterns, diet‐related triggers, and diet interventions used to treat and/or prevent migraine attacks, using an a priori protocol. MEDLINE and EMBASE databases were searched to identify studies assessing the effect of diet, food, and nutrition in people with migraine aged ≥18 years. Only primary literature sources (randomized controlled trials or observational studies) were included and searches were conducted from January 2000 to March 2019. The NICE checklist was used to assess the quality of the included studies of randomized controlled trials and the Downs and Black checklist was used for the assessment of observational studies.

Results

A total of 43 studies were included in this review, of which 11 assessed diet patterns, 12 assessed diet interventions, and 20 assessed diet‐related triggers. The overall quality of evidence was low, as most of the (68%) studies assessing diet patterns and diet‐related triggers were cross‐sectional studies or patient surveys. The studies regarding diet interventions assessed a variety of diets, such as ketogenic diet, elimination diets, and low‐fat diets. Alcohol and caffeine uses were the most common diet patterns and diet‐related triggers associated with increased frequency of migraine attacks. Most of the diet interventions, such as low‐fat and elimination diets, were related to a decrease in the frequency of migraine attacks.

Conclusions

There is limited high‐quality randomized controlled trial data on diet patterns or diet‐related triggers. A few small randomized controlled trials have assessed diet interventions in preventing migraine attacks without strong results. Although many patients already reported avoiding personal diet‐related triggers in their migraine management, high‐quality research is needed to confirm the effect of diet in people with migraine.

Impact of Ramadan on Emergency Department Patients Flow; a Cross-Sectional Study in UAE

Introduction:

Ramadan, the ninth month of the Islamic lunar calendar, is, to Muslims, the holiest month of the year. During this month, young, able-bodied Muslims are commanded to abstain from food and drink from dawn to dusk.

Objective:

The objective of the study is to analyze emergency department (ED) patients flow during the holy month of Ramadan and compare it to non-Ramadan days. We hypothesized that Ramadan would affect ED attendance by altering peak hours, and expected a dip in attendance around evening time (after sunset).

Methods:

In Abu Dhabi, United Arab Emirates, a retrospective study was conducted at a tertiary hospital (2014–2016). The data was strategically separated and patient presence was analyzed year-wise, weekday basis and based on the hourly presence of the patients in the ED of the chosen hospital.

Results:

A total of 45,116 ED’s patient visits were analyzed over the mentioned study period. There was a difference in the total volume of Ramadan and non-Ramadan patient between the years 2014–2016. In all of the years, the highest percentage of visits was during the non-Ramadan days and this had a small fluctuation from 53% in 2014 to 52% in 2016 (p=0.001). It was observed from the collected data that 53% of the patients were present in the hospital during the fasting hours whereas 47% were present during the non-fasting hours (p<0.001).

Conclusion:

We were successfully able to derive a pattern from the data of 3 years in relation to the patient flow in the ED of the hospital. Moreover, we observed the difference in the patient arrival pattern between the Ramadan and non-Ramadan days in the hospital along with the predominant categorization of patient chief complaints. Our study identified a unique pattern of ED hourly visits during Ramadan.

Prevalence and comorbidity of migraine headache: results from the Singapore Mental Health Study 2016

BACKGROUND AND AIM

Migraine is a highly prevalent and disabling neurological disorder associated with a wide range of psychiatric comorbidities. Studies have revealed that those with migraine headache and coexisting psychiatric disorders have poorer treatment outcomes and increased disability. The study aims to establish the prevalence, correlates, and comorbidities of migraine headache among the multi-ethnic Asian population in Singapore.

METHOD

Data were extracted from the Singapore Mental Health Study 2016 (SMHS 2016), a cross-sectional epidemiological survey of a nationally representative sample. Face-to-face interviews were completed with 6126 participants between 2016 and 2017. The data relating to chronic medical conditions, psychiatric conditions, and 30-day functioning and disability were captured using the World Mental Health Composite International Diagnostic Interview (CIDI) version 3.0.

RESULTS

The lifetime prevalence for migraine headache in the Singapore general population was 8.2%. Malay ethnicity (versus Chinese), female gender (versus male), and diploma holders (versus university) were significantly more likely to experience migraine headache. Participants belonging to the older age group (65 years and above versus 18-34 years of age), and those who were economically inactive (versus employed) were less likely to experience migraine headache. The mean age of onset for migraine was 26.4 years (SD = 11.1). Poisson regression analyses showed that migraine headache was also significantly associated with psychiatric conditions such as major depressive disorder (MDD) (prevalence ratio (PR), 1.80; 95% CI, 1.25-2.58), bipolar disorder (BD) (PR, 3.55; 95% CI, 2.29-5.51), generalized anxiety disorder (GAD) (PR, 2.04; 95% CI, 1.12-3.69), obsessive compulsive disorder (OCD) (PR, 2.20; 95% CI, 1.49-3.26), and alcohol use disorder (AUD) (PR, 1.93; 95% CI, 1.20-3.08). Those with migraine headache were significantly associated with poor functioning and disability compared to those without migraine headache.

CONCLUSIONS AND DISCUSSION

Our study showed significant associations between migraine headache and psychiatric disorders, as well as with role functioning and disability. The findings of our study emphasise the need for screening for psychiatric comorbidity among those with migraine and the development of appropriate interventions for this group.

Potential Protective Mechanisms of Ketone Bodies in Migraine Prevention

An increasing amount of evidence suggests that migraines are a response to a cerebral energy deficiency or oxidative stress levels that exceed antioxidant capacity. The ketogenic diet (KD), a diet mimicking fasting that leads to the elevation of ketone bodies (KBs), is a therapeutic intervention targeting cerebral metabolism that has recently shown great promise in the prevention of migraines. KBs are an alternative fuel source for the brain, and are thus likely able to circumvent some of the abnormalities in glucose metabolism and transport found in migraines. Recent research has shown that KBs-D-β-hydroxybutyrate in particular-are more than metabolites. As signalling molecules, they have the potential to positively influence other pathways commonly believed to be part of migraine pathophysiology, namely: mitochondrial functioning, oxidative stress, cerebral excitability, inflammation and the gut microbiome. This review will describe the mechanisms by which the presence of KBs, D-BHB in particular, could influence those migraine pathophysiological mechanisms. To this end, common abnormalities in migraines are summarised with a particular focus on clinical data, including phenotypic, biochemical, genetic and therapeutic studies. Experimental animal data will be discussed to elaborate on the potential therapeutic mechanisms of elevated KBs in migraine pathophysiology, with a particular focus on the actions of D-BHB. In complex diseases such as migraines, a therapy that can target multiple possible pathogenic pathways seems advantageous. Further research is needed to establish whether the absence/restriction of dietary carbohydrates, the presence of KBs, or both, are of primary importance for the migraine protective effects of the KD.

Increase in Ischemic Stroke Incident Hospitalizations Among Bedouin Arabs During Ramadan Month

Background

Previous studies have not shown any significant effect on stroke incidence during Ramadan. We aimed to investigate the association between ischemic stroke incident hospitalizations and Ramadan, accounting for seasonality and temperature.

Methods and Results

This retrospective cohort study included all patients admitted with acute ischemic stroke to Soroka University Medical Center from June 2012 to June 2016. We obtained daily mean temperatures and relative humidity rates from 2 monitoring stations in South Israel. We analyzed the association between stroke incidence and Ramadan month, adjusting for weekly temperature and seasonality using Poisson regression models. We compared the first versus the last Ramadan fortnight. We performed an effect specificity analysis by assessing stroke incidence in the non‐Bedouin population. We identified 4727 cases of ischemic stroke, 564 cases of which were Bedouin Arabs. Fifty‐one cases occurred during Ramadan. Ramadan was significantly associated with an increased risk for ischemic stroke (RR 1.48; 95% confidence interval, 1.04–2.09), mainly during the first fortnight (RR 1.73, 95% confidence interval, 1.13–2.66) when compared with non‐Ramadan periods. Mean weekly temperatures and the summer season were not associated with stroke incidence among Bedouin Arabs (RR 0.98; 95% confidence interval, 0.82–1.18 and RR 0.77; confidence interval 0.56–1.06 accordingly). Such association was not observed in the non‐Bedouin population.

Conclusion

The Ramadan month, particularly in its first 2 weeks, is an independent and ethnicity specific risk factor for ischemic stroke hospitalizations among the Bedouin Arab fasting population.

Headaches: a Review of the Role of Dietary Factors

Dietary triggers are commonly reported by patients with a variety of headaches, particularly those with migraines. The presence of any specific dietary trigger in migraine patients varies from 10 to 64 % depending on study population and methodology. Some foods trigger headache within an hour while others develop within 12 h post ingestion. Alcohol (especially red wine and beer), chocolate, caffeine, dairy products such as aged cheese, food preservatives with nitrates and nitrites, monosodium glutamate (MSG), and artificial sweeteners such as aspartame have all been studied as migraine triggers in the past. This review focuses the evidence linking these compounds to headache and examines the prevalence of these triggers from prior population-based studies. Recent literature surrounding headache related to fasting and weight loss as well as elimination diets based on serum food antibody testing will also be summarized to help physicians recommend low-risk, non-pharmacological adjunctive therapies for patients with debilitating headaches.

Emergency department attendance patterns during Ramadan

BACKGROUND

Patient attendance in the emergency department (ED) is inherently variable and unpredictable. Resources might be better allocated if use of the ER could be predicted during the month of fasting (Ramadan), healthy adult Muslims do not eat or drink from dawn to sunset and in the Middle East, social activities occur mostly during night. There is no published data that has reported changes in local ED attendance pattern during Ramadan.

OBJECTIVES

Determine if there are differences in tertiary care ed attendance during Ramadan compared to other times of the year.

DESIGN

Retrospective, using data from the hospital integrated clinical information system.

SETTING

Tertiary care institution in Riyadh, Saudi Arabia.

PATIENTS AND METHODS

All ED visits during the Islamic calendar years of 1431-1434 (December 18, 2009-October 13, 2013) were analyzed.

MAIN OUTCOME MEASURES

Patient volume, acuity, demographics and admission rate variability between Ramadan and other months.

RESULTS

During the study period of 4 years, of 226075 ED patients, 129178 (57.14%) patients were seen during the day shift (07:00 to 18:59). During Ramadan, 10 293 (60%) patients presented during the night shift compared with the day shift (P < .0001). This trend was seen consistently with no statistically significant differences in admissions 7%, triage acuity or when compared with other months.

CONCLUSION

During Ramadan, ED attendance changes as more patients present during the night shift. In Saudi Arabia and possibly other Muslim countries, appropriate resources should be allocated during Ramadan to manage the nocturnal ED patient surge.

LIMITATIONS

We believe that the majority of our patients fast, but it is not known how many ED patients were actually fasting during the study period. This study was conducted in a tertiary care hospital and the patient population presenting to our ed is predominantly Muslim; therefore, the results may not be generalized to populations that are not predominantly Muslim.

Cyclic vomiting syndrome versus inborn errors of metabolism: A review with clinical recommendations

BACKGROUND

Inborn errors of metabolism are on the differential for patients presenting with a cyclic vomiting syndrome phenotype. Classes of disorders to consider include: mitochondrial disorders, fatty acid oxidation disorders, urea cycle defects, organic acidurias, and acute intermittent porphyria.

AIM

This article reviews the metabolic differential diagnosis and approach to screening for inborn errors in children and adults presenting with a cyclic or recurrent vomiting phenotype.

CONCLUSION

Cyclic vomiting syndrome is thought to be an episodic syndrome that may be associated with migraine. It is a diagnosis of exclusion. Inborn errors of metabolism should be considered in the patient presenting with a recurrent vomiting phenotype. Mitochondrial dysfunction may play a role in cyclic vomiting syndrome, and true mitochondrial disorders can present with a true cyclic vomiting phenotype.

Dietary considerations in migraine management: does a consistent diet improve migraine?

The clinical expression of migraine is significantly impacted by dietary and gastrointestinal issues. This includes gut dysfunction during and between attacks, food triggers, increase in migraine with obesity, comorbid GI and systemic inflammation influenced by diet, and specific food allergies such as dairy and gluten. Practitioners often encourage migraineurs to seek consistency in their lifestyle behaviors, and environmental exposures, as a way of avoiding sudden changes that may precipitate attacks. However, rigorous evidence linking consistency of diet with improvement in migraine is very limited and is, at best, indirect, being based mainly on the consistency of avoiding suspected food triggers. A review of current data surrounding the issue of dietary consistency is presented from the perspective of migraine as an illness (vulnerable state), as a disease (symptom expression traits), and with a view toward the role of local and systemic inflammation in its genesis. Firm recommendations await further investigation.

Nighttime snacking, stress, and migraine activity

Missing meals and fasting have long been reported as headache triggers. Stress also has received attention for its role in precipitating headaches. This study explored the effects of eating behaviors on new-onset headache. Analyzing only the 1070 of 1648 (64.9%) diary days that followed a non-headache day, the study included 34 migraineurs who contributed a median (25th, 75th percentile) of 28 (22, 40) days of diary entries. Multivariable survival modeling with random effects was conducted, and hazards ratios and 95% confidence intervals were calculated. Nighttime snacking was associated with a 40% reduction in the odds of experiencing a headache compared to having no food (p=0.013). Eating a late dinner was associated with a 21% reduction in the odds of headache when compared to no additional food, but this association was not statistically significant (p=0. 22). These results demonstrate the potential for eating behaviors to be targeted in headache management, as regulated eating habits may have the potential to reduce the occurrence of headache. Although no causal relationship can be established, these results indicate that further research into the mechanisms of the association between eating behaviors and headache activity is warranted.

Prophylactic etoricoxib is effective in preventing "first of Ramadan" headache: a placebo-controlled double-blind and randomized trial of prophylactic etoricoxib for ritual fasting headache

BACKGROUND

Religious fasting is associated with headache. This has been documented as "Yom Kippur headache" and "first of Ramadan headache." Etoricoxib, a Cox-2 inhibitor with a 22-hour half-life, has been shown effective in preventing fasting headache when taken just prior to the 25-hour Yom Kippur fast. We hypothesized that etoricoxib would also be effective in preventing headache during Ramadan, despite the different characteristics of the fast.

METHODS

We performed a double-blind randomized prospective crossover trial of etoricoxib 90mg vs placebo, taken just prior to the onset of fasting, during the first 2 weeks of Ramadan 2010. Healthy adults aged 18-65 years were enrolled. Demographics, headache history and a daily post-fast survey were collected. We compared incidence, time of onset, and intensity of headache on each day and side effects in control and treatment groups.

RESULTS

We enrolled 222 patients and 189 completed the post-fast questionnaire (87%). Etoricoxib reduced the incidence of "first of Ramadan" headache by 54% (46% in placebo group [n=92] vs 21% [n=96] in etoricoxib group) (P<.0001, OR 3.19 [95% CI 1.68-6.06]). For days 1-6, the mean number of headache days for the placebo group was 1.60 (n=92) and for the treatment group the mean was 0.86 (n=99) headache days (P=.003). Median severity of headache in the treatment group was significantly lower. In the second week, there was no significant difference in incidence of headache between groups, and the incidence of headache in the placebo group dropped markedly over time.

CONCLUSION

Etoricoxib 90mg taken prior to a 15-hour ritual fast decreases incidence of and attenuates headache during the first 5 days of the month of Ramadan.