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Nutritional Neuroscience
An International Journal on Nutrition, Diet and Nervous System
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ynns20
Associations between diet quality, DASH and
Mediterranean dietary patterns and migraine
characteristics
Hande Bakırhan, Hilal Yıldıran & Tugba Uyar Cankay
To cite this article: Hande Bakırhan, Hilal Yıldıran & Tugba Uyar Cankay (2022) Associations
between diet quality, DASH and Mediterranean dietary patterns and migraine characteristics,
Nutritional Neuroscience, 25:11, 2324-2334, DOI: 10.1080/1028415X.2021.1963065
To link to this article: https://doi.org/10.1080/1028415X.2021.1963065
Published online: 11 Aug 2021.
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Associations between diet quality, DASH and Mediterranean dietary patterns
and migraine characteristics
Hande Bakırhan
a
, Hilal Yıldıran
b
and Tugba Uyar Cankay
c
a
Department of Nutrition and Dietetics, Faculty of Health Sciences, Istanbul Medipol University, Istanbul, Turkey;
b
Department of Nutrition
and Dietetics, Faculty of Health Sciences, Gazi University, Ankara, Turkey;
c
Department of Neurology, Faculty of Medicine, Recep Tayyip
Erdogan University, Rize, Turkey
ABSTRACT
Objectives/background: This study was conducted to describe the dietary patterns and diet
quality and to examine the correlation between diet quality, dietary patterns (Mediterranean or
DASH) and migraine attributes.
Methods: Individuals between the ages of 18–64 who applied to the headache outpatient clinic
and were diagnosed with episodic migraine were evaluated by a neurologist. Healthy Eating
Index-2010 was used to determine the diet quality. Dietary Approaches to Stop Hypertension
compliance scale and Mediterranean Diet Adherence Screener were used to describe the dietary
patterns.
Results: It was found that individuals with a low Mediterranean Diet Adherence Screener score had
more severe disability and more severe and frequent attacks (p< 0.05). In addition, a significant
negative correlation was found between Mediterranean Diet Adherence Screener score and
attack severity (r=−0.733, p< 0.05). Individuals with a low Dietary Approaches to Stop
Hypertension compliance scale score had more severe and frequent attacks (p< 0.05). There
was a significant negative correlation between attack severity and Dietary Approaches to Stop
Hypertension compliance scale scores (r=−0.700, p< 0.001). Individuals with poor diet quality
had more severe migraine attacks compared to others (p< 0.05). A significant negative
correlation was found between diet quality total score and attack severity (r= 0.458, p< 0.05).
High diet quality scores and higher vegetables, fruits, legumes, and oil seeds subscores, DASH
and Mediterranean dietary patterns were associated with lower migraine attack severity (p< 0.05).
Conclusion: A nutritional approach that adopts the Mediterranean diet or involves a good diet
quality pattern can help alleviate the symptoms of individuals with migraine.
KEYWORDS
Migraine; diet quality;
Mediterranean diet; DASH;
migraine severity; disability;
headache
Introduction
Migraine is a neurological disorder characterized by
severe pain in the anterior, posterior, or nuchal regions
of the head, sometimes accompanied by autonomic,
vasomotor, and gastrointestinal symptoms, and is
affected by genetic and environmental factors [1].
There is a lack of definite information on the pathophy-
siology of migraine, although primary neuronal mech-
anisms and vascular changes are thought to be
effective [2]. A migraine headache attack occurs by
neuronal and vascular changes involving cortical
spreading depression, cortical excitability, and the trige-
minovascular system [3].
Nutritional factors are believed to have a neurological
impact since they lead to a number of neuronal changes.
Some foods are thought to cause pain with their effects
on neuronal shrinkage/dilation in the central nervous
system. Dietary factors have also been reported to
affect the clinical expression of migraine owing to
their role in systemic inflammation, vasodilation, and
the cerebral glucose metabolism [4,5]. Research has
revealed the correlation between migraine and nutri-
tion, examining food intake and many other dietary
components [6–9]. Food intake and diet quality have
been associated with the course of migraine. It is
known that certain food and nutritional components
may trigger migraine and that migraine characteristics
can be alleviated through healthy eating behaviors [4–
9]. Sensitive individuals may develop allergies to certain
foods, which in turn may trigger migraine attacks. Iden-
tifying and eliminating the triggering foods specificto
individuals from their diet is key in migraine manage-
ment [10].
Researchers believe that a healthy, balanced, and
regular diet could help reduce the severity and fre-
quency of migraine attacks [4–9]. Studies have reported
a negative correlation between chronic migraine and
diet quality, suggesting that increased diet quality
© 2021 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Hande Bakırhan handecekici@hotmail.com
NUTRITIONAL NEUROSCIENCE
2022, VOL. 25, NO. 11, 2324–2334
https://doi.org/10.1080/1028415X.2021.1963065
would be useful in managing migraine attacks [11].
Since nutritional status affects the clinical reflections
of migraine, determining the diet quality of these
patients and making individual dietary interventions
are crucial for treatment. There have been some studies
on food intake and various dietary components with
regards to migraine [4–6], yet there is no comprehensive
research that evaluates the correlation between dur-
ation, frequency, disability and severity of migraine
and dietary patterns/diet quality. This study was
planned to investigate the correlation between duration,
frequency, disability and severity of migraine and diet
quality and Dietary Approaches to Stop Hypertension
(DASH) and Mediterranean dietary patterns.
Methods
Sample selection
The sample included 80 individuals (16 males, 64
females) aged between 19–64 years, who were admitted
to the neurology outpatient clinic of a training and
research hospital in between February and October
2019 and were diagnosed with episodic migraine by
an experienced neurologist. Detailed physical and
neurological examinations of the patients were per-
formed in the headache out-patient unit. Migraine fre-
quency, duration, characteristics, episode forms,
coexisting symptoms were evaluated by an experienced
neurologist. The diagnosis of episodic migraine and
headache classification of the sample was made based
on the criteria of the International Classification of
Headache Disorders-3 beta version (ICHD-3). The
diagnostic criteria for episodic migraine include two
types of migraine without aura and with aura. Individ-
uals aged under 19 years or over 64 years, those with a
body mass index (BMI) of 40.0 kg/m
2
and above or
18.5 kg/m
2
and below, a history of cardiovascular dis-
ease, hypertension, diabetes, cancer, hepatic and renal
disease, or other neurological disorders (epilepsy, mul-
tiple sclerosis, stroke, traumatic brain injury), those
who evaluated as secondary headache, those who used
antilipidemic and glucose intolerance drugs or vita-
min-mineral supplements, those who followed a special
diet, and those consuming less than 800 kcal or more
than 4000 kcal per day were excluded [4]. Patient
recruitment flow chart according to inclusion and
exclusion criteria is given in Figure 1. The study proto-
col was approved by the Non-Interventional Clinical
Research Ethics Committee at Recep Tayyip Erdogan
University on 06.02.2019 with decision number 232.
General information on the characteristics of
patients
A questionnaire about sociodemographic characteristics
and health history (diseases, drugs used, etc.) was
applied to determine the basic characteristics of the
individuals with migraine in face-to-face interviews. A
headache diary form, which evaluates the symptoms,
characteristics, frequency, duration and severity of the
attacks of the last 3 months, was filled in by each patient
in a face-to-face interview under the supervision of the
neurologist. In order to evaluate the physical activity
levels of the participants, a two-question short physical
activity assessment tool was applied through face-to-
face interviews. The total score obtained from the two
questions was calculated and it was evaluated as insuffi-
ciently active if it was in the range of 0–3 points, and as
sufficiently active if it was ≥4 points [12].
Evaluating duration, frequency, disability and
severity of migraine
The Migraine Disability Assessment Scale (MIDAS),
which is widely used to determine the disabilities in
individuals with migraine was applied. This scale aims
to reveal the number of days lost due to migraine dis-
ability in the last three months. The total number of
days lost was calculated by asking questions to the
patients, and the level of disability due to headache
was evaluated. Accordingly, the degree of disability is
evaluated as level 1 (none or very little) for 0–5 days
lost, level 2 (mild loss) for 6–10 days lost, level 3 (mod-
erate loss) for 11–20 days lost, and level 4 (severe loss)
for ≥21 days lost [13]. The visual analogue scale
(VAS), a questionnaire used to define and follow-up
pain level during headache episodes, was used to deter-
mine migraine severity. The mean severity of headaches
in the last three months was questioned using the VAS
scale. Patients stated the mean severity score for
migraine headache attacks. Patients score their per-
ceived pain level between 1 (no pain) and 10 (most
severe). Pain was categorized as mild if patient response
was ≤3, moderate if 3–6, and severe if >6 [14]. Individ-
uals’migraine duration and frequency were determined
through a questionnaire.
Determining diet quality and DASH and
Mediterranean dietary patterns
To determine the current dietary patterns and diet quality
of the sample, the Healthy Eating Index-2010 (HEI-2010),
Mediterranean Diet Adherence Screener (MEDAS), and
DASH adherence scale were applied by the researcher.
NUTRITIONAL NEUROSCIENCE 2325
Meditarrenean dietary pattern was rated as poor if
MEDAS score was ≤5, moderate if 6-9, and good if ≥10
[15]. DASH dietary pattern was considered low for a
total score of <4.5 and high for a score of ≥4.5 [16].
Diet quality was determined using three-day food intake
records taken from the individuals. How to fill in the
Figure 1. Patient recruitment flow chart.
2326 H. BAKıRHAN ET AL.
food intake forms was explained to the participants by the
researcher verbally and using visual materials (replicas,
food catalogs) and food intake records were taken for
threeconsecutivedays,oneofwhichwasontheweekend.
The intake of energy and nutrients was calculated using a
Nutrition Information Systems (Beslenme Bilgi Sistemi-
BeBiS) which is a food software program in compliance
with Turkish food was used for assessment nutrients,
food and food groups. The dietary quality of the partici-
pants was evaluated based on the data from the food
intake records using the HEI-2010. A total score of ≤50
was described as ‘poor diet quality’,scoresof51–80 con-
sidered ‘diet quality that needs to be improved’and scores
of >80 indicated ‘good diet quality’[17,18].
Statistical analysis
The data obtained here were statistically analyzed using
the SPSS Statistics 23.0 software. Quantitative variables
are expressed as mean and standard deviation and
min–max values and categorical data are given as
interpretations by frequency and percentage values.
The normality of the continuous variables in the differ-
ent population samples was assessed by the normality
test, as well as by the Shapiro–Wilk tests. MIDAS and
VAS scores were converted into categorical variables
by using the cut-offpoint of similar studies in the litera-
ture [13,14]todefine the disability and pain level in the
sample. The Kruskal–Wallis-H test was used for mul-
tiple comparisons and the Mann–Whitney U test was
used to compare two groups. The cross tables made
for frequency comparisons were examined using the
Chi-squared test. Spearman’s correlation was used to
obtain statistical correlations from continuous data.
All analyses were interpreted at a 95% confidence level.
Results
The research was completed with 80 participants who
met the inclusion criteria and did not meet any of the
exclusion criteria. There was no participant who was
excluded due to a lack of response or follow-up. Of
the individuals in the sample, 20.0% (n= 16) were
male and 80.0% (n= 64) were female, with a mean age
of 34.0 ± 9.02 and 35.7 ± 9.72 years, respectively. Most
of the patients (86.2%) were physically inactive and
there was no statistically significant relationship
between gender in terms of physical activity levels (p
> 0.05). Information on the migraine courses of the
individuals is given in Table 1. Mean duration of
migraine attacks was 22.1 ± 21.11 h, with no significant
difference between males and females. 43.7% of the
males and 50.0% of the females experienced severe
disability. However, there was no significant difference
between the genders in terms of disability degrees and
MIDAS score (p> 0.05). Migraine attacks are severe in
81.3% of males and 56.2% of females. There was no sig-
nificant difference between genders in terms of the
degree of pain severity. Despite the lack of a significant
difference between sexes in terms of the degree of pain
severity, males had higher VAS scores compared to
females (8.0 ± 1.31 and 6.8 ± 2.00; p<0.05). In addition,
there was no significant difference between migraine
types (without aura and with aura) in terms of mean
MIDAS and VAS score, the degree of disability and
pain severity (p> 0.05).
Mediterranean and DASH dietary patterns and diet
quality of the sample are given in Table 2. When the
current dietary pattern was evaluated, 56.2% of the indi-
viduals had poor, 36.3% had moderate, and 7.5% had
good Meditarrenean dietary pattern. There was no stat-
istically significant difference between sexes and
migraine types in terms of the Mediterranean diet pat-
tern (p> 0.05). Mean total MEDAS score was 5.5 ±
2.33. Females had a significantly higher MEDAS score
compared to males (5.8 ± 2.32 and 4.5 ± 2.18, p< 0.05).
Considering DASH dietary pattern, 86.3% of the indi-
viduals had low score, with no statistically significant
difference between sexes (p> 0.05). Regarding the
Table 1. Characteristics of individuals with migraine.
Male
(n= 16)
Female
(n= 64)
Total
(n= 80)
n%n%n%χ
2
/ZP-value
Migraine type
With Aura 4 25.0 18 28.1 22 27.5
Without Aura 12 75.0 46 71.9 58 72.5 0.063 0.802
Attack frequency
1–2 times a
week
12 75.0 49 76.6 61 76.2
1–2 times a
month
4 25.0 15 23.4 19 23.8 0.017 0.895
Attack duration (hour)
0–12 11 68.8 29 45.3 40 50.0
12–24 3 18.7 18 28.1 21 26.3 2.901 0.234
24–72 2 12.5 17 26.6 19 23.7
Mean ± SD 14.9 ± 18.2823.9 ± 21.5122.1 ± 21.11 −1.664 0.096
Use of migraine medication
No 14 87.5 50 78.1 64 80.0
Yes 2 12.5 14 21.9 16 20.0 0.516 0.111
Migraine disability (MIDAS)
None or very
little
3 18.8 6 9.4 9 11.2
Mild loss 4 25.0 14 21.8 18 22.5
Moderate loss 2 12.5 12 18.8 14 17.5 1.444 0.695
Severe loss 7 43.7 32 50.0 39 48.8
Migraine disability (MIDAS) score
Mean ± SD 19.5 ± 20.7825.9 ± 21.7824.5 ± 21.61 −1.222 0.222
Attack severity (VAS)
Mild –– 6 9.4 6 7.5
Moderate 3 18.7 22 34.4 25 31.2 3.806 0.149
Severe 13 81.3 36 56.2 49 61.3
Attack severity (VAS) score
Mean ± SD 8.0 ± 1.31 6.8 ± 2.00 7.1 ± 1.92 −2.147 0.032*
Note: Chi square and Mann–Whitney U test, *p< 0.05.
NUTRITIONAL NEUROSCIENCE 2327
types of migraine, it was found that individuals with
migraine without aura had higher DASH score than
those with migraine with aura (p< 0.05). Mean DASH
total score was 2.4 ±1.39. There was no statistically sig-
nificant difference between sexes or migraine types in
terms of DASH total scores and subscores (p> 0.05).
When evaluated in terms of diet quality, 57.5% of the
individuals with migraine had poor diet quality, 41.3%
had diet quality that needs to be improved, and only
1.2% had good diet quality. There was no significant
difference between sexes or migraine types in terms of
diet quality according to HEI-2010 (p> 0.05). Mean
HEI-2010 total score was 49.3 ± 15.54, with no signifi-
cant difference between sexes (p> 0.05).
Individuals’frequency and severity of the migraine
based on Mediterranean and DASH dietary patterns
and diet quality are given in Table 3. Individuals with
poor Mediterranean diet pattern experienced more
severe migraine attacks than those with moderate or
good (8.2 ± 1.13, 6.0 ± 1.59, and 3.8 ± 1.47, respectively,
p< 0.05) and females with poor Mediterranean diet pat-
tern experienced more severe migraine attacks com-
pared to other females with moderate or good (8.2 ±
1.12, 5.9 ± 1.60, and 3.4 ± 1.14, respectively, p< 0.05).
Among individuals with migraine with aura, those
with poor Mediterranean diet pattern were found to
experience more severe migraine attacks compared to
those with moderate or good (8.7 ± 1.28, 6.1 ± 1.72,
and 4.0 ± 1.41, respectively, p< 0.05). Similarly, among
individuals with migraine without aura, those with
poor Mediterranean diet pattern had more severe
migraine attacks than those with moderate or good
(8.1 ± 1.02, 6.0 ± 1.58, and 3.7 ± 1.70, respectively, p<
0.05). Regarding clinical migraine characteristics based
on the DASH dietary pattern, females with low DASH
score experienced more severe migraine attacks than
other females with high DASH score (7.3 ± 1.69 and
4.3 ± 1.49, respectively, p< 0.05). Considering migraine
types, among individuals with migraine without aura,
those with low DASH score had more severe migraine
attacks than those with high DASH score (7.6 ± 1.32
and 4.4 ± 1.50, respectively, p< 0.05). Overall, it has
been found that individuals with high DASH score
experienced less severe migraine attacks compared to
those with low DASH score (7.5 ± 1.63 and 4.4 ± 1.50,
respectively, p< 0.05).
Based on diet quality according to the HEI-2010,
there was a significant difference between diet quality
levels only in terms of attack severity (p< 0.05). Overall,
individuals with poor diet quality experienced more
severe migraine attacks compared to those with good
diet quality (VAS scores: 7.6 ± 1.49, 6.4 ± 2.26, and 5.0
± 0.0, respectively, p< 0.05). Also, females with poor
diet quality experienced more severe attacks than
other females with diet quality that needs to be
improved or good diet quality (VAS scores: 7.4 ± 1.56,
6.3 ± 2.30, and 5.0 ± 0.0, respectively, p< 0.05). Focusing
on migraine types, among patients with migraine with-
out aura, those with poor diet quality had more severe
attacks than those with diet quality that needs to be
improved (VAS scores: 7.7 ± 1.32 and 5.7 ± 1.97,
respectively, p< 0.05; Table 3).
Table 2. Diet quality and adherence to the Mediterranean diet and DASH in individuals with migraine.
Male
(n= 16)
Female
(n= 64)
Total
(n= 80)
With Aura
(n= 22)
Without
aura
(n= 58)
n%n%n%n%n%
MEDAS
Adherence level p/χ
2
p/χ
2
Poor 13 81.3 32 50.0 45 56.2 12 54.5 33 56.9
Moderate 2 12.5 27 42.2 29 36.3 0.068/5.276 8 36.4 21 36.2 0.118/0.943
Good 1 6.2 5 7.8 6 7.5 2 9.1 4 6.9
Adherence score p/Z p/Z
Mean ± SD 4.5 ± 2.18 5.8 ± 2.32 5.5 ± 2.33 0.027*/−2.210 5.7 ± 2.58 5.5 ± 2.25 0.671/−0.424
DASH
Adherence level p/χ
2
p/χ
2
Low 15 93.8 54 84.4 69 86.3 22 100.0 47 81.0
High 1 6.2 10 15.6 11 13.7 0.330/0.949 ––11 19.0 0.028*/4.838
Adherence score p/Z p/Z
Mean ± SD 2.3 ± 1.10 2.4 ± 1.46 2.4 ± 1.39 0.999/0 2.3 ± 1.08 2.4 ± 1.50 0.920/−0.103
Diet Quality (HEI-2010)
Adherence level p/χ
2
p/χ
2
Poor 12 75.0 34 53.1 46 57.5 9 40.9 37 63.8
Needs to be improved 4 25.0 29 45.3 33 41.3 0.273/2.596 12 54.5 21 36.2 0.068/5.389
Good –– 1 1.6 1 1.2 1 4.5 ––
Quality score p/Z p/Z
Mean ± SD 44.4 ± 10.14 50.5 ± 16.46 49.3 ± 15.54 0.142/−1.467 54.2 ± 15.33 47.4 ± 15.34 0.106/−1.616
Note: Chi square and Mann–Whitney U test, *p< 0.05.
2328 H. BAKıRHAN ET AL.
The correlation between DASH and Mediterranean
diet patterns, diet quality and migraine findings are
given in Table 4. Mediterranean diet was found to
be associated with lower attack severity (r=−0.733,
p= 0.001). Considering the subscores, intake of
olive oil (r=−0.307, p= 0.006), vegetables (r=−0.395,
p= 0.001), fruits (r=−0.503, p= 0.001), butter/margar-
ine/cream (r=−0.230, p= 0.04), sweet/carbonated
drinks (r=−0.304, p= 0.006), legumes (r=−0.363,
p= 0.001), non-homemade desserts (r=−0.320,
p= 0.004), hazelnuts–pistachios–almonds–walnuts
(r=−0.453, p= 0.001), and olive oil/tomato/tomato
paste/onion/garlic sauces (r=−0.465, p=0.001) was
significantly negatively correlated with VAS scores.
Regarding the frequency of migraine attacks, a signifi-
cant positive correlation was found between olive oil
(the most used oil) and attack frequency (r= 0.245,
p<0.05).
Table 3. Duration, disability and severity of migraine according to the diet quality/diet adherence.
MIDAS score
Mean ± SD
VAS score
Mean ± SD
Duration
Mean ± SD
Adherence to the Mediterranean diet
Female Poor 27.5 ± 8.21 8.2 ± 1.12 22.1 ± 18.54
Moderate 25.2 ± 20.17 5.9 ± 1.60 28.3 ± 25.27
Good 16.8 ± 15.00 3.4 ± 1.14 11.8 ± 11.27
P-value/χ
2
0.524/1.292 0.001*/37.107 0.355/2.073
Male Poor 25.8 ± 21.78 6.8 ± 2.00 23.9 ± 21.51
Moderate 14.5 ± 10.60 7.0 ± 1.41 5.0 ± 0.00
Good 2.00 ± 0.00 6.0 ± 0.00 24.0 ± 0.00
P-value/χ
2
0.469/1.516 0.143/3.897 0.478/1.476
With aura Poor 28.6 ± 26.03 8.7 ± 1.28 21.1 ± 19.31
Moderate 38.1 ± 24.70 6.1 ± 1.72 35.1 ± 28.26
Good 15.0 ± 12.72 4.0 ± 1.41 12.5 ± 16.26
P-value/χ
2
0.293/2.453 0.003*/11.798 0.262/2.682
Without aura Poor 25.0 ± 22.78 8.1 ± 1.02 19.9 ± 19.06
Moderate 19.2 ± 15.13 6.0 ± 1.58 23.5 ± 23.73
Good 14.0 ± 17.51 3.7 ± 1.70 14.5 ± 11.00
P-value/χ
2
0.451/1.591 0.001*/30.330 0.916/0.175
Total Poor 26.0 ± 23.44 8.2 ± 1.13 20.2 ± 18.92
Moderate 24.4 ± 19.73 6.0 ± 1.59 26.7 ± 25.09
Good 14.3 ± 14.71 3.8 ± 1.47 13.8 ± 11.25
P-value/χ
2
0.371/1.984 0.001*/ 42.889 0.587/1.065
Adherence to the DASH
Female Low 27.4 ± 22.55 7.3 ± 1.69 23.8 ± 21.48
High 16.9 ± 14.96 4.3 ± 1.49 24.2 ± 22.85
P-value/Z 0.129/−1.518 0.001*/−4.301 0.933/−0.084
Male Low 20.7 ± 20.96 8.1 ± 1.24 14.3 ± 18.76
High 2.0 ± 0.00 6.0 ± 0.00 24.0 ± 0.00
P-value/Z 0.230/−1.199 0.129/−1.516 0.324/−0.986
With aura** Low 30.8 ± 24.75 7.3 ± 2.17 25.4 ± 23.15
Without aura Low 23.7 ± 20.85 7.6 ± 1.32 20.1 ± 20.19
High 15.5 ± 14.88 4.4 ± 1.50 24.2 ± 21.67
P-value/Z 0.187/−1.321 0.001*/ −4.834 0.601/−0.523
Total Low 26.0 ± 22.24 7.5 ± 1.63 21.8 ± 21.16
High 15.5 ± 14.88 4.4 ± 1.50 24.2 ± 21.67
P-value/Z 0.096/−1.664 0.001*/−4.623 0.74/−0.332
Diet quality
Female Poor 23.8 ± 23.06 7.4 ± 1.56 19.1 ± 19.18
Needs to be improved 27.6 ± 20.66 6.3 ± 2.30 27.8 ± 21.94
Good 39.0 ± 0.00 5.0 ± 0.00 72.0 ± 0.00
P-value/χ
2
0.429/1.694 0.028*/7.127 0.064/5.488
Male*** Poor 15.6 ± 11.36 8.1 ± 1.24 16.0 ± 20.7
Needs to be improved 31.2 ± 38.00 7.7 ± 1.70 11.7 ± 8.7
P-value/χ
2
0.503/0.449 0.557/0.344 0.540/0.375
With aura Poor 33.0 ± 27.77 7.1 ± 2.08 19.6 ± 19.79
Needs to be improved 28.5 ± 24.36 7.7 ± 2.26 25.9 ± 22.68
Good 39.00 ± 0.00 5.0 ± 0.00 72.0 ± 0.00
P-value/χ
2
0.650/0.862 0.356/2.064 0.159/3.681
Without aura*** Poor 19.0 ± 18.24 7.7 ± 1.32 18.0 ± 19.58
Needs to be improved 27.8 ± 22.14 5.7 ± 1.97 25.9 ± 21.17
P-value/χ
2
0.134/2.2246 0.001*/15.549 0.089/2.886
Total Poor 21.7 ± 20.85 7.6 ± 1.49 18.3 ± 19.41
Needs to be improved 28.1 ± 22.59 6.4 ± 2.26 25.9 ± 21.37
Good 39.0 ± 0.00 5.0 ± 0.0 72.0 ± 0.00
P-value/χ
2
0.241/2.846 0.013* 0.056/6.163
Notes: Kruskal–Wallis and Mann–Whitney U test, *p< 0.05. ** There are no individuals with high compliance. *** There are no individuals with good diet
quality.
NUTRITIONAL NEUROSCIENCE 2329
Higher DASH score was found to be associated with
lower severity (VAS score) and higher frequency of
migraine attacks (r=−0.700, p=0.001, r=0.308, p=
0.005, respectively). For DASH subscores, intake of
grains (r=−0.261, p= 0.001), vegetables (r=−0.598,
p= 0.001), fruits (r=−0.462, p= 0.001), low-fat dairy
products (r=−0.356, p= 0.001), low-fat meat products
(r=−0.287, p= 0.01), legumes and oil seeds (r=
−0.267, p=0.017), and oil–fat scores (r=−0.572, p=
0.001) was significantly negatively correlated with VAS
scores. Focusing on disability, there was a positive signifi-
cant correlation between MIDAS scores and low-fat meat
product intake (r=0.227,p=0.043).Therewasalsoasig-
nificant positive correlation between attack frequency
and low-fat dairy product intake (r=0.356,p=0.001).
Considering diet quality, good diet quality (HEI-2010
score) was found to be associated with low attack sever-
ity (VAS) (r=−0.458, p= 0.001). Focusing on the sub-
scores, intake of fruits (r=−0.440, p= 0.001), whole
fruits (r=−0.396, p= 0.001), vegetables (r=−0.392,
p=0.001), dark green leafy vegetables and legumes
(r=−0.345, p= 0.002), proteins (r=−0.263, p= 0.018),
and empty calories (r=−0.223, p= 0.047) was found
to be significantly negatively correlated with VAS
scores. Examining other migraine characteristics, no
significant correlation was found between diet quality
and migraine attack frequency, migraine attack dur-
ation, or disability (p> 0.05). However, attack frequency
was positively associated with DASH score (r= 0.308,
p= 0.005). There was also a significant negative corre-
lation between attack severity and MEDAS score (r=
−0.733, p= 0.001), DASH score (r=−0.700, p= 0.001),
and HEI-2010 score (r=−0.458, p= 0.001). The data
suggest that a high MEDAS score is associated with a
more significantly lower attack severity than other
scores (r=−0.733, p= 0.001). The significance of corre-
lations can be ranked as Mediterranean diet > DASH >
HEI-2010.
Discussion
Evaluating the correlation between the
Mediterranean diet pattern and duration,
frequency, disability and severity of migraine
There is limited epidemiological research that docu-
ments the differences between individuals with migraine
and healthy individuals in terms of their diet quality,
macronutrient intake, nutritional program regularity,
or various nutritional measures like certain foods [19].
The underlying mechanism for the association between
healthy eating patterns and alleviating migraine course
Table 4. Correlation between diet quality, adherence to the DASH and Mediterranean diet and duration, frequency, disability and
severity of migraine.
MIDAS score VAS score Duration Frequency
rP-value rP-value rP-value rP-value
MEDAS score −0.059 0.602 −0.733 0.001* 0.071 0.532 0.191 0.093
Subscores
Olive oil (the most used oil) −0.141 0.211 −0.205 0.068 0.009 0.934 0.245 0.028*
Daily use of olive oil −0.185 0.101 −0.307 0.006* 0.030 0.790 0.204 0.070
Daily consumption of vegetables 0.099 0.384 −0.395 0.001* 0.074 0.513 0.196 0.081
Daily consumption of fruits −0.048 0.674 −0.503 0.001* 0.043 0.707 0.183 0.105
Daily consumption of butter/margarine −0.197 0.079 −0.230 0.041* −0.090 0.426 0.133 0.240
Daily consumption of sweet/carbonated drinks −0.123 0.276 −0.304 0.006* 0.132 0.241 0.104 0.357
Weekly legumes consumption 0.168 0.137 −0.363 0.001* −0.109 0.338 −0.059 0.601
Weekly non-homemade dessert or pastry products consumption 0.057 0.613 −0.320 0.004* 0.191 0.089 0.173 0.124
Weekly hazelnuts/ peanuts/ almonds/walnuts consumption −0.056 0.620 −0.453 0.001* −0.009 0.943 0.145 0.200
Consuming olive oil/ tomato/ tomato paste/onions/garlic sauces 0.009 0.938 −0.465 0.001* 0.082 0.467 0.007 0.952
DASH score −0.050 0.635 −0.700 0.001* 0.068 0.551 0.308 0.005*
Subscores
Grains −0.010 0.945 −0.261 0.001* 0.143 0.206 0.184 0.102
Vegetables −0.190 0.094 −0.598 0.001* 0.027 0.813 0.207 0.065
Fruits −0.060 0.585 −0.462 0.001* −0.037 0.744 0.212 0.059
Low-fat dairy products −0.090 0.443 −0.356 0.001* −0.072 0.527 0.356 0.001*
Low-fat meat products 0.227 0.043* −0.287 0.012* 0.069 0.545 −0.680 0.546
Legumes and oil seeds −0.150 0.194 −0.267 0.017* −0.055 0.629 0.213 0.057
Oil/fat −0.160 0.168 −0.572 0.001* 0.166 0.140 0.115 0.311
HEI-2010 score 0.071 0.534 −0.458 0.001* 0.127 0.263 0.082 0.468
Subscores
Total fruits −0.110 0.337 −0.440 0.001* 0.159 0.158 0.092 0.483
Whole fruits −0.070 0.565 −0.396 0.001* 0.180 0.110 0.080 0.483
Total vegetables 0.060 0.598 −0.392 0.001* −0.012 0.917 −0.065 0.565
Dark green leafy vegetables and legumes 0.109 0.377 −0.345 0.002* −0.016 0.890 0.011 0.923
Total protein foods −0.010 0.172 −0.263 0.018* 0.017 0.882 0.181 0.108
Empty calories 0.039 0.734 −0.223 0.047* 0.049 0.664 0.070 0.540
Notes: Spearman correlation test, *p< 0.05. The statistically significant subcomponents were included.
2330 H. BAKıRHAN ET AL.
has been suggested to be related to a decrease in inflam-
mation by improving diet quality [20]. The Mediterra-
nean diet is thought to be effective for preventing
diseases such as obesity, diabetes, cardiovascular dis-
eases, Alzheimer’s disease, and cancer, besides alleviat-
ing pain thanks to its significant antioxidant activity,
along with its unsaturated fatty acid, fiber, and low
energy content [21]. The actual impact of the Mediter-
ranean diet on headaches and migraine symptoms
remains unknown, however, and needs further investi-
gation. In this study, Mediterranean dietary pattern in
the sample was poor (56.2%, 36.3%, and 7.5%) and
females had higher MEDAS scores than males (mean
scores: 5.8 ± 2.32 and 4.5 ± 2.18, p< 0.05) (Table 2). Fur-
thermore, it was also found that all individuals with a
low MEDAS score experience more severe attacks (8.2
± 1.13), all individuals with a high MEDAS score had
less severe attacks (3.8 ± 1.47), females with a low
MEDAS score experienced more severe attacks, and
females with a higher MEDAS score had less severe
attacks (p< 0.05) (Table 3). On the basis of migraine
characteristics, those with low MEDAS score had more
severe disability and more severe and frequent attacks
than those with moderate or good score (Table 3).
Examining the correlation between the Mediterra-
nean diet and migraine characteristics, only attack
severity (VAS) and MEDAS score were found to be sig-
nificantly correlated (Table 4). There was a significant
negative correlation between MEDAS scores and attack
severity (VAS) (r=−0.733, p< 0.05). Accordingly, a
high MEDAS score is associated with lower attack sever-
ity (Table 4). Considering the subscores of the Mediter-
ranean diet, intake of olive oil, vegetables, fruits,
legumes, butter/margarine/cream, sweet/carbonated
drinks, non-homemade dessert or pastry products,
hazelnuts/peanuts/almonds/walnuts, and olive oil/
tomato/tomato paste/onions/garlic sauces were nega-
tively correlated with attack severity (r= 0.307, r=
0.395, r= 0.503, r= 0.363, r= 0.230, r= 0.304, r= 0.32,
r= 0.453, r= 0.465, respectively) (VAS) (Table 4). The
correlation between the Mediterranean diet and
migraine characteristics may be associated with its sig-
nificant antioxidant, unsaturated fatty acid, and fiber
content. High antioxidant content can help reduce oxi-
dative stress, preventing the trigger of migraine attacks
or alleviating their symptoms. Again, with its high unsa-
turated fatty acid content, it can reduce pain stimulation
by preventing neuroinflammation or the excessive
release of inflammatory mediators. The findings
obtained in this study suggest that increasing the daily
intake of vegetables, fruits and olive oil, and weekly
intake of legumes and oil seeds and decreasing the
intake of olive oil/tomato/tomato paste/onion/garlic
sauces and sweet/carbonated drinks, butter/margarine/
cream, and non-homemade dessert/pastry products
may reduce the severity of migraine attacks.
Evaluating the correlation between the DASH
diet pattern and duration, frequency, disability
and severity of migraine
DASH diet pattern may be useful in the management of
migraine with its high cardioprotective [22], systemic
inflammatory therapeutic [23], and anti-migraine
effects [24]. The decreased sodium intake, which is
included in DASH recommendations, has been reported
to be associated with a significantly lower risk of head-
aches [25,26]. Similarly, Gazerani reported in a review
study that the DASH can reduce the intensity and dur-
ation of headache in migraine [27]. One recent study
has associated the DASH model with lower attack sever-
ity and duration in migraine patients, indicating that
those with higher adherence to this model had lower
severe (46%) and moderate headaches (36%) compared
to those with lower adherence, with a significant nega-
tive correlation between DASH adherence and attack
duration [4]. In this study, it was found that individuals
with migraine had a low DASH score (86.3%, n= 69)
and that those with migraine with aura had lower adher-
ence compared to those with migraine without aura
(Table 2). In terms of migraine characteristics, those
with low DASH score experienced more severe and fre-
quent attacks compared to those with high adherence
(p< 0.005, Table 3). Considering the correlation
between DASH and migraine characteristics, there was
a significant negative correlation between attack severity
and DASH score (r=−0.700, p< 0.05) and a significant
positive correlation between attack frequency and
DASH score (r= 0.308, p< 0.05) (Table 4). A higher
DASH score is therefore associated with lower severity
and more frequency in migraine attacks (r=−0.700
and r=0.308, respectively, p< 0.05). There was also a
significant negative correlation between the intake of
grains, vegetables, fruits, low-fat dairy products, low-
fat meat products, legumes and oil seeds, oil/fat and
attack severity (r=−0.261, r=−0.598, r=−0.462, r=
−0.356, r=−0.287, r=−0.267, r=−0.572, respectively)
(Table 4). When evaluated in terms of disability, a posi-
tive correlation was found between MIDAS scores and
low-fat meat product intake (r= 0.227, p< 0.05).
Besides, there was a positive correlation between attack
frequency and low-fat dairy product intake (r= 0.356, p
< 0.05) (Table 4). The findings obtained in this study
suggest that DASH diet pattern is associated with low
attack severity, indicating that intake of whole grains,
vegetables, fruits, low-fat dairy products, low-fat meat
NUTRITIONAL NEUROSCIENCE 2331
products, legumes, and oil seeds can help alleviate attack
severity. This impact can be associated with the anti-
vasodilator and therapeutic effects of DASH as a natural
consequence of its sodium restriction and rich active
ingredient content. Using DASH for migraine treatment
may be of particular use to reduce attack severity. Still,
the complete picture regarding the correlation between
migraine and DASH should be revealed through further
research.
Evaluating the correlation between diet quality
and duration, frequency, disability and severity
of migraine
Research on the impact of food intake, various dietary
components, and diet quality on migraine have reported
that food intake and diet quality affect migraine charac-
teristics [4–6,8,9]. It is thought that certain nutritional
components may affect the duration of migraine attacks
and increase pain severity. Also, it has been suggested
that individuals with migraine who have healthy eating
behaviors may experience milder migraine symptoms
[4,6]. Addressing diet during migraine treatment can
improve the general health status of individuals suffer-
ing from migraine [6]. This highlights the importance
of having a good diet quality. It has been found that
individuals with migraine have low diet quality, which
has been significantly associated with migraine [6,11].
A research on the correlation between the diet quality
and migraine status of women diagnosed with severe
headache or migraine between the ages of 20–50 years
(n= 3069) reports that women with normal body weight
and no migraine had higher diet quality scores com-
pared to those with migraine (HEI-2005 scores: 52.5 ±
0.9 and 45.9 ± 1.0, p< 0.05) [6]. Similarly, another
study emphasized the importance of diet quality by stat-
ing that diet quality in normal weight women without
migraine may be significantly higher than in normal
weight women with migraine [28]. Another study
reveals that individuals with migraine (n= 285) had a
diet quality that needs to be improved (mean HEI-
2015 score: 57.2 ± 7.98). Hajjarzadeh et al. report that
in women with migraine (n= 285), there was a signifi-
cant negative correlation between chronic migraine
and HEI-2015 scores (p< 0.05) [11]. Costa et al. report
that Brazilian Healthy Eating Index-Revised scores were
negatively correlated with attack severity, regardless of
nutritional status or body weight change [20]. Investi-
gating the impact of personalized diets (90 days) on
migraine severity, it was found that the migraine sever-
ity scores of individuals were significantly lower at the
end of dietary intervention compared to baseline
(63.5 ± 8.4 and 57.9 ± 9.8, respectively, p< 0.05) [20].
Parallel to previous research, individuals had a low
mean diet quality (poor: 57.5%, needs to be improved:
41.3%, good: 1.2%; mean score: 49.3 ± 15.54), which
should be improved (Table 2). Individuals with poor
diet quality had more severe attacks than those with
good diet quality or diet quality that needs to be
improved (5.0 ± 0.00, 7.6 ± 1.49, and 6.4 ± 2.26, respect-
ively) (Table 3).
It has been suggested that healthy eating behaviors
could help alleviate migraine symptoms [4–9]. Simi-
larly, in this study; a negative correlation was found
between VAS and the HEI-2010 scores (r=−0.458, p
< 0.05, Table 4). The findings obtained in this study
suggest that increasing the intake of vegetables, fruits,
legumes, and proteins and decreasing the intake of
empty calories (alcohol, added sugar, fat) reduce attack
severity, indicating that good diet quality is associated
with lower attack severity (Table 4). In an intervention
study found that adherence to the Healthy Eating
Plate advice is useful in migraine management, reducing
migraine frequency and disability [29]. Besides, dietary
diversity may also be important in migraine character-
istics. In a study evaluating dietary diversity, the dietary
diversity score was found to be inversely related to
migraine disability, pain severity, and headache fre-
quency [30]. Poor diet quality can increase the severity
of migraine attacks, while a diet quality that needs to
be improved or good diet quality can reduce it. This
may be due to the fact that a good quality diet contains
all the nutrient components necessary for the normal
maintenance of neuronal activities. Healthy eating
behaviors and having a good diet quality are thought
to have an alleviating impact on pain transmission path-
ways through various mechanisms. Managing diet qual-
ity can be a good strategy to improve the progression of
migraine, regardless of nutritional status or weight
change [20]. In addition, the relationship between diet
and migraine is not unidirectional, and research needs
to explore not only the effects of diet on migraine but
also the physiological mechanisms of migraine [31].
While the correlation between diet quality and migraine
is a relevant issue, there is still limited research on the
matter. Thus, this correlation needs to be researched
further. Also, evaluating the diet quality of individuals
with migraine is important for relieving/preventing
their symptoms.
Conclusion
Individuals with low Mediterranean diet and DASH
score, and poorer diet quality were found to have
more severe disability and more severe and frequent
migraine attacks compared to others. Since the
2332 H. BAKıRHAN ET AL.
Mediterranean diet is associated with a lower migraine
attack severity, it can be a helpful strategy for alleviating
attack severity and correcting the negative clinical course
of migraine. Again, the preference of the DASH model, a
dietary intervention that adopts the intake of whole
grains, vegetables, fruits, low-fat dairy products, low-fat
meat products, legumes, and oil seeds, may be preferable
for its association with milder attack severity. The associ-
ation between having a gooddiet quality and milder clini-
cal signs of migraine emphasizes the significance of diet
quality in the medical nutritional treatment of migraine.
The common point between having a good diet quality
and adoption of the Mediterranean diet and DASH points
to the correlation of the intake of vegetables, fruits,
legumes, and oil seeds with lower migraine attack sever-
ity. When evaluated in terms of disability, there is no sig-
nificant correlation between diet quality, diet patterns and
disability. Since the Mediterranean diet is associated with
asignificantly lower attack severity, adopting this diet and
strengthening diet quality can result in positive changes
for alleviating symptoms and alternative approaches for
episodic and prophylactic treatment modalities of
migraine. As this research was carried out to determine
the correlation between diet quality/DASH and Mediter-
ranean diet patterns and duration, frequency, disability
and severity of migraine, it does not contain any interven-
tion. The limitation of this study is that it does not inves-
tigate the direct effect of diet quality/ DASH and
Mediterranean diet patterns on migraine prognosis.
Another limitation of this study is the limited number
of patients and the evaluation of only episodic migraine
patients. The patient’s assessment subjectively depends
on the perception of pain and patient’s degree of memory.
However, the strength of the current study stems from the
significance of informing future researchers, guiding the
dietary approaches to be recommended for migraine,
and clarifying the relationship between diet quality/diet-
ary patterns and duration, frequency, disability and sever-
ity of migraine for the first time. Since the literature
includes limited research on diet quality/interventions
in individuals with migraine, planning further studies
involving various dietary interventions specificto
migraine can be beneficial by revealing the relationship
between migraine and nutrition.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The data that support the findings of this study are available
on request from the corresponding author, B.H. The data
are not publicly available due to [restrictions e.g. their con-
taining information that could compromise the privacy of
research participants].
Notes on contributors
Hande Bakırhan is an Assistant Professor at the Department
of Nutrition and Dietetics, Faculty of Health Sciences, Istan-
bul Medipol University, Istanbul, Turkey. Her research inter-
est is to carry out various studies in the field of nutrition and
dietetics and investigate the association between diet and
diseases.
Hilal Yıldıran is a Professor at the Department of Nutrition
and Dietetics, Faculty of Health Sciences, Gazi University,
Ankara, Turkey. Her research interest is to carry out various
studies in the field of nutrition and dietetics and investigate
the association between diet and diseases.
Tugba Uyar Cankay is a associated medical doctor at the
Department of Acute Stroke Center, Medeniyet University,
Faculty of Medicine, İstanbul. Her research interest is to
carry out various studies in the field of stroke, neuronutrition
and headache.
ORCID
Hande Bakırhan http://orcid.org/0000-0001-9377-888X
Hilal Yıldıran http://orcid.org/0000-0001-7956-5087
Tugba Uyar Cankay http://orcid.org/0000-0003-4718-2852
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