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Best practice: migraine
  1. N Speight
  1. Paediatric Dept, University Hospital of North Durham, Durham DH1 5TW, UK; nigel.speight{at}cddah.nhs.uk

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In their otherwise very comprehensive review of this subject in your October issue of Education and Practice,1 Drs Barnes and Jayawant limit themselves to only two aspects of management in the prophylaxis of migraine: drug treatments, and psychological/behavioural therapy.

While it may be difficult to find hard evidence for some of the environmental areas they omitted, some mention of avoidance of obvious trigger factors would surely have been in order. These may vary in importance from child to child, but hypoglycaemia/hunger, lack of sleep, stress, vigorous exercise, and obvious dietary triggers can each be relevant in individual cases and therefore worthy of common sense advice.

Of probably far greater importance as an omission from this paper, and one for which there is an excellent evidence base, is the use of dietary measures in prophylaxis. Egger et al, in their Lancet paper in 1983,2 showed that a dietary approach could be very effective in a series of cases of severe intractable migraine, achieving a significant response in >80% of cases. They used an “oligoantigenic” or “few foods” diet followed by challenge with individual items of diet in a sequential manner. They found that a large number of “healthy” foods could be implicated in their cases, including wheat, cows’ milk, other cereals, and fruits, with many children having multiple intolerances. In other words there is more to diet and migraine than simply excluding the 5 Cs (cheese, chocolate, coffee, coke, and citrus fruits).

They performed double blind challenges in a selection of their cases; these were confirmatory of the results of open challenge in the majority of cases.

Such an approach to management can in my experience be extremely helpful in individual cases of severe intractable abdominal or cranial migraine. It is quite feasible to administer on an outpatient basis with good support from an experienced dietician. When successful this approach may make drug treatment unnecessary. When not attempted it can render drug treatment ineffectual.

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  • Competing interests: none declared