Nineteen percent of about 490 patients with classical or common migraine reported that headaches can be precipitated by chocolate, 18% by cheese and 11% by citrus fruit, and a highly significant majority of these patients were sensitive to all three foods. Twenty-nine percent of the patients reported sensitivity to alcohol; again this was significantly associated with sensitivity to the three food stuffs, though a substantial number of patients were sensitive to alcohol but not foods. Thirty-one percent of 331 female patients believed that oral contraceptives precipitated headaches, but this could not be related to any dietary response. Patients with affected relatives were significantly more likely to report sensitivity to alcohol and chocolate; sensitivity to cheese and citrus fruit was less strongly related, and there was no relationship at all for oral contraceptives. These correlations suggest that food induced headaches are mediated by chemical constituents common to these foods.

Five hundred seventy-seven consecutive patients attending the Princess Margaret Migraine Clinic from 1989 to 1991 have been questioned about dietary precipitants of their headaches. Four hundred twenty-nine patients had migraine, of which 16.5% reported that headaches could be precipitated by cheese or chocolate, and nearly always both. Of the migraine patients, 18.4% reported sensitivity to all alcoholic drinks, while another 11.8% were sensitive to red wine but not to white wine; 28% of the migrainous patients reported that beer would precipitate headaches. There was a definite statistical association between sensitivity to cheese/chocolate and to red wine (P < 0.001) and also to beer (P < 0.001), but none between diet sensitivity and sensitivity to alcoholic drinks in general. None of 40 patients with tension headache (diagnosed by International Headache Society criteria) reported sensitivity to foods, and only one was sensitive to alcoholic drinks. The prevalence of sensitivity among 46 patients with some migrainous features was intermediate between the migraine and tension headache categories. It is concluded that cheese/chocolate and red wine sensitivity, in particular, have closely related mechanisms, in some way related more to migraine than to more chronic tension-type headache, while quite separate mechanisms play a major role in sensitivity to alcoholic drinks in general.

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In a questionnaire-based study we compared the clinical features of migraine with aura (classical migraine) and migraine without aura (common migraine) in 354 and 397 patients, respectively, attending The Princess Margaret Migraine Clinic. Other than those related to the aura, no significant differences were seen in any clinical features of the attack (e.g. frequency or duration of attacks, time of day at onset, location of headache at onset, severity of headache, or nausea and vomiting). Common migraine attacks were significantly more likely to occur at weekends (p = 0.002). Dietary triggers tended to be more troublesome in classical migraineurs while pregnancy and the menstrual cycle affected both migraine types equally. Classical migraine patients were twice as likely to have a history of hypertension (p less than 0.05) and showed a slightly but not significantly greater tendency to depression. Family histories of migraine were similar in each migraine type. We conclude that classical and common migraine are fundamentally similar in their clinical characteristics and that the occurrence of focal neurological symptoms during a migraine attack has little influence on the rest of the attack.

SUMMARYWe have reviewed the 130 patients presenting to an accident and emergency (A & E) department with a headache, followed up for 2 years. These are infrequent attenders but we have found that there is a high incidence of serious neurological pathology (16%) in this group of patients. We suggest that patients presenting to the A & E department with headache should be thoroughly examined and investigated and in the absence of a definite benign diagnosis should at least be admitted for a period of observation.