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After nearly 3-month closure; Larkspur Community Center could open April 1

BEND, Ore. (KTVZ) -- The Bend Park and Recreation District said Tuesday it will reopen the Juniper Swim & Fitness Center for the first time in nearly three months next Monday at 5:30 a.m., with advance registration offered and limited capacity to meet COVID-19 guidelines.

Fitness classes, lap swim and other activities will require advanced reservations for limited capacity activities allowed to occur within the newly announced High Risk framework for Deschutes County. Fitness center use will be available by reservation and for drop-in use as space allows.

Beginning Monday, 43 fitness and water fitness classes will be offered weekly, as well as lap swim, cycle on your own and fitness center access.

Patrons can register online beginning at noon on Thursday atwww.bendparksandrec.org/juniperreservations.

Capacity is reduced to ensure proper distancing in accordance with state requirements. Drop-in visitation will not be available for swim or fitness class sessions, but will be available for the fitness center or cycle on your own if space is available.

Juniper Swim & Fitness Center will have two separate entrances and areas, to increase safety for patrons and staff. All visitors must enter through the south side of the building located off NE Franklin Avenue and NE 7thStreet.

The facility closed Nov. 17 when a pre-Thanksgiving "freeze" was declared by Gov. Kate Brown.

We are pleased that the case counts in Deschutes County are at a level that the facility can reopen for community members who value the fitness and swim activities as part of their lifestyle, said Sue Glenn, recreation services manager. Our safety measures and reservation systems are in place to help make a smooth transition for those ready to return to in-person activities.

Hours will be:Monday to Thursday: 5:30 a.m. 6:30 p.m.Friday: 5:30 a.m. 4 p.m.Saturday and Sunday: 8 a.m. 1 p.m.

Group exercise rooms have floor markings to designate individual spaces and outdoor spaces will be used for some activities and classes when weather allows. One-way traffic flow patterns are established to minimize congestion and close contact.

Cleaning procedures include thorough cleaning nightly, as well as extensive sanitization efforts during open hours. In addition, air circulation systems have been re-programmed to circulate 100% outside air during all hours of operations.

A per-visit fee will be charged at the time of registration to reserve your spot. These fees are lower than regular drop-in rates and similar to the 10-visit pass rate. Payment is non-refundable. A credit will be issued if reservations are cancelled at least 24 hours in advance.

Fitness Center In-District Out-of-District

Adult $6.00 $7.20

Senior (60+) & Youth (13-18) $5.00 $6.00

Group Exercise Classes

Adult $7.00 $8.40

Senior (60+) & Youth (13-18) $6.00 $7.20

This per-session fee aims to provide equitable access to limited capacity opportunities for all community members and will be regularly evaluated as the public health situation evolves. The only passes that will be allowed with this reopening are Medicare Advantage passes for those who qualify for the insurance programs.

The online system can accept reservations up to seven days in advance for a day and time in the facility. Registration will remain open up until 15 minutes before the time of the scheduled activity for any available openings.

Some programs will not be immediately available upon reopening, including family and recreation swim, swim lessons and hot feature amenities, including the sauna, hot tub and steam room.

Bend Park and Recreation District is renovating the indoor pools and due to construction, the north entrance and adjacent spaces are closed during the project.

Hot features, family swim and recreation swim should become available with the completion of the indoor pool renovation, which is expected to be completed in time for the summer season.

A project to renovate the indoor pools was scheduled prior to the recent closure, and patience is much appreciated as these amenities are improved over the next few months. Class schedules have been adjusted to best offer a wide range of activities.We look forward to a future opening of the Larkspur Community Center to further develop our comprehensive fitness and swim offerings in two locations, added Glenn.

The Larkspur Community Center, home of the Bend Senior Center, may open as early as April 1, if Deschutes County continues to maintain or progress to less-restrictive levels in the statewide framework. Details and specific timelines will follow as soon as confirmed.

More information is available at:www.bendparksandrec.org/juniperreservations.

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BPRD to reopen Juniper Swim & Fitness Center on Monday, with many changes - KTVZ

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Changes in the health and fitness rocked the industry in 2020, prompting more consumers to buy home fitness equipment. The fitnessindustry,worth $94 billion in 2018, according to The International Health, Racquet & SportsclubAssociation, had to adapt and find a new reality.

That new reality now shows up in email newsletters and app downloads. The concept of at-home gyms began a few years ago with theintroduction of high-tech equipment like Peloton.Health and fitness app downloads rose47%in Q2 2020.

The top-grossing health & fitness category app worldwide forAugust 2020 was Strava, with more than $13.8 million in user spending -- 5.5 times its revenue inAugust 2019.

The fitness category typically performs strongly at the beginning of the New Year, but this year it outperformed even historical averages.

Many of our mostsuccessful fitness brands are leveraging email not just for prospecting, but for creating Identity graphs that help personalization on their own sites, said Kerel Cooper, CMO at LiveIntent.

Cooper said that nearly after a year in quarantine, people are accepting the reality that they need to buy fitness equipment rather than wait for gyms to re-open.

Brands that sell fitnessequipment and fitness programs are becoming more sophisticated both with their content and strategies, he said.

LiveIntents study on health and fitness brands, released Tuesday,analyzed dozens of campaigns running on its platform, which reaches 250 million logged-in people each month via its 2,500 brands and publisher partners.

In January, advertisers in the fitnesscategory saw click-and-impression volumes two times higher than in the previous six months. The click-through rate (CTR) for fitness advertisers was 45% higher than non-fitness advertisers on theplatform in January 2021.

Those using email to send newsletter experienced 15% higher CTR in January 2021, compared with the previous three months. Newsletters devoted to fitness saw 36%higher CTR versus the average newsletter on the platform in January 2021. The conversion rate for fitness newsletters was 7% higher than the average newsletter.

CTR for fitness advertisersreached 7% higher in Jan 2021 versus the year-ago month. CTRs for other advertisers fell 15% during the same time frame, but the conversion rates in both cases were lower this year versus lastyear.

The CTR for fitness newsletters in January 2021 rose 25% higher than January 2020.

When considering targeting options, weekends and Mondays are best for the fitnesssector.The CTRs and CCRs for fitness advertisers were the best on weekends and Mondays, about 20% higher than mid-week days like Tuesdays and Wednesdays.

Fitness newslettersperformed the best on Sundays and Mondays, with about 50% higher CTR and 16% higher CCR as compared to Tuesdays and Wednesdays, when they performed the worst.

Women responded most to fitnessads and content, with CTRs for fitness ads coming in 21% higher, compared with the CTR for men. The conversion rate was 12% higher for women compared to men. It makes sense that the CTRs for people 55years of age and older came in 70% higher than younger age groups, but their conversion rates were 50% lower than younger age groups.

The fitness newsletter CTRs for women and men were aboutthe same in January 2021. Women saw higher click and impression volumes overall. The CTRs for age groups 45 and older were about twice as high than the CTRs for younger age groups in January 2021.

Originally posted here:
Why Fitness Ad CTRs Rose 45% Higher Than Other Advertisers' 02/10/2021 - MediaPost Communications

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Global cardio fitness equipment market is set to witness a substantial CAGR in the forecast period of 2019- 2026. The report contains data of the base year 2018 and historic year 2017. Rising health consciousness and increasing gyms & fitness centers are the factor for the growth of this market.

A new versatile research report on Global Cardio fitness equipment Market Size, Share, Growth and Forecast 2021-2027 is aimed at promising a unique approach towards an industry assessment of the Cardio fitness equipment market covering the most important factors driving the growth of the industry. latest market research report contains an extensive analysis of micro and macroeconomic indicators affecting the development of the global market in the forecast period. The data which has been looked upon is done considering both, the existing top players and the upcoming competitors. Cardio fitness equipment Market 2021 research report presents key players or brands which include developments, product launches, joint ventures, mergers the industry thoroughly by considering several aspects. According to this market report, the global market is anticipated to observe a moderately higher growth rate during the forecast period.

Get a Sample Report + All Related Graphs & Charts: https://www.databridgemarketresearch.com/request-a-sample/?dbmr=global-cardio-equipment-market&SR

Competitive Analysis: Global cardio fitness equipment market

Few of the major competitors currently working in the global cardio equipment market are Amer Sports, Cosco (India) Limited, Nortus Fitness, Sunsai sports & fitness, Anson Sports, Technogym, Shandong Baodelong Fitness Co.,Ltd, BODYCRAFT, Precor Incorporated, Into Wellness., MANGOGYMEQUIPMENT.COM GUANGZHOU MANGO FITNESS CO.,LTD; Zest Fitness, Promaxima, Cybex International, Inc, TechFit, Kawachi Group. MATRIX FITNESS SOUTH AFRICA, SportsArt, http://www.johnsonfitness.com. Exigo, SAI Works, Rishi Industries, MCfitness among others.

Manners and channels driving the germination of mediation market are, with the progressing pace of anxiety and mental strain and narrowing ratio of concentration, customers are actively relying on the measures provided by the Cardio fitness equipment market. The up-and-coming tradition of thoughtful awareness is serving in inclination of organizations endeavoring mindfulness Cardio fitness equipment. The swelling predominance of subconscious health dysfunctions, such as mood complications and anxiety troubles, over multiple age assemblies are rising in an extensive shift to the Cardio fitness equipment market, during the forecast period of 2020 to 2027.

Some of the factors may act as the restrain for the Cardio fitness equipment market growth is dearth of familiarity among the people and low penetration of the Cardio fitness equipment market in the emerging economies. In coming future the heightening level of work and personal lifestresswill act as catalyst to maintain the equilibrium of market growth.

Key Factors Of Cardio fitness equipment Market Report:

Click to View Full Report TOC, figure and tables: https://www.databridgemarketresearch.com/toc/?dbmr=global-cardio-equipment-market&SR

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By Geographical Regions:-

What key benefits of knowledge does the Cardio fitness equipment statistical Coverage give?

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Cardio fitness equipment Market Study Based on Shares, Current Opportunities with Future Growth Scenario by 2027 | The Courier - The Courier

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Having already put himself through the physical fitness test used by the Russian armed forces to screen new recruits, YouTuber Brandon William sets his sights closer to home for his latest challenge. In a new video, he takes on the FBI fitness test without any prior training, and soon finds that, perhaps unsurprisingly, they're called special agents for a reason.

The test consists of five events, with no more than 5 minutes of rest between each round:

William starts with the situps, churning out 50 reps in the allotted minute, earning him 6 points on the test. His performance on the sprint, however, looks like it could put him in trouble: he finishes the 400 meters in 1:03, which he puts down to doing laps back and forth instead of running on an open track.

"I think I could have been a little bit faster in that," he says. "Every single time I have to stop and turn, it takes away all of the momentum." This leads to 2 points being deducted from his cumulative score.

The third round is a test of an individual's pushup max: William completes 55 reps, which adds 6 points to his score. "I wanted to pause and keep going, but you can't pause," he says.

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Round 4 is the 1.5-mile run, where a minimum time of 13 minutes is required in order to pass. William finishes in 12:29, which while technically a pass, does not add any points to his final score.

The final test is pullups to failure. William maxes out at 20 reps, earning him the highest possible score of 10 points in this event, bringing his total score to 20 points: a pass. "Honestly, I'm pretty happy about that," he says. "This test was not as hard as the Russian Army fitness one."

This content is created and maintained by a third party, and imported onto this page to help users provide their email addresses. You may be able to find more information about this and similar content at piano.io

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Watch This 'Average College Kid' Try the FBI Agent Fitness Test Without Practice - menshealth.com

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To say the building of the new Orem Fitness Center has been a process is a bit of an understatement.

Since 1979, the center has set a standard for recreation in Utah County, said Mayor Richard Brunst during a groundbreaking ceremony for the new facility in July of 2019. Today we take the next step in providing recreation opportunities. ... This project has been a work of many hands. We look forward to its opening in early 2021.

That much-anticipated opening is scheduled for March 20.

Karl Hirst, director of Parks and Recreation, is also excited for that day to arrive. Between COVID-19 and Hirst being called to serve as acting Police Chief for a good part of 2020, he can tell you that it has been a bit of a roller coaster.

At times its like, is anything happening? Hirst noted. Things are screaming now.

Hirst said hell call for a meeting because something is needed that day and construction cant wait. However, with all that buzz, much has been completed and Hirst said it is starting to look good.

Here is a rattled-off list of what Hirst said is done; gym floors, the playground, racquetball courts, boulder climbing walls, the incline walk up and the adult-sized slide back down, and the dance studio.

The disco lights in the spin room are up, Hirst said. And they are polishing all of the concrete floors, and the hot tub is in.

They have also added six pickleball courts in the gym.

Hirst said about 90% of the pools are done, but have remained open for high school competitions. They will close on March 1 for the finishing touches to be done including new paint so it will be fresh and new like the rest of the building, Hirst added.

Hirst said he had private reasons why he is excited to see the fitness center grow and be refurbished. His mother helped campaign for the first bond election to bring the fitness center to Orem with new and better swimming pools 40 years ago.

Hirst has three brothers and said every one of them met their spouse at Orem pools.

The cost of the building is about $29 million. The city has a bond for $22 million and had about $8 million saved up in the city coffers for the construction.

You dont get this opportunity as a city or a neighborhood very often, said Hirst of the new fitness center.

Private groups also have partnered with the city to make sure the fitness center gets built. It was announced at the groundbreaking the Woodbury Corporation had donated $1 million to the project.

This is one way we are showing our continual commitment to the city of Orem and its ongoing success, said Randy Woodbury, president and CEO of Woodbury Corp.

Hirst also gave a nod of gratitude to Method Studio, the facilitys architects, and to Big D Construction, the general contractors on the project. This is considered a fast track project and will take much effort to have it all completed by the projected opening date.

He said the third prong of the group is the Alpine School District with help from Mountain View High School.

Residents drive by the center out of curiosity, but Hirst said they wont have to wait much longer.

On March 17, tours will begin for the new facility. In the meantime, Hirst said there is a 20% sale on memberships from now through opening-day March 20.

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New-and-improved Orem Fitness Center sprinting toward completion - Daily Herald

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New outdoor space in downtown Phoenix features FilmBar, food trucks and fitness - AZFamily

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Back in 2014, questions were being asked about just how long then-37-year-old Tom Brady could carry on playing pro football and the quarterback wasnt happy. When I suck, Ill retire, he said. [But] I dont plan on sucking for a long time.

Nearly seven years on and Tom Brady will, on Sunday evening, attempt to break his own record as the oldest QB ever to win a Super Bowl when his Tampa Bay Buccaneers take on the reigning champs, the Kansas City Chiefs, on the Bucs home turf.

Suffice to say, Brady is one of a kind, a phenomenon who shows no sign of slowing down any time soon in a sport where longevity is rare. Thats why he landed a two-year, $50 million deal with Tampa last March, making it likely hell still be playing when hes 45.

Put simply, Brady is an obsessive a man with a plan and the determination (and money) to execute it, as John Burns, CEO of Bradys TB12 health and wellness organization, explains.

Toms sustained success over the past 20-plus years is a testament to his incredible drive and his meticulous approach to everything he does. Burns said. Its that mindset that allows him to keep going.

When Brady in 2002 won the first of his record six Super Bowls, George W. Bush was president, Justin Timberlake was still a member of NSYNC, and Chiefs MVP quarterback Patrick Mahomes was 6 years old.

But nearly two decades later, Brady is still there, doing what he does better than pretty much anyone else at a remarkable 43 years old.

Heres how he does it.

Its been said that trainer Alex Guerrero knows Tom Bradys body better than the QBs wife, Gisele Bndchen. As well as being his business partner in the TB12 health-and-wellness brand including a chain of fitness centers that they plan to expand across the US Guerrero has been described by Brady as his body engineer.

Hes micromanaged the athletes training schedule months and even years in advance.An average day will begin early with a pre-workout deep force massage session with Guerrero. It only lasts four minutes but targets 20 muscle groups for around 20 seconds each. It helps prepare Bradys body for an intense workout, beginning with 40 minutes of resistance bands, to make muscles more pliable, soft and resilient.

As the quarterback has aged, he works out less with weights, which could leave him prone to muscle tears. Now its all about planks, lunges and squats, followed by more pliability exercises, such as doing crunches with a vibrating roller beneath his back.

After, theres another massage, this time with the focus of flushing out the lactic acid that builds up during exercise, to help improve muscle recovery time.

During the NFL season, hell work out with teammates in the afternoon. Off season, he might get in some surfing. Theres also another pliability session, to improve muscle recovery time, before bed.

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While theres no denying that Bradys spartan diet has played a major part in prolonging his playing career, some of his former New England Patriots teammates thought it obsessive and unappetizing or as one put it, that birdseed st.

Caffeine is off the table. So is white flour, white sugar, dairy products and anything with gluten. He steers clear of veggies tomatoes, eggplants, peppers, mushrooms that could cause inflammation. Everything has to be organic. Brady each day tries to drink a couple of hundred ounces of water, usually enhanced with electrolytes. (He sells those, along with various nutritional supplements, through his TB12 site.)

Allen Campbell was Bradys personal chef from 2013 to 2016 and helped him to create the TB12 Nutrition Manual, published in 2017. He told The Post that, at this time of year, We focused on dark leafy greens, some grass-fed animal protein as well as legumes and whole grains.

But thats not what Brady will eat before the Super Bowl. His game-day meals are even more basic: a smoothie and a sandwich of almond butter and jelly.

Its all a far cry from his rookie season in 2000; Brady admitted that his pregame snack used to be nachos while his default lunch was ham-and-cheese subs with onion rings and a large orange soda.

So does he ever cheat on his diet now?

If Im craving bacon, I have a piece, he told Mens Health last year. Same goes for pizza. Whats changed as Ive gotten older is now if I want pizza, I want the best pizza, Brady added. I dont eat a slice that tastes like shit and then wonder, Why am I eating st pizza?

Tom talks often of his love for a good burger and dark chocolate, Campbell told The Post. Specifically, the QB has said hes into Unreal Chocolate, a brand of vegan, gluten-free, low-sugar candies.

Brady sticks to an 80/20 (plant-based/animal protein) diet. Even his favorite ice cream is plant-based, made from avocado with a little cacao mixed in so it tastes like chocolate.

Besides having worked with a life coach in the past, Brady practices transcendental meditation, striving to become what Guerrero has described as emotionally stable and spiritually nourished.

Hes also had neuroscans so he can better understand the way his brain processes information and create strategies to improve that.

Brady exercises his brain using apps such as BrainHQ. Although the app was designed to help those with brain conditions such as cognitive damage or memory loss, Brady has used it to sharpen his reactions working his way through two dozen brain games or more each day.

Tom explained it like this, said Henry Mahncke, CEO of the apps creators, Posit Science. When he gets the [ball], he remembers the play, then he has to scan the field, locate the receivers, figure out which ones are on their routes and which are open, and make the pass. All in about three seconds.

Brady loves sleeping. Before his first Super Bowl in 2002, he even took a nap in the locker room only to be woken up with just 12 minutes left before the Patriots were due on the field.

These days, he hits the hay at 8:30 each night and wakes at 5:30 a.m. But everything has to be right. From sleeping on a mattress with a layer of diamond memory foam to setting the bedroom thermostat to between 60 and 65 degrees and shutting down all digital distractions at least 30 minutes before he retires, Brady is as obsessive about sleep as he is about, well, everything else in his life.

And then theres his magic pajamas: bioceramic-infused sleepwear made by Under Armourto increase energy, promote recovery and improve performance. And you can, too, can sleep like Tom, although a complete set will set you back nearly $200.

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Everything we know about Tom Brady's extreme diet and fitness routines - New York Post

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By Averee Dovsek |February 5, 2021 1:00 pm

Have you ever been in a crunch to make your tee time? You begin to rush and you begin to pray to the golf gods that your group will allow you a breakfast ball because you didnt have time to hit the range?

We have all been there and know the wave of panic that comes over you before you tee off. In the latest episode of, Fitness with Averee, Averee Dovsek demonstrates how to utilize a warm up technique that will only take a couple of minutes and will save you strokes.

Combine what you learn through Fitness with Averee withSteve Scotts instruction seriesand you will be a different golfer on and off the course.

Watch this episode of Fitness with Averee above andcheck here for previous episodes.

Golfweeks latest newsletter, Get Better which covers everything Instruction and Fitness related, is up and running.Sign up for Get Better here.

Averee, Fitness, Golf Fitness, Video, videos, Instruction, Videos

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Fitness with Averee: The two iron warm-up - usatoday.com

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When was the last time you tried a new diet and felt great, got to eat what you loved, and successfully lost weight? It may have never happened. Most diets leave you feeling hungry, deprived and then when you inevitably "cheat" and eat satisfying food, you end up defeated.

Yet it is possible to fill up on healthy, satisfying foods, have energy, and successfully lose weight, according to nutrition expert Nicole Osinga, a Registered Dietician who created The VegStart Diet as a way of helpingyou lose weight the healthy way, while still eating what you love, and filling up on plant-based meals and snacks that are so full of healthy ingredients, energizing antioxidants and filling fiber, that you never feel deprived, hungry or sluggish, and you lose weight in a sustainable way that makes it easy to keep it off.

Last week,we hosted Osinga on Facebook Live to discuss the health benefits of a plant-based diet, weight loss, and everything you need to know about our most popular meal plan,The VegStart Diet.

Osinga, a well-known nutritionist, created healthy, filling, low-calorie recipesfor the VegStartDiet, which are designed to help you lose weight while eating the foods you love, like pasta and bread, comfort food like soup, and even tasty sweet or crunchy snacks. The recipes are delicious, as confirmed by the 1.2million TikTok viewers who loved the Roasted Carrot and White Bean Soup. Osingadoesn't believe in extreme dieting andconsiders The VegStart a "sustainable weight loss program," so there's no worry of going hungry.

The program also includes a full meal plan with breakfast, lunch, and dinner, and snacks for Monday through Sunday,helpful shopping lists, and expert tips, plus a supportive community group, and live videos with Osinga so you can ask her one-on-one questions.

Aside from the diet questions, Osinga speaks the truth about the importance ofindulgences like wine, chocolate, and desserts. She shared her go-to cheat meals, how totreat yourself the healthy way, plus the tastiest plant-based proteins, and the most useful ingredients that everyone should have on hand. If this is your first approach to a plant-baseddiet or you started eating plant-based a while back, when meat alternatives weren't around, you probably have a lot of questions. Here are the top questions about weight loss and plant-based dieting,explained and answered by Nicole Osinga.

Nicole Osinga RD:I don't believe in extremes. I believe in sustainable changes. I have a lot of conversations with people today about this topic. If we're looking to lose weight, The VegStart diet program is designed for weight loss but certainly, everyone's individual needs are different. The diet focuses on sustainable weight loss that is still going to keep you feeling satisfied and meet your nutrition needs because we don't want to become nutrient deficient when we're sort of trying to follow something.There's definitely a lifestyle change aspect to the diet if you're not plant-based already.

Nicole Osinga RD:It's a great evidence-based way of eating that has been shown to reduce the risk of various conditions like cardiovascular diseases, and a number of cancers. I'm working part-time at the hospital in the cancer care clinics. So, I deal with people often who have various diagnoses and Irecommend those patients eatplant-based foods.

Nicole Osinga RD:It might be overwhelming to find different ways to cook those plant-based proteins and how to incorporate them into your family's meals, but find those proteins you like and focus on incorporating them into your diet.

Nicole Osinga RD: Probably my favorite is tempeh, followed by tofu which is a big one, and edamame...I love the ease of cooking it like typically I buy it frozen. I might just thaw it or put it in like a stir fry.

Nicole Osinga RD: I'd have to say basil and oregano. Those are definitely my go-to spices. I also love paprika, cumin, and cinnamon. I certainly have a sweet tooth so I like to add cinnamon into my overnight oats. I like the smoky flavors of cumin and paprika on my tempeh.

Nicole Osinga RD: I take a B12 supplement and an iron supplement. I mean, just because you follow a plant-based doesn't mean you're going to be low in iron, but I'm a runner as well. I'm a female of childbearing age. So, I'm sort of at a higher risk for iron deficiency. But you can also get the B12 from nutritional yeast and plant-based milk instead of taking a supplement.Sometimes I will takea plant-based omega-3 supplement, but again, you can get omega-3s in flaxseeds, chia seeds, and walnuts. The bottom line is, you certainly don't have to supplement, you can get enough nutrients through food but those are just ones I take for extra assurance.

Nicole Osinga RD: Whenever we're enjoying desserts, I call them fun meals. They sure don't have a ton of nutrients as our other meals do, but whenever we're enjoying them, eat them without guilt because if we have guilt we won't have acceptance then that's when it turns into you eating the whole bag of chips or chocolates. When we feel good about eating something we're likely to acknowledge it quicker. I normally say to aim for 90% regular meals and 10% fun meals. It's ok to have three fun meals per week, and the rest should be healthy meals. Definitely leave some room for un!

Nicole Osinga RD: The biggest thing you want to do is to feel sated. Of course, you want to meet those nutrient needs because we're not going to hit those long-term weight loss goals if we're feeling deprived. Whatever changes you're going to make, just make sure you can sustain them. I see so many people in my practice that are yo-yo dieters give up. That cycle is going to continue if we do things that are so, so restrictive. I saw someone yesterday in my practice who was eating one meal a day, just, that's it. That system worked for them, but, for most people, that's not going to besustainable.

Nicole Osinga RD: Not necessarily. If you're eating a whole food plant-based diet, you're eating beans and tofu for protein, and tofu costs $1 or $2 for a block, and you can get beans for less than a dollar. If you live in a warmer climate you obviously have better access to fresh produce all year round, but it's okay if to use frozen produce like I do because I live in Canada. I think it's cheaper to eat plant-based and it's a great way to save money.

Nicole Osinga RD: Just keep going. The best part is, you can keep mixing those recipes into your day-to-day routine anduse those lessons and tips you learned from TheVegStart diet. If you started meal prepping and planning, keep going with that. The calorie level of the diet is around 1,400 a day and if that works for you, continue doing that buy you can always make modifications to the recipes. I would recommend making more plant-based meals. The Beetposts new recipes every day so you know where you can get them. Try to make a plant-based diet part of your lifestyle.

Nicole Osinga RD:Personally, when I first went plant-based, about 10 years ago or so, I had a slow transition but it only took a month after eating this way to feel a noticeable difference.

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Introduction

Interest in headache1 is potentially as old as recorded human history. With all the advancements in understanding and management of headaches over the years, headache in general has remained a major complaint for which patients feel an urge for a medical consult. Costs related to headaches are high and are classified as direct (medical care) and indirect costs (loss of productivity). Therefore, if headaches can be diagnosed correctly and earlier, and if they can be managed properly, the burden to patients and societies will be dramatically reduced.

Based on the latest version of the headache classification, migraine is a form of primary headaches,2 ranked among the most disabling medical conditions.3 Number four of the Trndelag Health Survey (HUNT4 study) revealed that 18.1% of the studied population had active migraine.4 Migraine is characterized by headache attacks and associated symptoms presented in a multiphasic nature,5 where both peripheral nervous system and central nervous systems are considered involved.5,6 The recurrent nature of migraine and the fact that it can be triggered,7 have provided a key feature to explore internal and external triggers and through those, to study the mechanisms underlying the disorder. This phenomenon has also presented a unique opportunity to modify triggering factorsthose that can be modifiedto reduce intensity of migraine and how often it occurs. This concept is attractive, as it has been found that lifestyle factors,8 such as diet,9 can trigger migraine, and lifestyle modifications,10 for example diet modifications, and nutraceutical interventions11 have collectively shown beneficial effects in patients with migraine. Considering these options is important, because despite remarkable advancement in understanding of the pathogenesis of migraine and targeting migraine by the novel therapeutic options,6 challenges remain related to sufficient efficacy, and desirable safety, and the fact that nonresponders are present.12 In addition, a number of individuals with migraine are continuously searching for natural and device- or drug-free interventions outside of the typical therapeutic options. In this line, functional medicine approach to manage migraine has been proposed as a potential tool. This approach considers individual's genetic, biochemical, and lifestyle factors to construct plans for personalized treatment. Functional medicine consists of timeline, matrix, and the therapeutic lifestyle factors (for example, sleep, exercise, diet, and stress). Within this framework, functional food can also be defined for migraine. Generally, a food is defined functional if it is satisfactorily demonstrated to affect beneficially one or more target functions in the body, beyond adequate nutritional effects in a way that is relevant either to an improved state of health and well-being and/or reduction of risk of disease.13 Functional food has been tested to identify if it can exert beneficial effects for several diseases, for example for metabolic syndrome.14 This syndrome consists of several metabolic disorders (eg, high levels of fasting glucose and obesity) and enhances the risks of other diseases, for example stroke, diabetes, and cardiovascular diseases.14 Interestingly, migraine has also been recognized as a disorder related to metabolic imbalance, and that highlights a potential for functional food for migraine.15 William Amery in 1982, provided the first evidence that the metabolism is linked to the pathogenesis of migraine.16 Recent studies investigating metabolic alterations in migraine have proposed that a mismatch seems to exist between brain energy sources and the consumption of the sources,17 and have linked this energy deficit to mitochondrial dysfunction in migraine.18 It is hypothesized that energy-reserve deficit alone or combined with an overload of sensory input could activate the trigeminovascular system in the cascade of pathophysiological events in migraine.18 Based on this, a metabolic treatment of migraine has been proposed.17,19

While identification of dietary triggers and dietary interventions for migraine prevention are profound in the literature, the concept of dietary choices, and pattern of diet in migraine patients have been investigated less.20,21 The idea that mechanisms underlying migraine pathogenesis might influence dietary choices is valuable, but has sporadically been discussed.20,21 Epidemiological findings have demonstrated that choice of diet by individuals with migraine is different compared with individuals without migraine. Potential reasons for such difference have been explained by several factors, for example, contribution of neurotransmitters such as serotonin and orexin, hormones, and state of aura.21 A potential bidirectional relationship (Figure 1), where migraine influences food intake, and consumed food affects the manifestations of migraine, needs further investigation. Within this framework, investigation of the gutbrain axis contribution seems highly valuable.21

Figure 1 A potential bidirectional relationship between migraine and diet.

In the following sections, some examples from the current literature are presented to highlight what we already know about the effects of diet on migraine and the effects of migraine on dietary choices, and what remains unknown to stimulate further research. Therefore, the purpose of this targeted review is not to provide a comprehensive systematic review of the current literature on the role of diet in migraine; since several excellent reviews are already available (eg,9,2226). PubMed, Cochrane Library, EMBASE, and Web of Science databases were searched for studies using keywords of diet, migraine, food, and lifestyle with the aim of providing the current overview, and a viewpoint to the potential future directions. The ultimate goal is to form testable scientific hypotheses for future investigation of the bidirectional relationship of migraine and diet.

Studies that have investigated whether and how the consumption of dietary components can influence the manifestations of migraine are abundant. The potential role of dietary triggers, contribution of the immune system, metabolic systems, and the gutbrain axis contribution are among the examples focused on the effect of diet on migraine. The other direction, where migraine might also influence the food intake, has been less investigated. Presence of aura,2729 some neurotransmitters involved in pathogenesis of migraine (eg, serotonin,30,31 and orexin32), hormones (eg insulin33), and level of adiocytokines34 have been proposed to influence the choice of diet by affected individuals in terms of content, pattern, and amount of food intake.21 Several familiar and unknown factors can potentially influence this bidirectional relationship. These include, but are not limited to, gender, age, and geographical locations.9,24,3537

A large number and diverse range of factors (eg, dietary factors) with a high degree of heterogeneity have been reported capable of triggering migraine.38 For example, stress has been shown to exacerbate migraine, and having or expecting a migraine can negatively affect stress level of affected individuals. Menstrual migraine is a typical example of the link between hormones and migraine. Sleep and migraine have also been found interrelated where sleep disturbances aggravate migraine. Other environmental factors such as intense light, strong odors and high altitude have also been reported to influence migraine.39 Consequently, long lists of recommendations exist for avoiding potential triggers or coping strategies in order to prevent migraine or subsiding its frequency and severity; hence, enhancing the quality of life in affected patients.40

A meta-analysis of available studies for headache triggers has summarized data from 27,122 participants from 85 articles published between 1958 and 2015, and has provided 420 triggers.41 86% of the included participants in this meta-analysis had the minimum of one trigger for their headaches. Findings from this study highlighted that stress was the most prevalent trigger.41 Heterogeneity, however, was high and intra- and interindividual variations among trigger frequency and potency were also profound.41 Knowledge of migraine triggers can help in improving the management, coping, and care for migraine; but studying migraine triggers is not challenge-free. Using smartphone-based dairy studies that use ecological momentary assessment systems, has presented fatigue, sensory sensitivity, negative affect, specific foods, menstruation, and yawning as the most frequent triggers of migraine.4244 Correct understanding of trigger perception has been discussed by Turner et al45 to highlight how important are the behavioral changes in response to a headache trigger that is perceived by patients as a precipitating factor. An example is the avoidance of bright light if the individual with migraine perceives it as a migraine trigger. This controlling avoidance behavior may influence the scope of individual activities, and can negatively influence the quality of life.40,46,47 Perhaps that is why coping strategies are prioritized to avoidance strategies, in general.47

Collectively, the current ultimate recommendation for individuals with migraine has pointed to the value of maintaining an appropriate and healthy lifestyle.48 Lifestyle can be defined as the controlled behavior and activities of a person and many activities, habits, and practices involve risk factors. The contribution of dietary factors within the lifestyle modification has been recognized; however, proposed beneficial changes in lifestyle, consider a broader spectrum to not only include dietary aspects, but also monitoring of exercise, sleep, and stress.49

It has been proposed that modification of lifestyle might prevent migraine, which in turn would decrease the burden to individual patients, and health-related costs.50 However, due to the complexity of migraine, as a multidimensional disorder, and also the complexity of designing studies to test how dietary factors can influence migraine,49 inconsistency exists in the literature, ranging from a limited importance of dietary modification for migraine to some promising effects. Cross-sectional studies have been important in providing an overview of potential triggers;51 however, if the goal is to prove (or falsify) that a causal or a bidirectional relationship exists in the dietmigraine interaction, prospective studies with proper control groups must be designed that are also longitudinal in nature. For example, age of onset is extremely important.51 A migraine patient passes through different phases in an age span, from pediatric to geriatric migraines, for example. Puberty has been shown linked with migraine and migraine that occurs before puberty differs from post-puberty migraine. Several factors such as alteration in lifestyle, habits, and hormonal levels have been proposed to shape this evolution from pre- to post-puberty. A recent study52 has investigated this evolution in a selected pre-pubertal patients who were diagnosed with migraine. Researchers in this study collected medical records, migraine manifestations, and lifestyle-related factors, at baseline and at the two-year follow-up. Nineteen patients (migraine with aura: 27.5%) were recruited. The results of this study demonstrated that migraine accompanying symptoms changed with a significantly higher prevalence of dizziness, vertigo, mood changes, confusion, and allodynia.52 Prodromal symptoms became more prevalent, where sleep disturbances and schedule changes showed a significant increase as migraine triggers. Interestingly, at baseline, food was triggered at 11% of cases, but after two years, it went down to zero. Another study on the participants aged above 16, has also identified the appearance of new triggers over time. For example, new factors, including pain in neck, consumption of alcohol, hormonal changes, and smoking were notified.53 These studies provide valuable information that migraine triggers show changes during puberty, and new triggers can appear together with changes in habits along with physical and lifestyle changes, which collectively highlight attention to a potential dynamic pathological process that deserves further investigation. These studies also present a valuable point that besides studying dietary factors other daily lifestyle features, for example how a patient sleeps, makes a workrest balance, and deals with stressful situations are important to observe and note, because these factors are often interrelated and can influence each other directly or through indirect interactions. Comorbid conditions, such as other neurological, psychological, or cardiovascular disorders are also important and influential, because patients, influenced by those conditions, might follow a special lifestyle, including certain diets.1 For example, those who are diabetic or have a heart disease may follow a vegan diet for its beneficial effects,54,55 and some migraine patients might be on a vegan diet for comorbidy or other reasons.

A systematic review from 202022 has summarized the findings from 43 studies that have investigated and reported dietary patterns (11 studies), triggers (20 studies), and dietary interventions (12 studies) in patients with migraine.22 Level of evidence was determined as low level, because the authors identified that >50% of the studies were cross-sectional or patient surveys. Caffeine and alcohol were found as major triggers that could increase migraine frequency.22 Several dietary interventions were also reviewed, for example, elimination diets, low-fat diet, and ketogenic diet that presented promising results in managing migraine.22 However, this review did not present a choice or a favorable, so-called migraine diet, due to lack of qualified and sufficient information.

Elimination diets can be based on a diary for identification of triggers, or based on tests for the IgG-positive food, both strategies to limit those triggers. When participants were tested for antibodies against 266 foods and individually eliminated those foods that they had positive tests for, a reduction of 29% in migraine days was found.56 This study was, however, a small cross-sectional study, with some limitations. Another study, which was designed as a randomized controlled trial, eliminated those foods from diets of migraine patients who participated and were positive for certain food-related antibodies. When headache days were determined after four weeks on the elimination diet, a 19% reduction was found.57

Dietary interventions have mostly been investigated in a small population with no proper control group, hence results are heterogeneous and a sharp conclusion cannot be made. For example, a diet high in carbohydrate and low in tryptophan was tested in a group of seven patients and showed beneficial to subside headaches. The authors proposed that the positive effect has been apparently due to a mixture of lower intake of food that could trigger headache and also elevated levels of serotonin following the tested diet.58

Dietary lipids were investigated afterwards, because it was proposed that a diet high in lipids could cause headache following a potential lowering of serotonin levels in plasma that might be a result of higher platelet aggregation.59 A diet with a very low level of lipids (~20 g per day), therefore, was proposed to prevent headaches.60 A randomized, crossover trial reported in 201561 that low lipid compared with moderate lipid dietary intake could subside occurrence of migraine and headache intensity. It has also been reported that the dietary approaches to stop hypertension (DASH) diet could diminish the intensity of headache and duration in migraine.62 This particularly points to the importance of migraine comorbidities, and how dietary factors can influence an overall well-being of the affected patient.

Supplementation by a diverse range of vitamins and minerals has been reported beneficial for migraine. For example, based on a review from 2018, vitamin D, vitamin B2, vitamin B12, magnesium, carnitine, and niacin have reduced frequency of magnesium, carnitine, and niacin have reduced frequency of migraines.63

Even though beneficial effects of these dietary interventions have been reported in the literature,22 one must consider that individual patients may require special needs that importantly points towards the concept of precision medicine in migraine.64 Including larger cohorts of patients and considering follow-ups of longer duration could help in properly examining the effect of dietary interventions, a point to be considered in the future investigations. In this line, patient adherence and age influence on diet choices and dietary patterns emphasize the value of long-term assessments. However, plan, design, and conduct of long-term studies are difficult and several intractable factors need to be considered and integrated into the assessments. At present, comparisons between studies remain difficult because age, gender, cultural, and religious variations among different studied populations have largely been ignored. Gender of affected individuals is an important factor to consider,51 because changes in hormonal concentrations, for example plasma estrogen concentrations, have shown an association with migraine.65 Alternatively, dietary intakes that can alter estrogen activity to a lower level have been shown beneficial for premenstrual symptoms.66 Therefore, low fat, high fiber, or vegan diets, might help some patients, for example those who have menstrual migraines. In fact, a study67 has tested this hypothesis, by investigating the effects of a four-week low-fat vegan diet in migraine. Overall, headache severity, headache days and frequency subsided, but this study has some limitations in design preventing drawing a sharp conclusion.67 Besides linking beneficial effects of a vegan diet to a low fat content, and lowering estrogen activity, several other mechanisms have been proposed, for example antioxidant and anti-inflammatory properties of plant-based food. Since an involvement of neurogenic inflammation in migraine68 has been suggested, this might be an explanation. In addition, dairy products (eg, cheese) and meat49 are not present in a vegan diet and these components have often been reported as migraine triggers in the literature.69,70 Therefore, absence of these components in a vegan diet might exert an anti-inflammatory effect against migraine.

Weight loss has been reported beneficial in migraine,71,72 although open questions remain in the field due to design and studied populations in the current literate. A proof of concept study in 2015 presented that weight loss could result in symptom improvement.73 Based on a pilot study published in 2019,11 enhancing the quality of diet and maintaining a healthy weight, could improve some clinical features of migraine. In this open, and nonrandomized study, women with migraine received an individualized diet plan, which was based on a professional nutritional diagnosis. This study was first to provide evidence that diet quality and maintaining a healthy weight are important,11 not the weight loss per se. This means that for underweight patients a weight gain might be the successful strategy, while for overweight patients, a weight reduction strategy would provide beneficial effects on migraine.11

Bond et al74 designed a study to test if two different strategies for weight loss would be comparable or different. Migraine patients who were overweight or obese women (a population considered to be most affected by obesityrelated migraine risks)35,75,76 were included and divided into two groups. One group received a behavioral weight loss (BWL) that included both exercise and diet, and the other group received educational instructions on migraine. Findings from this study showed that both groups benefited from a reduction in headaches following the two strategies and there was no significant difference between the groups. This study presented that independent of the type of strategy; strategies for weight loss might be beneficial for this special population.

According to a systematic review and meta-analysis77 that has summarized and compared two strategies for weight loss, it was revealed that independent of technique, weight loss could reduce headache severity, frequency, duration, and associated disabilities. Therefore, weight loss was highlighted as the critical factor, not the amount of weight reduction, or the strategies that were used to achieve the loss.77 In fact, the obesity and migraine link has been a matter of investigation for a while. The fundamental questions are, do people with migraine gain weight because of migraine related disability? Or does obesity lead to greater migraine frequency? In other words, which comes first, obesity or migraine. Results are mixed in the literature. Winter et al in 201278 found that among 19,162 middle-aged women, those with migraine had a significantly higher risk to shift towards being overweight or obese. The risk was not different for women with or without aura.78 Age plays a role in obesitymigraine interactions,79 because age affects the body mass index (BMI), distribution of body fat, hormones, and prevalence of migraine. Reported in 2020, the HUNT3 (the third population-based Nord-Trndelag Health Study)80 showed that a greater association exists between migraine and obesity in younger adults, ie, those >50 years old, still within the reproductive age. Therefore, one must consider that in the study by Winter et al,78 where middle-aged women were included, other risk factors might have played a role.

A meta-analysis81 of 12 studies, including data from 288,981, demonstrated that body composition is a critical factor. When pooled data were adjusted for age and sex in this analysis, an increase risk of migraine (27%) was identified in obese vs normal weight and was not lost even after multivariate adjustments. The risk was shown slightly elevated (13%) in underweight vs normal weight and again it was not changed even after application of multiple adjustments. Therefore, it seems based on these results, that obesity and being underweight could enhance risk of migraine.81 An increased risk of migraines in underweight and obese women vs normal weight was presented in 2015 by Ornello et al.82 However, pre-obese subjects did not show any increasing risk.82

Multiple underlying mechanisms for the impact of obesity on migraine have been proposed, one of which is a neurometabolic impact.18 This has been based on reports in the literature that metabolic factors can trigger migraine, for example, fasting/hypoglycemia, dehydration, stress, alcohol, and lack of sleep. These factors have been found linked to reduced brain energy levels in migraine patients. It has been proposed that these triggers could reduce mitochondrial function, ATP generation, cellular glucose transport, and lipid oxidation, promote neuroinflammation (neuronal and glial signaling modulation), and astrocytic signaling.18,19 These mechanisms are also linked to increased cortical excitability that has been proposed in migraine pathophysiology.83 The review by Gross et al18 in 2019, summarized the available literature on the metabolic changes in migraine and how those changes can contribute in pathophysiology and being potential targets for treatments. One important feature in this context is that nutritional intervention to improve nutrient metabolism, neuroinflammation, and oxidative stress, can eventually improve migraine.18 This has shed light on the concept of obesity and migraine. Observations have provided evidence that the hypothalamus which is the first station for detecting of changes in peripheral energy status, is involved in migraine pathogenesis.84 Interestingly, it has been found that hypothalamic astrocytes have distinct responses to nutrients, ie fatty acid and glucose metabolism coupling.85 In addition, it has been found that different brain cells utilize, store, and modify their response to lipids. L-carnitine, which transports fatty acids into the mitochondria, where those are oxidized to produce ATP, has shown efficacy in blunting migraine.86 In contrast, saturated high-fat diets leading to obesity, promote metabolic dysfunction, depressive like behavior, and neuroinflammation.87 This has led to applying a strategy in which targeting obesity could suppress neuroinflammation and consequently block the depressive symptoms. Interestingly, increased mood disorders have been seen in migraine patients, so these basic research findings are clarifying some underlying mechanisms that might share commonalities in obesity, migraine, and mental health.88

The concept that migraine might be a response to low brain energy level or uncompensated oxidative stress,89 has brought the ketogenic diet back into attention.90 This diet acts in a similar way to fasting, where ketone bodies are elevated and can be used as an alternative source of energy to correct abnormalities in glucose metabolism reported in migraine. Some reports, including a proof of concept study,73 have demonstrated beneficial effects of a ketogenic diet to reduce migraine frequency. Recently, an alternative method has been considered to apply exogenous ketogenic substances.91 This means to provoke nutritional ketosis with ketogenic substances, for example, beta-hydroxybutyrate (HB) salts.91 A recent review90 summarized the potential mechanisms underlying the effect of ketone bodies and presented those as signaling molecules that can interfere with pathways involved in migraine pathophysiology.90 For example, ketogenic substances can reverse mitochondrial dysfunction, subside oxidative stress, reduce cerebral excitability, or lower the inflammation.90 Even though an extensive amount of work has been done in animals, clinical research is lacking to validate the findings as if these protective effects of ketone bodies (KBs) would also be present in patients with migraine. Supplementation with HB without a strict dietary change is under investigation91 and could help provide evidence and address those open questions.

Diet-induced obesity has been shown to reduce brain fatty acid uptake.92,93 This has opened up a concept that obesity could enhance deficits in brain energy reserves and metabolism that characterize migraine. Within this concept, omega-3 fatty acid supplementation has shown antidepressive action and reduced migraine frequency.94 Fish oil supplementation in obese mice95 has shown reduction in metabolic and anxiodepressive effects of diet-induced obesity and related alterations in the composition of brain lipid. Further investigation is required in humans, as mood, food, and obesity have been found interrelated in a complex interaction.96 In addition, it is still not known whether a migraineobesity association is different in females and males, in different ages, and in different subtypes of migraine, considering mood disorders and emotional behaviors in humans.

As the evidence continues to accumulate, it is suggested that physicians recommend weight loss to their patients who have comorbid obesity. This is because weight loss has proven to improve sleep, mood, and other factors that increase susceptibility for having more frequent or severe migraine attacks. Lifestyle changes overlap with migraine and can be beneficial in migraine management, in particular when migraine is comorbid with other conditions, such as depression. There are lifestyle modification approaches for obesity. For example, according to Wadden et al,97 diet, exercise, and behavioral therapy were major determinants of lifestyle modification, where a reduced-calorie diet and a high level physical activity could yield a long-term weight loss.97 Based on a recent review,26 diets that promote weight loss, such as the ketogenic diet, and low-calorie diets, could be considered beneficial for those headache patients who are obese. In addition, lowering intake of omega-6 and intake of higher amount of omega-3 in this group can be advantageous. However, another review9 has emphasized that the net outcome depends on several factors, for example, age, gender, genetic predisposition, and environmental factors. Therefore, in order to provide evidence-based dietary recommendations for migraine, we need to consider these influential factors in study designs. In addition, the more we know about the mechanisms leading to migraine, the better we can investigate different factors, including dietary factors, which can interfere with those mechanisms. Future research is needed to provide evidence of whether diet can be a disease-modifying agent for migraine, and how. Considering the big picture, this would also enable personalized recommendations that - are in line with biopsychosocial considerations in targeting migraine.

In addition, one must consider that if comorbidities exist with migraine, dietary modification might be beneficial in controlling the condition. For example, several studies have highlighted a solid link between migraine and gastrointestinal diseases, in particular, irritable bowel syndrome (IBS). For review see Camara-Lemarroy et al.98

The gutbrain axis is a term to describe a potential two-way relationship between the gut and the brain. The gutbrain axis might potentially explain the existing link between IBS and migraine.98 Evidence is accumulating on the role of gutbrain axis in several neurological disorders, and migraine is not an exemption, where this has been reviewed in a recent review.99 However, we still do not know how the gut and the brain may interact in migraine.99 Several mechanisms have been proposed,100 for example, composition of gut microbiota, proinflammatory substances such as interleukins, neuropeptides (eg, calcitonin gene-related peptide; CGRP), hormones, and dietary components.101

In a recent metagenome-wide association study (MWAS),102 fecal samples of elderly women with migraine have been compared with matched controls to determine if gut microbiota is associated with migraine. Results showed that patients and controls are different in terms of diversity of species in the gut. Clostridium species (an unhealthy composition) were significantly higher in the migraine group. However, a healthy composition (eg, Faecalibacterium prausnitzii, Bifidobacterium adolescentis, and Methanobrevibacter smithii) were profound in controls. Patients also presented a diminished metabolic function of the gut compared with the controls.102 These findings may pave the way toward diagnosis, prognosis, and response to treatment strategies, or point to a novel therapeutic target. Based on the results,102 and to maintain healthy composition of the gut microbiota, proper probiotics have been suggested to correct dysbiosis in migraine patients. The concept of using probiotics for maintaining well-being is not new,103 however, identification of the role of probiotics in minimizing neuroinflammation, a mechanism proposed for migraine,104 has attracted attention toward the use of probiotics for alleviating migraine attacks.105,106 In patients with episodic and chronic migraine, a multispecies probiotic supplement has been investigated to identify a potential beneficial effect and profile of inflammatory markers.106 Findings revealed that probiotic supplementation could reduce the frequency and severity of migraine attacks. In addition, patients had a lower number of migraine days in the month and consumed a lower number of drugs to stop migraine headaches.106 According to the findings by Sensenig et al, mineral and vitamins added into a probiotic regimen for 12 weeks could result in a remarkable improvement in headache in 60% of migraine patients. Improvement in quality of life was reported by 80% of patients.107

Probiotic interventions as a prophylactic way to treat migraine have been summarized in a recent systematic review.108 Out of 68 screened studies, only two studies were analyzed, one with negative 109 and one with positive outcome106 in diminishing migraine frequency and intensity. The authors of this review108 have recommended points for inclusion and exclusion for the enrolment of patients, considerations for study design that can recruit standard and comparable methods, and proper control groups, within sufficient time.108 Microbiome analysis, pre- and postintervention, has also been encouraged.108

Another potential explanation for the existing link between gastrointestinal disorders and migraine is the gut permeability,110 where the leaking of lipopolysaccharides from the lumen into the blood can trigger a proinflammatory response,111 which is known to play a role in migraine pathogenesis.112 In a group of migraine patients diagnosed with comorbid IBS, probiotics combined with an elimination diet were tested.113 Sixty patients were randomized into three groups to receive the elimination diet, probiotics, or diet plus probiotics.113 The study results demonstrated that the combination method was superior for improving migraine comorbid with IBS.113

In addition to gut composition, which was found different in migraine patients, collected samples from the oral cavity of patients with migraine have demonstrated different composition from controls.114,115 Significantly higher nitrate, nitrite, and nitric oxide reductase genes were found in oral cavity samples of migraine patients. Interestingly, nitrates and food additives are reported among headache triggers, and nitric oxide pathway has been linked to migraine.116,117 Therefore, bacterial composition can be investigated in oral cavity and fecal samples in migraine and composition might reveal differences from controls.114

Identification of the CGRP role in migraine, has led to the development of new targets118 such as monoclonal antibodies that target CGRP itself, or its receptor, and also new oral gepants, antagonists of CGRP receptor.119 Evidence is limited as if dietary components could interfere with CGRP in migraine. Cady and Durham treated rats with cocoa-enriched diets for 14 days and investigated the expression of CGRP in the trigeminal ganglion cells, where they reported a significant decrease in the expression.120 In cell models, CGRP secretion has also been diminished after treating cells with petasin, which is the active component of butterbur, grape seed, and ginger extract.121,122

In relation to CGRP, a new study123 has demonstrated that when migraine patients with episodic migraine were supplemented with vitamin D, they had lower headache days and disability assessed on the migraine-related disability score (MIDAS) showed a significant improvement after 12weeks.123 Researchers in this study analyzed the serum levels of CGRP and presented that in the group on vitamin D supplementation, CGRP level was significantly lower.123 Based on the findings and correlational analysis, the authors have proposed that vitamin D might exert some of its effect through lowering of the CGRP levels.123 A larger study with a longer duration together with supportive basic research studies to look into underlying mechanisms of vitamin D in lowering CGRP and exertion of antinociceptive effect through this path, have been suggested.123

Considering beneficial effects of targeting CGRP with recent compounds,118,119 this line of investigation remains open to identify how dietary components or patterns might interact with expression and function of CGRP to interact with migraine manifestations.

Neurologists often encourage their patients with migraine to follow a consistent lifestyle. This is based on the observation that sudden changes in any lifestyle component may provoke migraine attacks. This includes several components, such as exercise, sleep, workrest cycles, diet, etc. However, evidence is still limited. In addition, the pattern of diet or habits of dietary choices might be equally as important as content of the diets. A cross-sectional study in 2015124 that used logistic regression, found that migraine is associated with low intake of food, regardless of the type of food.

A review125 on dietary consistency has presented the topic from three different views to migraine. The authors have proposed migraine as an illness, a disease, and a state of inflammation.125 Within this proposed framework, the authors looked at the relationship between diet and migraine as a function of changes in these three.125 Other researchers have considered migraine a brain disorder of maladaptive response and have described a feedforward allostatic cascade model that can lead to migraine.126 In this model specific stressors such anxiety, noise, food, odors, and bright light can be tested. Each of these factors can contribute to the allostatic load with a different magnitude, and factors can be summed over time. Therefore, the authors have proposed that modification of these effectors or stressors can help to intervene with the skewed allostatic load in migraine.126 Independent of the viewpoint to migraine, maintaining consistency in daily living is not easy and most likely requires education, monitoring, and support, and scientifically driven patterns.125

Studies are vast in the literature to examine dietary triggers for migraine and to lesser to examine dietary intervention. However, the question remains open as to whether certain dietary intake patterns are specific to migraine and whether migraine pathogenesis would influence dietary choices and patterns. In this line, it is important to identify if the subtypes of migraine can have an influence on the choices. For example, if the state of aura would lead patients with migraine to select a specific dietary component or patterns, while those choices might be different from those patients who do not have aura, and in comparison with migraine-free individuals. To address this side of the diet-migraine relationship, studies with proper control groups, such as nonheadache and nonmigraine control groups, and including subtypes of migraine (episodic, chronic, with and without aura) would allow for a proper evaluation. However, the evidence is very limited. Pattern of food intake has been investigated in one study,124 where a large population of middle-aged women was included. This study124 was designed based on a hypothesis that migraine patients and healthy individuals are different when it comes to food intake and food avoidance behavior, and that subtypes of migraine (eg, with and without aura) may influence these behaviors even further. This study124 demonstrated that a migraine-specific pattern of food intake existed that was different from healthy individuals. The only exception was alcohol consumption. In addition, and based on the presence or absence of aura in migraine subtypes, the choice of certain food items was influenced. Those items were, for example, chocolate, processed meats, dairy products, and wine.124 Interestingly, lower intake of dietary compounds known as migraine triggers was not evident. This led to an assumption that those food items might have been avoided by patients within a particular subtype of migraine.124 Further studies, however, are required to investigate this arm of migrainediet relationship. Epidemiological findings have demonstrated that choice of diet by individuals with migraine is different from individuals without migraine and the difference reflects on several nutritional metrics,21 for instance, diet quality,127 diet composition,128 dietary schedule,50 and amount of consumption in a wide range of different foods.23,124,129 We still do not know if mechanisms underlying migraine pathogenesis might influence dietary intake.20,21 Future studies are warranted to identify the patterns and potential underlying mechanisms and to examine if migraine type, migraine frequency, and food intake are interrelated. Besides, longitudinal studies are preferred to cross-sectional studies.

Migraine pain and related disturbances may influence individuals with migraine to select a convenient, simple, or easy choice in diet, which might differ from those without migraine that have a tendency for a more complex dietary pattern. The choice can reflect on the amount, quality, timing, and patterns of dietary intake. This might be due to the fact that the hypothalamus has been found activated in the premonitory phase of migraine, the time that food cravings often occur.28,130 Food cravings, for instance for chocolate, have been reported to present and have accounted for triggering migraine attacks while this might be a part of the onset.1 Interestingly, chocolate has been a matter of investigation as one of the migraine triggers.131 A recent systematic review132 has looked into 25 studies that evaluated if chocolate acts as a trigger in migraine, where 23 studies reported that chocolate could trigger migraine. There were also three provocative studies133135 that tested the triggering effect of chocolate compared with placebo, and neither of those could identify a significant outcome. Therefore, based on these findings, the authors of the systematic review concluded that evidence is still lacking to draw any recommendation for migraine patients about eating or avoiding chocolate.132

Neurotransmitter, hormone, and adipocytokine levels in migraine patients are different compared with controls that might also influence the desire for food, or food intake or even the metabolic control of the hypothalamus18,136 in affected patients. For example, orexin A, was elevated in headache phase,32 while serotonin levels were lower during the interictal phase.30,31 Higher insulin resistance and elevated adipocytokines such as leptin are also reported in migraine patients compared with controls.33,34

The choice of mealtime by migraine patients might also affect the meal intake and its properties. There is a gap here for understanding how migraine history would influence a preferred mealtime in an attempt to manage migraines proactively. Mealtime can influence the content of meal depending on the time, and hence plays a role in the bidirectional loop of migraine-diet. In fact, a study from 2016137 has looked into the pattern of regular lifestyle behavior for three elements of sleep, mealtime, and daily exercise in patients with episodic and chronic migraine. This is the first study of the combined three variables compared with previous studies138140 that considered each domain separately. Findings from this study137 demonstrated that all three elements (ie, regular mealtime, regular sleep, and daily exercise) were lower in frequency among migraine patients with chronic migraine compared with episodic migraine. Interestingly, regular mealtime was found as the element that was adopted the best by both groups of migraine patients.137 The authors, therefore, proposed that self-regulated behaviors, such as regular mealtimes, would be beneficial for the affected patients to control their migraine.137 It is interesting to investigate whether genetic or epigenetic factors64 can influence the choice of mealtime by patients with migraine and if this differs between episodic and chronic migraine.

A small number of patients have been seen anecdotally to respond to the paleo diet or variations of this diet. The rationale follows a theory that modern era diseases, for example, diabetes, heart disease, and obesity were absent in the Paleolithic era. Therefore, a clear diet could also help prevent migraine. This diet is known for weight loss, and it is free from refined and processed food, additives and preservatives.

The gutbrain axis that is a bidirectional path, might also affect dietary choices here. Interestingly, the gutbrain axis has been discussed in terms of psychological aspects,141 named as gutbrain psychology, which brings mind to the equation of the brain and gut relationship. Based on this synchronism of gut, brain, and mind, it has been proposed that the gut microbiota could affect normal mental processes and under pathological mental and neurological disorders.141 Whether this can influence choice of diet in migraine, or when migraine is co-existent with other psychological conditions, eg, stress and anxiety, needs further investigation. This also remains to be tested as if other factors, eg, gender of migraine patients can affect this (by, eg, hormones or psychology-related factors). Figure 2 is an overview of the gutbrain axis and potential players in the bidirectional relationship of migraine and diet.

Figure 2 A bidirectional relationship of the gut and brain, and different factors that can potentially influence migrainediet bidirectional relationship within this system. Green arrows are toward improvement of migraine headache, while red arrows reflect on negative impact. For a comprehensive review on the gutbrain axis and migraine headache, please see Arzani et al.99

Taken together, a potential bidirectional relationship, where migraine influences food intake, and consumed food affects the manifestations of migraine, needs further investigation. The question, therefore, remains open as to whether migraine can affect dietary choices and to what extent, and how dietary choices can influence migraine. In a broader spectrum, the allostatic model in migraine126 could potentially help studying the influence of migraine on food intake and the influence of dietary intake on migraine. Table 1 provides an overview of the main points mentioned earlier for the dietmigraine relationship and considerations for future studies.

Table 1 A Summary of Main Elements in Bidirectional Aspects of DietMigraine and MigraineDiet Relationship

Diet as a potential trigger for migraine has been discussed for some time. Identification of potential dietary triggers for migraine125 has mainly emerged via keeping dairies, avoidance behavior, or elimination diets to help managing migraine.142,143 Some triggers appear common among the migraine population, while others appear to be unique to individuals. Therefore, identification of personal food triggers in each individual seems valuable to assist with a better way of coping with migraine. No particular migraine diet exists yet to lean on a strong evidence, and hence the investigation of dietary patterns is needed to confirm efficacy before recommending for migraine prevention. Types of evidence, including level of effect are, therefore, expected from these interventions. For each, one must consider the burden of various diets for patients and if any potential side effects or safety issues may occur.20

Comorbidities are also important to consider, such as IBS and in this regard, studying the role of the gutbrain axis is encouraged. Migraine has been also associated with cardiovascular and psychological disorders. Therefore, studying dietary interventions that can be beneficial for comorbid conditions are valuable. Dietary recommendations for migraine may aid in immediate control, slow progression, or prevention of diet-related comorbidities (eg, obesity, diabetes, and cardiovascular diseases). These recommendations are often included in a broader lifestyle modification, including sleep hygiene, stress management, regular exercise, or smoking cessation. A focus on maintenance of a consistent healthy lifestyle, in addition to nonpharmacological and pharmacological management of migraines seems to be the key for most of migraine patients.20 Implementation of any lifestyle changes, including dietary factors, needs a careful evaluation and a clear communication to help both clinicians and patients to achieve expected and reasonable goals. Education, monitoring, and support are essential elements in particular in long-term interventions and follow-ups.20 Effect of migraine or its evolution over age and among the genders for dietary choices, and dietary pattern is not known.51 Pattern, quality, and amount of food can also be influenced by geographical locations, cultural, and religious factors. These factors must be considered and reported in future studies of any potential bidirectional relationship between migraine and diet.

The author reports no conflicts of interest in this work.

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