Women's Health Promotion Unit

-- Name withheld

Identification of problem foods using food and symptom diaries. Kueper T, Martinelli D, Konetzki W, Stamerjohn RW, Magill JB Wisconsin Data Laboratory, Ltd, Waukesha, WI. Otolaryngol Head Neck Surg 1995 Mar;112(3):415-20

Food and symptom diaries were used to identify problem foods for each of 164 patients with chronic medical problems such as headache, fatigue, congestion, abdominal pain, and sinus problems. A statistical analysis related the total load of 90 biologic families, as well as caffeine, alcohol, and lactose, to changes in symptom intensity during a 2-week diary. The results helped 75% of the patients when used as a guide for elimination diets. Open challenges confirmed 47% of the identified food components. This study required a database and software to estimate recipe components for an average of 243 foods per patient. The analysis of each patient's diary produces a main report that lists suspect food components for each symptom. The report lists components in decreasing order of statistical confidence and gives lag times between food ingestion and symptom change. This report also shows that initial direction of the symptom change as a direct or masking effect. Foods that appear "safe" or unrelated to the symptoms are also listed. A second report lists the patient's food sources for each of the suspected food components. The report shows the percentage contribution of source foods and is useful for patient education and the design of elimination diets. An abstract about unusual activities, including eating, that precipitate headaches, now labeled as Exertional Headaches, follows:

Cough, exertional, and other miscellaneous headaches. Sands GH, Newman L, Lipton R Long Island Jewish Medical Center, Albert Einstein College of Medicine, New Hyde Park, New York. Med Clin North Am 1991 May;75(3):733-47

We have discussed several miscellaneous headache disorders not associated with structural brain disease. The first group included those headaches provoked by "exertional" triggers in various forms. These include benign cough headache, BEH, and headache associated with sexual activity. The IHS diagnostic criteria were discussed. Benign exertional headache and cough headache were discussed together because of their substantial similarities. In general, BEH is characterized by severe, short-lived pain after coughing, sneezing, lifting a burden, sexual activity, or other similar brief effort. Structural disease of the brain or skull was the most important differential diagnosis for these disorders, with posterior fossa mass lesions being identified as the most common organic etiology. Magnetic resonance imaging with special attention to the posterior fossa and foramen magnum is the preferred method for evaluating these patients. Indomethacin is the treatment of choice. The headache associated with sexual activity is dull in the early phases of sexual excitement and becomes intense at orgasm. This headache is unpredictable in occurrence. Like BEH, the headache associated with sexual activity can be a manifestation of structural disease. Subarachnoid hemorrhage must be excluded, by CT scanning and CSF examination, in patients with the sexual headache. Benign headache associated with sexual activity has been successfully treated with indomethacin and beta-blockers. The second miscellaneous group of headache disorders includes those provoked by eating something cold or food additives, and by environmental stimuli. Idiopathic stabbing headache does not have a known trigger and appears frequently in migraineurs. Its occurrence may also herald the termination of an attack of cluster headache. Indomethacin treatment provides significant relief. Three headaches triggered by substances that are eaten were reviewed: ingestion of a cold stimulus, nitrate/nitrite-induced headache, and MSG-induced headache. For the most part, avoidance of these stimuli can prevent the associated headache. Lastly, we reviewed headache provoked by high altitude and hypoxia. The headache is part of the syndrome of AMS during its early or benign stage and the later malignant stage of HACE. The pain can be exacerbated by exercise. The best treatment is prevention via slow ascent and avoidance of respiratory depressants. Acetazolamide and dexamethasone have proved useful in preventing this syndrome.

An even more serious cause of pain with eating concerns the action of the chewing muscles, and the arteries that supply the structures of the jaw, neck, and head. A condition of giant cell arteritis (inflamation of the arteries) affects individual over 50yrs, and a condition of autonomic failure, (the nerves controlling the circulation of the head and neck) when the regulation is not functioning normally, also may be the cause of pain, particularly after eating, and upon standing upright; lying down may relieve it. Arteritis may become associated with vision loss, and requires biopsies of the temporal arteries for reaching a diagnosis. The condition of autonomic failure is abstracted below:

The head and neck discomfort of autonomic failure: an unrecognized aetiology of headache. Robertson D, Kincaid DW, Haile V, Robertson RM Department of Medicine, Vanderbilt University, Nashville, TN 37232-2195. Clin Auton Res 1994 Jun;4(3):99-103

Information concerning the frequency, severity, character, location, duration, diurnal pattern of headache and ancillary symptoms were obtained in 25 patients with autonomic failure and 44 control subjects. Precipitating and ameliorating factors were identified. Autonomic failure patients had more head and neck discomfort than controls. Their discomfort was much more likely to localize in the occiput, nape of the neck and shoulder, compared with controls. There was a greater tendency for the discomfort to occur in the morning and after meals. It was sometimes less than 5 min in duration and was often associated with dimming, blurring, or tunnelling of vision. It was provoked by upright posture and relieved by lying down. Patients with severe autonomic failure and orthostatic hypotension often present with a posture-dependent headache or neck pain. Because the relationship of these symptoms to posture is often not recognized, the fact that these findings may signal an underlying autonomic disorder is underappreciated, and the opportunity to consider this aetiology for the headache may be missed.

The last condition that needs to be mentioned is reactive hypoglycemia. This is a very complex metabolic condition which was considered a psycho-somatic condition 15 years ago, but has recently been found to have an endocrine basis. Dysfunctional release of insulin, and its anatgonist, glucagon, appear to account for the rapid drop in blood sugar which promotes the headache. The drop is triggered by eating refined sugars or alcohol, even wine. Avoiding sweetened drinks, orange juice, candy bars, liquor, etc. is likely to prevent these responses. Substituting complex carbohydrates such as honey, or using artificial sweeteners are common avoidance solutions. Another symptom that commonly goes with reactive hypoglycemia is a sense of internal jitteryness, or even tremor that is relieved by eating. The real answer to this condition remains to be found, but I have treated many women successfully by having them eat a half-dozen almonds, or other nuts (gotta be careful to not get too many calories from this) in anticipation of the symptoms, say 2-3 hours after a meal. This provides protein that stabilizes the blood sugar levels. I have long recognized that eating small amounts of food frequently, rather than large meals, is another way to reduce such events.

Perhaps this very general discussion is helpful for confirming that your symptom may be very specific, and not widely recognized, or understood-that the association is a real one for which a diagnosis may be reasonably sought by an understanding physician. I hope that this information is useful to you, and Good Health!

LeRoy Heinrichs, MD

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