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Food Insecurity and Migraine Are Linked in Young Adults
How to Address This Association With Patients

Article In Brief

In a research letter, investigators reported that young adults who lack reliable access to affordable, nutritious food had a significantly higher chance of being diagnosed with migraine. The study suggests that food insecurity leads to psychological stress, missed meals, and poor diet habits, which can trigger migraine.

Young adults who lack reliable access to affordable, nutritious food— considered food insecure—had a significantly higher chance of being diagnosed with migraine, according to a research letter published online in the June 24 edition of JAMA Neurology, though the direction of this risk could not be determined.

Diet and migraine have long been connected—and the association between lower household income and migraine prevalence has been established in previous research, but this is the first US population study to look specifically at food insecurity and migraine in young adults.

Using cross-sectional, national data, the researchers found that “one quarter of food-insecure young adults experienced migraine,” Jason Nagata, MD, MSc, assistant professor at the University of California San Francisco Benioff Children's Hospitals, told Neurology Today.

“Few studies have examined the association between food insecurity and neurologic outcomes. To our knowledge, prior research on food insecurity and migraine is limited to 1 cross-sectional study representative of the Canadian population 12 years or older, which found a positive association,” Dr. Nagata and colleagues wrote. “We confirm this finding in a nationally representative sample of young adults from the United States.”

“Given these new findings, clinicians should ask their patients about food insecurity using validated one or two-question screening questionnaires, such as those used in the JAMA Neurology paper, and provide referrals and resources for food-insecure patients,” Dr. Nagata said.

Study Findings

The authors used cross-sectional data from nearly 15,000 US young adults, between the ages of 24 and 32, included in the wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health. The mean age of participants was 28 years old, about half were women, and almost two-thirds of participants were non-Hispanic and white.

The authors measured food insecurity with a self-reported answer to the question: “In the past 12 months, was there a time when (you/your household were/was) worried whether food would run out before you would get money to buy more?” Migraine diagnosis was also based on self-reports.

Food insecurity was identified in 11 percent of the young adults in the study. Migraine was more frequently present in food-insecure young adults—23.9 percent vs 13.6 percent; p<.001—and young adults who were food insecure also had a greater odds ratio (OR) of migraine in both unadjusted (OR, 2.00; 95% CI, 1.68-2.38; p<.001) and adjusted (OR, 1.58; 95% CI, 1.30-1.95; p<.001) models.

Although this study included a large, nationally representative sample, due to its cross-sectional nature, the direction of causality could not be confirmed, Dr. Nagata noted. “Food insecurity can lead to psychological stress and poor diets including missed meals and frequent hunger, which can trigger migraine,” he added.

On the other hand, “migraine may also contribute to food insecurity. Migraine may lead to lower productivity and attendance at work, and subsequent lost wages. People who experience migraine may not be able to perform household activities such as shopping or cooking,” Dr. Nagata told Neurology Today. Another limitation of the research, he said, was the fact that data were from 2008 and did not distinguish between episodic and chronic migraine.

“Programs such as the Supplemental Nutritional Assistance Program (SNAP, or the former Food Stamp Program) could be important resources for these patients,” he said.

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“Given these new findings, clinicians should ask their patients about food insecurity using validated one or two-question screening questionnaires, such as those used in the JAMA Neurology paper, and provide referrals and resources for food-insecure patients.”—DR. JASON NAGATA

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“Importantly, this article helps to raise awareness about food insecurity among individuals with migraine. This means more physicians will talk to their patients about problems they may be having related to food insecurity and suggest resources, such as SNAP or other local assistance programs.”—DR. PAMELA M. RIST

Moving forward, Dr. Nagata plans to study other health consequences, such as mental health and chronic disease, from food insecurity in young adult populations.

“Future clinical research could develop interventions to address food insecurity and examine if this prevents migraine,” he added.

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“This study shows a large effect size in the impact of food insecurity on migraine at a population level. Hence, future studies can base their sample size and study power estimations on these results.”—DR. YOHANNES W. WOLDEAMANUEL

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“We should be assessing the healthy eating patterns for most of our patients to ensure they have the fruits, vegetables, and proteins needed on a daily basis. The American Academy of Pediatrics has a great paper on food insecurity in children, including recommendations for screening and available resources.”—DR. JENNIFER BICKEL

Expert Commentary

Experts not involved with the report agreed that it took an important step in addressing the connection between food insecurity and migraine in patients—an association that has not been sufficiently studied to date.

The large sample size, population-based design, and the fact that the authors adjusted for potential confounders while measuring association between food insecurity and migraine are all strengths of the study, said Yohannes W. Woldeamanuel, MD, instructor in the department of neurology and neurological sciences and senior fellow at the Center for Innovation in Global Health at the Stanford University School of Medicine.

Jennifer Bickel, MD, FAAN, chief of the headache section and associate professor of pediatrics at Children's Mercy Kansas City/University of Missouri-Kansas City School of Medicine, said: “While association does not equal causation, it makes physiological sense that a poor diet could increase migraine frequency.”

Dr. Woldeamanuel added that study limitations include the self-reported nature of migraine diagnosis, which is known to be under diagnosed or misdiagnosed. “This is also inherent to the research being based from a secondary dataset and not primarily conducted to address the study question,” he said. “The statistical analysis did not include correction to multiple testing.”

Pamela M. Rist, ScD, associate epidemiologist at Brigham and Women's Hospital, noted that the lack of temporal information on the association was another limitation of the study. “This study was unable to determine if migraine leads to food insecurity or if food insecurity itself affects migraine frequency and severity,” she said.

The authors also could not examine whether certain individuals with migraine are at higher risk for food insecurity than others, Dr. Rist pointed out. “For example, it is unknown whether individuals with chronic migraine are at higher risk for food insecurity than individuals with episodic migraine.”

Previous studies have shown the increased prevalence of migraine in lower socioeconomic status populations, Dr. Woldeamanuel added, so this study corroborates those results. Skipped meals are a well-known trigger for migraine, he said, therefore “keeping consistent mealtimes is of paramount importance in the regular lifestyle behavior recommendations we provide patients, the other lifestyle domains being regular sleep and exercise.”

Importantly, this article helps to raise awareness about food insecurity among individuals with migraine, said Dr. Rist, which means more physicians will talk to their patients about problems they may be having related to food insecurity and suggest resources, such as SNAP or other local assistance programs.

Clinicians should incorporate assessments for food insecurity with their migraine patients and advise them about the importance of maintaining regular mealtimes involving adequate amounts of proteins whenever possible, agreed Dr. Woldeamanuel. “Migraine is the body's response to internal or external environmental changes, and avoiding glycemic fluctuations helps preempt migraine triggers.”

Dr. Bickel said she doesn't believe that clinicians are currently screening for food insecurity regularly enough. “We should be assessing the healthy eating patterns for most of our patients to ensure they have the fruits, vegetables, and proteins needed on a daily basis. The American Academy of Pediatrics has a great paper on food insecurity in children, including recommendations for screening and available resources.”

She suggested that adding two questions, adapted from a Pediatrics paper by Hager et al., when taking a patient's history “could prove incredibly helpful in better understanding the needs of the young adult: 1. Within the past 12 months, we worried whether our food would run out before we got money to buy more (Yes or No). 2. Within the past 12 months, the food we bought just didn't last and we didn't have money to get more (Yes or No).” An affirmative response to either one of these statements should encourage follow-up questions.

In her own clinical practice, in those situations where there are concerns, Dr. Bickel added, they are “fortunate enough to have a dedicated headache social worker who can assist in situations of family financial struggles.” Children's Mercy also offers free summer lunches to all kids to help address the food insecurity problems that intensify when school is out of session and kids don't have access to free school lunches.

In the future, Dr. Woldeamanuel said, researchers can design interventional studies with personalized mealtime protocols for migraine therapy using the results from this research letter.

“This study shows a large effect size in the impact of food insecurity on migraine at a population level. Hence, future studies can base their sample size and study power estimations on these results.”

Disclosures

Drs. Bickel, Nagata, Rist, and Woldeamanuel had no conflicts to report.

Link Up for More Information

• Nagata JM, Weiser SD, Gooding HC, et al. Research letter: Association between food insecurity and migraine among US young adults https://jamanetwork.com/journals/jamaneurology/article-abstract/2736340. JAMA Neurol 2019; Epub 2019 June 24.
    • Gitterman BA, Chilton LA, Cotton WH, et al; for the Council on Community Pediatrics, Committee on Nutrition. Promoting Food Security for All Children https://pediatrics.aappublications.org/content/136/5/e1431. Pediatrics 2015;136(5):e1431–438.
      • Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity https://pediatrics.aappublications.org/content/126/1/e26. Pediatrics 2010;126(1):e26–32.
        • Woldeamanuel YW, Cowan RP. The impact of regular lifestyle behavior in migraine: a prevalence case-referent study https://link.springer.com/article/10.1007/s00415-016-8031-5. J Neurol 2016;263(4):669–676.