What is causing the woman's headaches that occur every time she eats?

Headaches Triggered by Eating: Differential Diagnosis and Management

This patient requires immediate evaluation for food-triggered migraine, but you must first rule out serious secondary causes including idiopathic intracranial hypertension (IIH), which can present with headaches and requires urgent assessment to prevent permanent vision loss.

Initial Critical Assessment

Red Flag Symptoms to Evaluate Immediately

You need to specifically ask about and examine for the following warning signs that indicate serious pathology 1:

• Visual symptoms: Papilledema, transient visual obscurations, diplopia, or photophobia (suggests IIH) 2
• Neurologic deficits: Focal weakness, sensory changes, or coordination problems 1
• Headache pattern: Thunderclap onset, awakening from sleep, worsening with Valsalva maneuver, or rapidly increasing frequency 1, 3
• Associated symptoms: Pulsatile tinnitus, fever, neck stiffness, or altered consciousness 2, 3
• Age and progression: New onset after age 50 or progressively worsening pattern 3, 4

Physical Examination Priorities

Perform a focused neurologic examination looking for 1, 2:

• Fundoscopic exam for papilledema (if present, this is IIH until proven otherwise) 2
• Focal neurologic deficits or motor weakness 3
• Neck stiffness or meningeal signs 4

Diagnostic Pathway Based on Findings

If Red Flags Present or Papilledema Detected

Obtain urgent MRI brain with and without contrast immediately 2, 3. If papilledema is present, this requires:

• Lumbar puncture with opening pressure measurement 2
• Immediate ophthalmology referral for formal visual field testing 2
• Consider IIH as the primary diagnosis requiring urgent management 2

If Normal Neurologic Exam Without Red Flags

Proceed with detailed headache characterization to distinguish between primary headache disorders 1.

Primary Headache Disorders Triggered by Eating

Migraine Without Aura (Most Likely Diagnosis)

Diagnostic criteria require at least two of the following 1, 3:

• Unilateral location 1
• Throbbing/pulsating character 1, 4
• Moderate to severe intensity 1
• Worsening with routine activity 1

Plus at least one of 1:

• Nausea and/or vomiting 1
• Photophobia AND phonophobia 1

Duration: 4-72 hours untreated 4

Tension-Type Headache (Less Likely Given Eating Trigger)

Diagnostic criteria require at least two of 3:

• Bilateral location 3
• Pressing/tightening (non-pulsatile) character 3
• Mild to moderate intensity 3
• No aggravation with routine activity 3

Must have both 3:

• No nausea or vomiting (anorexia may be present) 3
• No photophobia AND phonophobia together (may have one or the other) 3

Food as Migraine Trigger: Evidence and Mechanism

Common Dietary Triggers

The following foods are most frequently reported as migraine triggers 5, 6, 7:

• Alcohol (especially red wine and beer) 5, 7
• Aged cheese (contains tyramine) 5, 6, 7
• Chocolate 5, 6, 7
• Caffeine (both consumption and withdrawal) 8, 7
• Food additives: Sodium nitrate, monosodium glutamate (MSG), aspartame 5, 7
• Citrus fruits, bananas, nuts 5
• Processed/cured meats (contain nitrates) 5, 7

Timing of Food-Triggered Headaches

Food triggers can precipitate headache within 1 hour or develop up to 12 hours post-ingestion 7. This temporal relationship is critical for identifying specific triggers 8, 6.

Fasting and Hypoglycemia

Fasting itself is a frequently reported migraine trigger 6, 7. Some patients develop reactive hypoglycemia due to diet-induced hyperinsulinism, which can precipitate attacks 6. Ask specifically about missed meals or prolonged fasting periods 1.

Treatment Algorithm

Acute Treatment for Food-Triggered Migraine

First-line therapy: Start with NSAIDs 1, 4:

• Naproxen 500-825 mg at onset 3
• Ibuprofen, diclofenac, or aspirin are alternatives 4
• Consider combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks 3

If inadequate response to NSAIDs alone, add a triptan 1:

• Combine triptan with NSAID for better efficacy 1, 4
• Options include sumatriptan, rizatriptan, eletriptan, or others based on patient preference and cost 1

For severe nausea/vomiting: Use nonoral triptan plus antiemetic 1

Critical Medication Overuse Warning

Limit acute treatment to no more than 2 days per week 3. Medication overuse headache develops with 1, 3:

• NSAIDs used ≥15 days per month for ≥3 months 1, 3
• Triptans used ≥10 days per month for ≥3 months 1, 3

Do not use opioids or butalbital for migraine treatment 1.

When to Consider Preventive Therapy

Initiate preventive medication if 1, 3:

• Headaches occur more than 2 times per week 1, 3
• Frequent attacks cause significant disability 3
• Patient requires acute medication too frequently (approaching overuse threshold) 1

First-line preventive options 3:

• Propranolol 80-160 mg daily 3
• Alternative options: Topiramate, antidepressants, or CGRP monoclonal antibodies 3

Dietary Management Strategy

Identification of Specific Triggers

Have the patient maintain a detailed food diary documenting 8, 6:

• All foods and beverages consumed 1
• Timing of consumption relative to headache onset 7
• Headache characteristics and severity 8

12-60% of migraine patients report dietary triggers, but specific triggers vary widely between individuals 8, 6. Identification requires systematic tracking rather than blanket elimination 6.

Lifestyle Modifications

Counsel the patient on the following evidence-based modifications 1:

• Maintain regular meals (avoid fasting/skipping meals) 1, 6
• Stay well hydrated 1
• Secure sufficient and consistent sleep 1
• Engage in regular moderate-to-intense aerobic exercise 1
• Manage stress with relaxation techniques or mindfulness 1

Dietary Interventions with Evidence

Consider comprehensive dietary approaches if simple trigger avoidance fails 9:

• Low-fat, high omega-3/low omega-6 fatty acid diet (demonstrated efficacy in randomized controlled trials) 9
• Folate supplementation may benefit patients with migraine with aura and specific genetic variants 9

Common Pitfalls to Avoid

Do not assume all eating-related headaches are benign migraine 2. Always screen for IIH, especially in women of childbearing age with obesity, as this can cause permanent vision loss if untreated 2.

Do not recommend broad elimination diets without evidence 6. Studies on IgE or IgG-mediated food hypersensitivity elimination diets show inconclusive results 6. Focus on patient-specific trigger identification through systematic tracking 8, 6.

Do not overlook medication overuse as a perpetuating factor 1, 3. Patients using acute medications too frequently may develop rebound headaches that complicate the clinical picture 1.

Begin acute treatment as soon as possible after headache onset 1. Early intervention with combination therapy (triptan plus NSAID) improves efficacy 1.