Headache Medicine 2021, 12(4):300-308 p-ISSN 2178-7468, e-ISSN 2763-6178

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DOI: 10.48208/HeadacheMed.2021.50

Headache Medicine

Original

Association between eating behavior and lifestyle habits and

increase in migraine attacks in university students during

Covid-19 pandemic

Hellen Maria Santos da Silva , Nathalia Herculano de Sousa , Ana Patrícia Pascoal Queiroz de Araujo ,

Maria da Glória Canto de Sousa , Alcylene Carla de Jesus dos Santos , Acássia Benjamim Leal Pires ,

Eduardo Souza Cardoso , Luana de Oliveira Leite

Universidade do Estado da Bahia, Salvador, Brazil.

Abstract

Background

The Covid-19 pandemic caused changes in the population's lifestyle and dietary patterns

which are important triggers for migraine crises.

Objective

Evaluating the association between eating behavior and lifestyle habits and the increase

of migraine attacks in university students during the Covid-19 pandemic.

Methods

Descriptive, cross-sectional, retrospective study carried out with university students from

Salvador, Bahia, Brazil, between December/2020 and June/2021. The university stu-

dents were invited by

® and institutional email and then directed to the free

and informed consent form and questionnaire, lled through the research management

application. This research was approved by the Research Ethics Committee under evalua-

tion report 4.351.573. Data were analyzed by descriptive analysis.

Results

A sample of 83 individuals, 89.2% women, 45.8% sedentary, 51.8% gained weight

recently, 73.4% had low water intake, 59.0% had difculty to conciliate and 50.6% had

difculty to maintain the sleep. Before the pandemic, 7.3% reported 7-14 days of migrai-

ne per month and, after, this gure increased to 24.1%. 36.1% of students associated

food with migraine attacks, the main triggers were: coffee (20.5%), chocolate (14.5%),

sausages (12.0%), alcohol (9.6%) and sugar (6.0%). The increase in migraine days was

associated with difculty in maintaining sleep (p<0.002).

Conclusion

Despite the statistically signicant result only between difculty to conciliate the sleep

and greater frequency of migraine, changes in lifestyle and eating behavior caused

by the Covid-19 pandemic also seem to imply in an increase in days with migraine in

university students.

Hellen Maria Santos da Silva

hellenmariaa.11@gmail.com

Edited by:

Marcelo Moraes Valença

Keywords:

Migraine disorders

Covid-19

Eating behavior

Lifestyle

University student

Received: December 2, 2021

Accepted: December 15, 2021

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Silva HMS, Sousa NH, Araujo APPQ, Sousa MGC, Santos ACJ, Pires ABL, Cardoso ES, Leite LO

Association between eating behavior and lifestyle habits and increase in migraine attacks in university students during Covid-19 pandemic

Introduction

ith the onset of the Covid-19 pandemic, caused by the

emergence of the Sars-CoV-2 virus and made ofcial

by the World Health Organization (WHO) in March 2020,

measures have been enacted to contain the spread of the

virus.

Thus, in face of the health crisis that was installed,

social isolation was required, which caused direct impacts

on the lifestyle of the population around the world. There-

fore, there were impacts on the health and quality of life

of the general public, including individuals with migraine.

Migraine is a type of primary headache, considered an

incapacitating disease. This clinical condition, recognized

by the International Classication of Diseases (ICD),

presents multifactorial etiology and, among its triggers

are stress, unhealthy eating habits, dehydration, physical

inactivity, hormonal changes, insomnia, and others. The

symptomatology generated by migraine may vary among

individuals, for instance nausea, vomiting, intolerance to

sensorial stimuli (such as light, noise and smell), tinnitus

and vertigo.

The pandemic caused changes in the lifestyle and eating

habits of the population, which are important triggers for

migraine crises. Therefore, in the pandemic period, some

changes could be observed in the onset of crises, driven

by changes in sleep patterns, physical exercise, changes

in diet and water intake, and a possible increase in

inammatory status with weight gain, which is associated

with the onset of migraine.

4,5

Therefore, it can be seen that

migraine patients were largely affected by these changes.

Considering the impact of the pandemic period, it is

imperative to study the relationship between Covid-19 and

eating behavior and lifestyle in the migraine population in

order to contribute to prevention and better treatment of

migraine attacks. Thus, the aim of this study was to evaluate

the association between eating behavior and lifestyle and

increased migraine attacks in university students during the

Covid-19 pandemic.

Methods

An observational, cross-sectional, retrospective study,

with descriptive approach, carried out with students from

the Universidade do Estado da Bahia (UNEB), Campus

I, located in Salvador, Brazil, whose data collection

occurred from December 2020 to June 2021. The students

were summoned through the

® app and an

institutional e-mail and, subsequently, directed via link to

access the informed consent form, with the need to ll it

out. After lling out the consent form, the university student

had access to the questionnaire through a research

management application.

We included only participants aged 18 years old or above,

from undergraduate courses in the health area belonging

to the Department of Life Sciences- Departamento de

Ciências da Vida (DCV) of the UNEB. Academics from

other areas not belonging to the DCV and from graduate

courses, as well as professors and employees, pregnant or

nursing women, were not included.

A structured questionnaire was used to collect demographic

information - sex and age (stratied as <20 years old, 20 to

59 years old); marital status (single, married/stable union,

and divorced); color/race (white, mixed black, black,

indigenous), socioeconomic - monthly family income (<1

minimum wage, between 1 and 2 minimum wages, or ≥3

minimum wages); and lifestyle - physical activity frequency,

smoking, alcohol consumption, and sleep pattern (difculty

in reconciling and maintaining sleep). Anthropometric

data were collected as weight in kilograms and height

in meters. The body mass index (BMI = weight/height²)

was calculated from the weight and height data. We

followed the criteria of the Ministry of Health (2014)

and

the World Health Organization (1998)

, for classication

of nutritional status of adolescents and adults, respectively.

In addition, they were asked about weight gain during the

pandemic period.

Regarding dietary habits, we asked about daily water

intake (0 - 500 ml, 500-1,000 ml, 1,000-1,500 ml, and

>2,000 ml), which was later recoded as up to 1.5 liters

and ≥2 liters; fasting time (up to 3 hours, between 4

and 6 hours, and >6 hours); and positive association

between specic foods and increased migraine attacks

(coffee, chocolate, tea, soft drinks, sausages, alcoholic

beverages, sugar, milk, and others). We also asked about

the frequency of coffee consumption (1 to 2 times a week,

3 to 4 times a week, 5 to 7 times a week, 1 to 2 times a

month, and rarely).

Clinical information regarding the diagnosis of migraine

was collected, using as a parameter the guidelines of the

International Headache Society3. In addition, results were

obtained on the monthly frequency of migraine attacks (1

to 7 days, 7 to 14 days, more than 15 days, and daily)

in the period before and after the start of the pandemic,

which broke out on March 17, 2020.

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Silva HMS, Sousa NH, Araujo APPQ, Sousa MGC, Santos ACJ, Pires ABL, Cardoso ES, Leite LO

Association between eating behavior and lifestyle habits and increase in migraine attacks in university students during Covid-19 pandemic

For categorical variables, absolute frequencies (n) and

relative frequencies (%) were used. For quantitative

variables, the results were presented as means and

standard deviations, considering the normal distribution

of data. Pearson's chi-square test and Fisher's exact test

for categorical variables were used to detect signicant

differences with p-value <0.05. SPSS Statistics version

20.0.0 statistical software was used for data analysis.

This research was approved by the Research Ethics

Committee of UNEB, under opinion number 4.351.573.

Results

The sample consisted of 83 individuals, 89.2% were

female, aged between 18 and 43, with a mean of 25.4 ±

6.9 (SD) years old. Regarding lifestyle habits 45.8% were

sedentary, 32.5% were alcoholics and 4.8% smokers,

59% and 50.6% stated, in respective order, difculty in

reconciling and maintaining sleep.

Table 1. Demographic, socioeconomic and life habit characterization of university students (n=83) with migraine in the

Covid-19 pandemic. Salvador-Bahia, 2020-2021.

Variable n %

Sex

Female 74 89.2

Male 9 10.8

Age

<20 9 10.8

20 to 59 74 89.2

Color/Race

White 15 18.1

Mixed black 26 31.3

Black 34 41

Indigenous 6 7. 2

Prefer not to declare 2 2.4

Marital Status

Single 68 81.9

Married/Unmarried (stabile union) 12 14.5

Divorced 3 3.6

Family income (in minimum wage)

<1 14 16.9

1-3 55 66.3

4-5 8 9.6

7-10 3 3.6

>10 3 3.6

Physical activity

Yes 45 54.2

No 38 45.8

Alcohol Consumption

Yes 27 32.5

No 56 67. 5

Smoking

Yes 4 4.8

No 79 95.2

Difficulty reconciling sleep

Yes 49 59

No 34 41

Difficulty maintaining sleep

Yes 42 50.6

No 41 49.4

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Association between eating behavior and lifestyle habits and increase in migraine attacks in university students during Covid-19 pandemic

Regarding the nutritional status of the research participants,

although most of them were not overweight according to

the BMI, 50.6% of the respondents reported weight gain

in recent months, and among these the majority gained

between 5 and 10 kg (42.9%). Regarding the daily

hydric intake, 73.4% of the respondents reported a hydric

volume intake of 0-1,500 ml/day. About fasting periods,

74.7% of the college students with migraine reported

frequent fasting intervals of up to 3 hours (24.2%),4-6

hours (54.8%), and more than 6 hours (21%).

Regarding eating behavior, 38.6% responded positively

when asked about the increase in migraine attacks being

associated with some food. The most common food triggers

Table 2. Characterization of eating behavior and nutritional status of university students (n=83) with migraine in the

Covid-19 pandemic. Salvador-Bahia, 2020- 2021.

Variables n %

BMI

Not overweight (≤24.9 kg/m²) 56 67. 4

Overweight (≥25.0 kg/m²) 27 32.6

Weight gain in the last 3 months

Yes 42 50.6

No 41 49.4

Amount of weight gain in kg

0-4.9 15 35.7

5-9.9 18 42.9

10-15 7 16.7

>15 2 4.7

Water intake

0 – 1,500 mL/day 61 73.4

>1,500 mL/day 22 26.5

Fasting

Yes 62 74.7

No 21 25.3

Fasting Frequency

Up to 3 hours 15 24.2

4-6 hours 34 54.8

>6 hours 13 21

Food is a trigger for crises

Yes 32 38.6

No 51 61.4

Frequency of trigger foods

Coffee

Chocolate 17 20.5

Sausages 12 14.5

Alcoholic beverage 10 12

Sugar 8 9.6

Others* 5 6

Soda 5 6

Milk 4 4.8

Coffee consumption

Yes 67 80.7

No 16 19.3

Coffee intake frequency

1 to 2 times a week 10 14.9

3 to 4 times a week 8 12.0

5 to 7 times a week 39 58.2

1 to 2 times a month 1 1.5

Rarely 9 13.4

* Popcorn, avocado, orange, tangerine, and onion.

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Association between eating behavior and lifestyle habits and increase in migraine attacks in university students during Covid-19 pandemic

were coffee (20.5%), chocolate (14.5%), sausages (12%),

alcoholic beverages (9.6%), sugar (6%), milk (4.8%), and

cola (4.8%). The other foods mentioned less frequently

were popcorn, avocado, and citric fruits. As for the intake

of coffee, 80.7% said they consumed the beverage with a

frequency of 5 to 7 times a week (58.2%), followed by 1

to 2 times a week (14.9%), 3 to 4 times a week (12%), 1

to 2 times a month (1.5%), and rarely (13.4%).

Regarding the number of days with migraine, before the

pandemic 84.3% of the undergraduates claimed to have

an average of 1-7 days with migraine crisis, 7.3% reported

7-14 days of crisis per month, and 8.4% reported more

than 15 days, also considering the period of one month.

After the beginning of the health crisis caused by Sars-

CoV-2, 65.1% of the students reported 1-7 days of migraine

headache per month, 24.1% and 8.4% reported on

average, 7-14 days, and more than 15 days per month of

migraine attacks, respectively, and the remaining, 24.4%

of the respondents, reported to have migraine headache

on a daily basis.

About the main symptoms cited, 91.56% of the

undergraduates reported vertigo (dizziness), 40.96%

*Others: Lateral eld loss, irritability, eye pain, smell irritability, and hearing loss

Figure 1. Monthly frequency of symptoms presented by university students (n=83) in Salvador,

Bahia, Brazil during 2020-2021.

Figure 2. Frequency of presentation symptoms (%) by university students in Salvador, Bahia,

Brazil during 2020-2021.

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Association between eating behavior and lifestyle habits and increase in migraine attacks in university students during Covid-19 pandemic

"darkening" of vision, 22.89% hearing fullness, 22.89%

tinnitus, 20.48% imbalance, 19.27% oating sensation,

12.04% nausea, 10.84% sinking sensation, 6.02%

photophobia, 6.02% falling, 6.02% others, and 3.61%

hearing loss (Figure 1).

Most individuals, who had an increase in the days of

migraine attacks during the pandemic, consumed coffee

(78.3%), fasted (69.6%), gained weight (65.2%), consumed

less than 1,500ml of water per day (69.6%), had difculty

reconciling sleep (73.9%), difculty maintaining sleep

(78.3%), and did not practice physical activity (52.2%).

Nevertheless, we only identied statistical signicance for

the relationship between increased migraine attacks and

difculty in maintaining sleep during the pandemic (p=0.002).

Discussion

In this study, the respondents reported an increase in the

number of days of monthly migraine attacks during the

pandemic, and behavioral changes were identied in

the research participants. In this period, college students

predominantly had difculty in reconciling and maintaining

sleep, reported weight gain in recent months, low water

intake, and an important number remained sedentary.

Regarding eating behavior, there was a prevalence of

participants who fasted and responded positively when

asked about the emergence of migraine attacks associated

with some food.

The Covid-19 pandemic brought signicant consequences

Table 3. Increased migraine attacks of university students (n=83) with migraine in the Covid-19 pandemic according to

nutritional and lifestyle variables.

Variable

Increased number of days with migraine

Value

No Yes

Coffee consumption

Yes 81.7% (49) 78.3% (18) 0.760*

No 18.3% (11) 21.7% (5)

Fasting

Yes 76.7% (46) 69.6% (16) 0.505**

No 23.3% (14) 30.4% (7)

Nutritional status

Not overweight 73.3% (44) 52.2% (12) 0.066**

Overweight 26.7% (16) 47.8% (11)

Weight gain in the last 3 months

Yes 45% (27) 65.2% (15) 0.099**

No 55% (33) 34.8% (8)

Water intake

≤1500 mL/day 75% (45) 69.6% (16) 0.616*

>1500 mL/day 25% (15) 30.4% (7)

Difficulty reconciling sleep

Yes 53.3% (32) 73.9% (17) 0.088**

No 46.7 % (28) 26.1% (6)

Difficulty maintaining sleep

Yes 40% (24) 78.3% (18) 0.002**

No 60% (36) 21.7% (5)

Physical exercise

Yes 56.7% (34) 47.8% (11) 0.469**

No 43.3% (26) 52.2% (12)

Alcohol Consumption

Yes 77.8% (21) 22.2% (6) 0.438**

No 65% (39) 73.9% (17)

*Fisher's exact test.

**Pearson's chi-square test.

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Association between eating behavior and lifestyle habits and increase in migraine attacks in university students during Covid-19 pandemic

to the population, changing lifestyle, and eating habits.

The reduced activity level, imposed by the mandatory

lockdown, along with the large amount of information

and the uncertainties about the pandemic led to changes

in sleep patterns, increased stress and anxiety and,

concomitantly, increased consumption of more palatable

foods as a comforting strategy to mitigate the emotional

and psychological impact that the health crisis has caused,

which may consequently result in weight gain.

Still regarding food, during the pandemic period we

observed an increase in the consumption of foods commonly

considered triggers for migraine attacks, especially coffee,

chocolate, sausages, and alcoholic beverages. In addition,

it was noted that coffee was predominantly consumed by

respondents, with a high weekly frequency, i.e., coffee

consumption on a daily basis (7 days a week).

It is known that the eating behavior of each person is

inuenced by internal and external issues, such as food

preferences, cultural, physiological, emotional, social

factors, among others.

8,9

Thus, in face of the SARS-CoV-2

outbreak and the emotional impact it caused, there was an

expression of emotional eating, leading to the adoption

of food consumption in order to deal with negative

emotions. The food choices, therefore, are mostly for

high-fat, carbohydrate-rich, and sugary foods, giving the

consumption of these foods a greater sense of pleasure.

Despite the pleasurable sensation inherent to the

consumption of more palatable foods, in individuals with

migraine, such foods and their respective substances may

be responsible for triggering migraine attacks, such as

coffee (caffeine) chocolate (caffeine, tyramine, sucrose,

and sweeteners), alcoholic beverages (alcohol, histamine,

and tyramine), sugar (sucrose), sausages (nitrite and

nitrate, tyramine and sodium chloride, and excess fat),

soda (caffeine and monosodium glutamate), and milk

(tyramine).

The cause-and-effect relationship between trigger foods

and migraine would be associated with the fact that, in

individuals with migraine, the substances present in such

foods act as proinammatory compounds that stimulate

the trigemino-vascular system, causing its activation, and

consequently a cascade of reactions that trigger migraine

episodes.

It is noteworthy that the increase in migraine days per month

during the health crisis was related not only to college

students who consumed coffee, but also to those who fasted

for a long time, did not practice physical activity, and had

low water intake, as well as those who gained weight and

had difculty reconciling and maintaining sleep, although

with statistical signicance only for difculty maintaining

sleep.

As for sleep, it is possible to associate its irregularity with

the increased level of anxiety caused by the pandemic

along with reduced physical activity and increased

consumption of palatable foods. The result obtained in this

study is in line with data presented by Di Stefano and

coworkers

which showed an increase in the Insomnia

Severity Index (ISI) score due to the positive correlation

between sleep quality and frequency and intensity of

migraine during the coronavirus outbreak. In this study, it

was observed that patients with worsening migraine had

greater difculty falling asleep (p < 0.001), maintaining

sleep (p = 0.001), and a higher level of dissatisfaction

with their sleep pattern (p= 0.002).

5,14

Individuals who are anxious and less physically active

may develop a state of hyperexcitability of the sympathetic

system, generating fragmented sleep, frequent awakenings

during the night, and reduction of deep sleep. In the case

of foods, the substances found in them can increase the

secretion of serotonin, which reduces the secretion of

melatonin (which is also reduced because of the worsening

of sleep quality), inuencing migraine. In addition, the

neurotransmitter can lead to migraine attacks from the

direct activation of the trigeminovascular nerve.

10,11

Another factor related to decreased sleep is associated

with the irregular sleep pattern induced by increased

secretion of pro-inammatory cytokines due to excess

adipose tissue, commonly present in cases of overweight/

obesity, a nutritional state that has become more prevalent

in the pandemic due to, among other factors, altered

eating behavior and increased emotional eating.

15,16

Regarding nutritional status, in this sample, there was

a predominant report of weight gain and increase in

the number of days with migraine, which may favor the

emergence of overweight/obesity. According to the study,

there was a worsening of migraine attacks during the

pandemic related, amongst others, to the consumption

of food and/or beverages considered triggers for the

neurological disorder, thus highlighting the relationship

between the emotional state, and eating behavior with

a tendency to consume more caloric, fatty, and sugary

foods.

Considering the pandemic context, it is possible to

hypothesize that the increased consumption of more

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Silva HMS, Sousa NH, Araujo APPQ, Sousa MGC, Santos ACJ, Pires ABL, Cardoso ES, Leite LO

Association between eating behavior and lifestyle habits and increase in migraine attacks in university students during Covid-19 pandemic

palatable foods, as a result of emotional eating, in

association with the reduction of physical activity, may

have corroborated to the higher weight gain, fact that

generates a predominantly inammatory state, inuencing

the emergence of migraine, considering that this feature is

common between both clinical conditions: migraine and

obesity.

Regular exercise may be benecial in cases of migraine due

to improved vagal tone as well as heart rate variability.

Besides, it could be an ally to avoid weight gain by

balancing the proportion between energy expenditure and

daily caloric intake, which, if excessive, can favor weight

gain, mainly due to the foods that are usually consumed,

which could potentiate the inammatory state and inuence

the occurrence of migraines.

According to an Italian study

, migraine improvement was

more frequent among patients who increased the level

of physical exercise compared with those who reduced

the activity. Such result is convergent with the data found

from the sample evaluated, that 52.2% of non-exercising

individuals reported an increase in the number of days with

migraine.

On the other hand, fasting, by increasing the number of

hours without eating, can also be a contributing factor to

trigger migraine crises, due to lower rates of brain glucose

that will be offered and the depolarization of neurons

The practice of fasting was reported by most of the students

who had an increase in the number of days with migraine

in this research.

As well as the importance of regular meals in association

with adequate quality and quantity, the correct hydric intake

is also necessary, especially to prevent migraine attacks. The

low intake, often cited by respondents, culminates in a state

of dehydration, which is also one of the factors responsible

for causing migraine attacks.

11,12

In the participants of this

research, most individuals with a daily water intake of less

than 1,500 ml reported an increase in the number of days

with migraine, thus emphasizing the association between

low water intake and migraine attacks.

This study has limitations since it is retrospective and

cross-sectional, which does not determine cause-and-effect

relationships. The number of participants in the research

can also be characterized as a limitation, and in addition,

the questionnaire applied was lled out by self-report,

which may inuence the results of the research. More robust

studies are needed to demonstrate the association between

the eating behavior and lifestyle habits of individuals with

migraine in the face of the Covid-19 pandemic, but it

does not invalidate the observations reported here and

important ndings.

The changes in lifestyle and eating behavior caused by

the Covid-19 pandemic had repercussions in the increased

number of days with migraine per month in college

students. It was identied that individuals who consumed

coffee, fasted for a long time, did not practice physical

activity, had low water intake, as well as those who gained

weight and had difculty in reconciling and maintaining

sleep increased the days of monthly migraine attacks

during the pandemic. Thus, we highlight the importance

of conducting studies to understand the repercussions

of the Covid-19 pandemic on the lifestyle habits of the

migraine population and propose intervention measures

that encourage the recovery of healthy habits and assist in

the control of migraine attacks increased during this period

and, consequently, contribute to improve the quality of life

of this public.

Conflicts of interest: The authors deny.

Authors' contribution: LOL designed the study and

analyzed the data. HMSS, NHS, APPQA, MGCS, ACJS,

ABLP, ESC, and LOL tabulated the data, interpreted,

discussed, and wrote the results. All authors contributed to

the revision of the manuscript and LOL approved the nal

version.

Funding: This study did not receive any funding.

Acknowledgments

We thank the Interdisciplinary Project of Health Care for

Migraine Patients of Bahia State University.

Hellen Maria Santos da Silva

https://orcid.org/0000-0002-9090-5190

Nathalia Herculano de Sousa

https://orcid.org/0000-0003-3426-4242

Ana Patrícia Pascoal Queiroz de Araujo

https://orcid.org/0000-0002-1951-6360

Maria da Glória Canto de Sousa

https://orcid.org/0000-0001-9123-5283

Alcylene Carla de Jesus dos Santos

https://orcid.org/0000-0002-0074-6000

Acássia Benjamim Leal Pires

https://orcid.org/0000-0002-0225-0359

Eduardo Souza Cardoso

https://orcid.org/0000-0001-9244-7149

Luana de Oliveira Leite

https://orcid.org/0000-0002-3031-8576

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Association between eating behavior and lifestyle habits and increase in migraine attacks in university students during Covid-19 pandemic

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