ISSN 0017-8748

Headache  doi: 10.1111/head.13623

© 2019 American Headache Society Published by Wiley Periodicals, Inc.

Research Submission
Comparison of Diet Quality Between Women With Chronic
and Episodic Migraine
Samaneh Hajjarzadeh, M.Sc. student; Zeinab Nikniaz, PhD; Davood Shalilahmadi, MD, PhD;
Reza Mahdavi, PhD; Maryam Behrouz, PhD

Background/Objectives.—Different triggers including environmental, hormonal, and dietary factors have been introduced as
migraine risk factors. There is some evidence to suggest that a high quality of diet could be effective regarding management
of migraine. In this present study, we hypothesized that the diet quality of women with chronic migraine (CM) might be dif-
ferent from women with episodic migraine (EM).
Methods.—In this cross-sectional study, 116 women with chronic and 169 women with episodic migraine (25-55 years old)
were recruited from the neurology clinics of Golestan hospital in Ahvaz (southwest Iran) based on the International Classification
of Headache Disorders-III. Anthropometric data including weight, height, waist, and hip circumference were measured. Dietary
intake data were obtained using a reliable and valid semi-quantitative food frequency questionnaire that included 168 food items.
The diet quality of subjects was calculated using the Healthy Eating Index-2015 (HEI-2015).
Results.—The mean HEI score of participants was 57.29  ±  7.98. The participants were classified into 3 groups of “poor,”
“needs improvement,” and “good” based on their diet quality. The frequencies of each group were 50/285 (17.5%), 233/285
(81.8%), and 2/285 (0.7%), respectively. Moreover, the mean of HEI score in women with CM was significantly lower than
women with EM (55.93  ±  7.90 vs 58.93  ±  7.93, P  =  .02). Moreover, there was a significant negative association between CM
and HEI score of women (β  =  −2.03; 95% CI: [−3.97 to −0.10]; P  =  .04).
Conclusions.—Women with CM had a lower diet quality than that of EM. Moreover, CM was significantly and inversely
associated with HEI score in women.

Key words: migraine, chronic migraine, episodic migraine, diet quality, healthy eating index, women

Abbreviations: B
 MI body mass index, CM chronic migraine, DASH dietary approaches to stop hypertension, DGA dietary
guidelines for Americans, EM episodic migraine, FFQ food frequency questionnaire, GBD Global Burden of
Disease survey, HC hip circumference, HEI healthy eating index, ICHD-III (Beta version) International Classification
of Headache Disorders-III (Beta version), MUFA monounsaturated fatty acid, PUFA polyunsaturated fatty acid,
SPSS statistical package for social science, USDA United States Department of Agriculture, VAS the visual
analog scale, WC waist circumference, WHR waist to hip ratio, YLDs years of life lived with disability

(Headache 2019;59:1221-1228)

From the Student Research Committee, Faculty of Health and Nutrition,  Tabriz University of Medical sciences, Tabriz, Iran
(S. Hajjarzadeh, M. Behrouz); Liver and Gastrointestinal Diseases Research Center,  Tabriz University of Medical sciences, Tabriz,
Iran (Z. Nikniaz); Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (D. Shalilahmadi); Faculty of Health and
Nutrition,  Tabriz University of Medical Sciences, Tabriz, Iran (R. Mahdavi).

Address all correspondence to Z. Nikniaz, Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical sciences,
Tabriz, Iran, email: znikniaz@hotmail.com

Accepted for publication April 21, 2019.

1221
1222
INTRODUCTION
Migraine is a disabling headache1 with unpredict-
able attacks resulting in reduced quality of life and
intrusion with normal daily activities.2 Based on the
Global Burden of Disease survey 2016 (GBD-2016),
migraine ranked as the sixth prevalent disorder and the
second most disabling condition worldwide in terms
of years of life lived with disability.3 Migraine affects
11% of the total adult population globally.4 Chronic
­migraine (CM) is one of the migraine subtypes that usu-
ally originates from episodic migraine (EM). Episodic
migraineurs convert to chronic migraine with an
approximate annual rate of 3%.5 It has been indicated
that the process of chronification can be overturned by
mitigating the risk factors of migraine attacks.5
Different triggers including environmental, hor-
monal, and dietary factors have been introduced as
migraine risk factors.6,7 In this regard, specific elimina-
tion diets have been recommended for migraine man-
agement.8 Moreover, some studies assessed the effect
of 1 or more ingredients on migraine in the format of
interventional diets such as low-fat diets, low-omega-6
and high-omega-3 diets, ketogenic, and Atkins diets.9
But, the role of overall diets made from core compo-
nents of foods such as carbohydrates, proteins, fats,
vitamins, and ions on migraine is a controversial topic
yet.8,9 Diet quality is one of the common approaches
in the way of assessing the relationships between diets
and diseases.10 Evans and colleagues8 have revealed sig-
nificant differences between the diet quality of women
with and without migraine and suggested that improv-
ing diet quality may be effective as part of the migraine
treatment process.8 In addition, some evidence indi-
cates that a higher consumption of healthy food items
including fruits, vegetables, and whole grains and a
lower consumption of fats might be effective in reduc-
ing migraine severity and attack frequency.9,11-14
As far as the researchers of the current study could
find, no study comparing the overall diet quality in
women with CM and EM has yet been conducted. So,
the purpose of the current study was to compare the
diet quality using HEI-2015 in Iranian women with
CM and EM.
Conflict of Interest: None
Funding: This work was funded by the Nutrition Research
Center of Tabriz University of Medical Sciences.
September 2019
METHODS
Study Design and Participants.—The data for this
analysis were obtained from a previous study that
assessed the association of dietary patterns with attack
frequency in women with migraine.14 In that previous
paper, the main dietary patterns of participants were
analyzed using factor analysis but in the present
analysis we assessed the adherence of migrainous
women to the Dietary Guidelines for Americans
(DGA) using the HEI score. In the current cross-
sectional study, 300 volunteer migrainous women
referring to the neurology clinics of Golestan Hospital
in Ahvaz (southwest of Iran), were recruited from July
2017 to March 2018. The neurology clinics of Golestan
Hospital are the most referred centers of patients with
neurological problems in Ahvaz.
Migrainous women were included if they were in
the age range of 25-55 years old, were not pregnant or
lactating, were not on a special diet, and had no his-
tory of epilepsy, asthma, and hormonal or thyroidal
dysfunction.
Migraine and aura status were diagnosed by a neu-
rologist based on the third edition of the International
Classification of Headache Disorders (ICHD III-Beta
version).15 Also, the written informed consent letters
were filled and signed by all the participants. The
study was approved by the ethics committees of Tabriz
University of Medical Sciences and Ahvaz Jundishapur
University of Medical Sciences in February 2017.
Dietary Assessment.—Dietary intake of participa­
nts was collected using a valid and reliable semi-
quantitative food frequency questionnaire (FFQ)
through face to face interview.16,17 This questionnaire
included 168 food items (with standard serving sizes)
usually consumed by Iranians. The usual frequency of
using each food item was determined on a daily, weekly,
monthly, or yearly basis.
Diet Quality.—The diet quality of participants was
assessed using the Healthy Eating Index-2015 (HEI-
2015). The HEI-2015 is a scoring index that evaluates
adherence to the dietary guidelines for Americans
(DGA), 2015-2020. For calculating the HEI score of
participants, the food consumption data converted to
a daily intake for every participant. Then, all the food
consumption data were converted into serving size
equivalents based on the My Pyramid Equivalents
Headache 1223

Table 1.—Components and Scoring Standards of HEI-2015

HEI-2015 Total/Component Score Max Score Standard for Max Score Standard for Minimum Score

Adequacy
Total fruit 5 ≥0.8 cup eq/1000 kcals No fruit
Whole fruit 5 ≥0.4 cup eq/1000 kcals No whole fruit
Total vegetables 5 ≥1.1 cup eq/1000 kcals No vegetables
Greens and beans 5 ≥0.2 cup eq/1000 kcals No Dark Green Vegetables or Legumes
Whole grain 10 ≥1.5 oz eq/1000 kcals No whole grain
Dairy 10 ≥1.3 cup eq/1000 kcals No dairy
Total protein foods 5 ≥2.5 oz eq/1000 kcals No protein foods
Seafood and plant proteins 5 ≥0.8 oz eq/1000 kcals No seafood and plant proteins
Fatty acid ratio 10 (PUFAs + MUFAs)/SFAs ≥ 2.5 (PUFAs + MUFAs)/SFAs ≤ 1.2
Moderation
Refined grain 10 ≤1.8 oz eq/1000 kcals ≥4.3 oz eq/1000 kcals
Sodium 10 ≤1.1 gram/1000 kcals ≥2 gram/1000 kcals
Added sugars 10 ≤6.5 % of energy intake ≥26 % of energy intake
Saturated fats 10 ≤8 % of energy intake ≥16 % of energy intake
Total score 100 – –

Database.18 Finally, the components and total score of
HEI-2015 were calculated based on the DGA 2015-
202019 and the USDA standards for HEI-2015 (the last
version of HEI).20 An overview of the USDA standards
for calculating components and total score of the HE-
2015 are shown in Table 1. All the participants were
stratified into 3 diet quality categories including “poor”
(a HEI score of 50 or less), “needs improvement”
(a HEI score of between 51 and 80), and “good”
(a HEI score of 81 or more) based on the recommended
HEI criteria.21
Assessment of Anthropometric Measures.—Weight
was measured without shoes while the women
were minimally clothed to the nearest 100  g by
using the digital scale Seca model 769. Height was
measured while the subjects were standing, without
shoes and the shoulders in normal position to the
nearest 1mm using a stadiometer. For calculating body
mass index (BMI) (kg/m2), weight (kg) was divided
by height (m2). All the participants were categorized
into 4 groups based on their BMI measures, including
underweight (BMI < 18.5), normal (18.5 ≤ BMI < 25),
overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30).22
Waist circumference (WC) was measured at the
narrowest point between the lowest rib and the iliac
crest without any pressure to the body surface to the
nearest 1mm. Hip circumference (HC) was measured
at the maximum level over light clothing to the nearest
1mm. Waist and hip circumferences were measured by
using an inelastic tape. Waist to hip ratio (WHR) was
calculated as WC divided by HC. Then participants
were divided into 2 groups, including “a WHR of lower
0.85” and “a WHR of 0.85 or greater” based on the
standards of world health organization (WHO). All
variables were measured by a single person to prevent
measurement errors.
Potential Covariates.—Additional covariate
information including age, marital status, and migraine
status (pain intensity, attack frequency and family
history of migraine) were obtained by a questionnaire
through a face-to-face interview. The visual analog scale
(VAS) for pain was used to measure pain intensity.23
Participants were divided into 2 groups including
women with CM and women with EM based on the
ICHD criteria.15 Headaches occurring 15 or more days
per month and for more than 3 months, with features of
migraine headache on at least 8 days per month, were
considered as chronic; and the migraine and migraine
headaches occurring less than 15 days per month were
considered episodic.15
Statistical Analysis.—Data were analyzed using
SPSS software (SPSS Inc., Chicago, IL, version 20).
This is a preplanned and primary analysis of this data.
The scores of the 13 components were summed to
yield a total HEI score. Distribution of each variable
was considered normal if the standard deviation was
1224 September 2019

Table 2.—Demographic and Migraine Characteristics of Women With Episodic and Chronic Migraine

Episodic Migraine Chronic Migraine

Characteristics Total (N = 285) 169 (59.3%) 116 (40.7%) P Value

Age (year) 37 ± 9 35 ± 8 38 ± 9 .002‡

Marital status Married 220 (77.2) 134 (79.3) 86 (74.1) .52§
Not married 65 (22.8) 35 (20.7) 30 (25.9)
Migraine type With aura 26 (9.1) 152 (89.9) 107 (92.2) .54¶
Without aura 259 (90.9) 17 (10.1) 9 (7.8)
Pain intensity (0-10)† 7.58 ± 1.56 7.61 ± 1.55 7.55 ± 1.57 .74‡
Migraine family history No 169 (59.3) 105 (62.1) 64 (55.2) .90§
Yes 116 (40.7) 64 (37.9) 52 (44.8)

Continuous variable are presented as mean ± standard deviation. Qualitative variables are presented as frequency (percentage).
†Based on VAS scale.
‡P value based on independent sample t-test.
§P value based on Fisher’s exact test.
¶P value based on Pearson chi-square.

lower than half of the mean. Independent sample
t-test, Mann-Whitney, and chi-square test (Pearson
chi-square and Fisher’s exact test) were applied where
appropriate to compare general characteristics and
HEI scores of women with CM and EM. A multiple
regression model was employed using several
covariates to compare the HEI scores of women
with EM and CM (model 1: unadjusted, model 2:
adjusted for energy intake per day, BMI category and
WHR category, model 3: further adjusted for age,
marital status, migraine type, pain intensity, and
family history of migraine). Testing of hypothesis was
2-tailed and the statistical significance was considered
at the P < .05 level.
RESULTS
Fifteen participants were excluded due to having
more than 70 blank items on the FFQ. There was no sig-
nificant difference between characteristics of 15 excluded
patients and 285 remained participants. Demographic
and migraine characteristics of the women with episodic
and chronic migraine are shown in Table 2. The mean
age of participants was 37  ±  9 years and the women
with CM were significantly older than the women with
EM (P = .002). Most of the participants were married
(220/285 [77.2%]). Only 26/285 (9.1%) of the partici-
pants had migraine with aura and 169/285 (59.3%) of
them had no family history of migraine.
The anthropometric characteristics and dietary in-
take of participants are shown in Table 3. Compared
with episodic migrainous women, the chronic patients
had a significantly higher intake of energy from fat
(P  =  .01) and a lower intake of energy from carbo-
hydrate (P  =  .02). In addition, 116/285 (40.7%) and
95/285 (33.3%) of the patients were overweight and
obese, respectively; and 147 (51.6%) of them had
WHR  ≥  0.85. There were a significant difference
between women with EM and CM in the terms of
WHR categories (P = .04).
The HEI components and total scores are pre-
sented in Table 4. The women with CM had a lower
score in terms of total fruit (P  <  .001), whole fruit
(P < .001), greens and beans (P = .001), and total score
(P = .02) significantly. In addition, the women with CM
had a higher score in terms of dairy products (P = .01)
and fatty acid ratio (P = .01) significantly. Moreover,
based on the HEI criteria, 50/285 (17.5%), 233/285
(81.8%), and 2/285 (0.7%) of migrainous women had
“poor,” “needs improvement,” and “good” diet quality,
respectively.
Results of the multiple regression model to as-
sess the relation between HEI scores are shown in
Table 5. In the unadjusted model, there was a signif-
icant negative association between CM and the HEI
score (β = −2.30; 95% CI: [−4.18 to −0.42]; P = .02).
After adjusting for anthropometric, dietary intake,
Headache 1225

Table 3.—Anthropometric Characteristics and Dietary Intake of Women With Episodic and Chronic Migraine

Episodic Migraine Chronic Migraine

Characteristics Total (N = 285) 169 (59.3%) 116 (40.7%) P Value

Mean ± SD
Weight (kg) 71.55 ± 13.72 72.07 ± 13.20 70.81 ± 14.47 .45†
BMI (kg/m2) 28.26 ± 5.43 28.46 ± 5.16 27.98 ± 5.83 .46†
Energy intake per day (kcal) 3140.81 ± 1094.33 3147.59 ± 1158.68 3136.16 ± 1051.37 .93†
Percent of energy from carbohydrate 55.53 ± 5.47 56.18 ± 5.46 54.58 ± 5.75 .02†
Percent of energy from protein 13.61 ± 1.74 13.77 ± 1.68 13.38 ± 1.81 .07†
Percent of energy from fat 33.56 ± 5.47 32.82 ± 5.27 34.65 ± 5.61 .01†
Frequency (percent)
BMI category BMI < 18.5 6 (2.1) 3 (1.8) 3 (2.6) .21‡
18.5 ≤ BMI < 25 68 (23.9) 34 (20) 34 (29.3)
25 ≤ BMI < 30 116 (40.7) 78 (46.2) 38 (32.8)
≥30 95 (33.3) 54 (32) 41 (35.3)
WHR category <0.85 138 (48.4) 73 (43.2) 65 (56) .04§
≥0.85 147 (51.6) 96 (56.8) 51 (44)

†P value based on independent sample t-test.

‡P value based on Fisher’s exact test.
§P value based on Pearson chi-square.

Table 4.—Comparing HEI Scores of Women With Chronic and Non-Chronic Migraine Headaches

Episodic Migraine Chronic Migraine

HEI-2015 Total/Component Score Total (N = 285) 169 (59.3%) 116 (40.7%) P Value

Total fruit 4.16 ± 1.02 4.35 ± 0.84 3.87 ± 1.19 <.001†

Whole fruit 4.86 ± 0.48 4.96 ± 0.24 4.72 ± 0.67 <.001†
Total vegetables 3.96 ± 1.02 4.06 ± 0.95 3.82 ± 1.11 .05†
Greens and beans 4.32 ± 0.98 4.47 ± 0.89 4.09 ± 1.07 .001†
Whole grain 0.5 (0-10) 0.5 (0-10) 0.5 (0-10) .13‡
Dairy 4 (0.5-10) 3.5 (0.5-10) 4.5 (0.5-10) .01‡
Total protein foods 3.56 ± 0.98 3.59 ± 0.98 3.51 ± 0.99 .48†
Seafood and plant proteins 4.28 ± 0.97 4.34 ± 0.95 4.2 ± 0.99 .24†
Fatty acid ratio 6.43 ± 2.90 6.07 ± 2.93 6.95 ± 2.80 .01†
Refined grain 0 (0-10) 0 (0-10) 0 (0-10) .71‡
Sodium 0 (0-10) 0 (0-9) 0 (0-10) .19‡
Added sugars 9.68 ± 0.82 9.71 ± 0.79 9.64 ± 0.86 .52†
Saturated fats 7.55 ± 2.21 7.56 ± 2.26 7.54 ± 2.15 .94†
Total score 57.29 ± 7.98 58.23 ± 7.93 55.93 ± 7.90 .02†

Variables are presented as mean ± standard deviation or median (min-max).

†P value based on independent sample t-test.
‡P value based on Mann-Thitney test.

and demographic characteristics, the association DISCUSSION

remained significant (β  =  −2.03; 95% CI: [−3.97 to
−0.10]; P = .04). In the other word, the women with
CM exhibited a −2.034 points lower HEI score in
comparison to the women with EM (β  =  −2.03) in
the third model.
Diet has been recognized as one of the principal fac-
tors contributing to health complications and chronic
diseases.24 Many studies evaluated the effect of single or
multiple dietary factors on migraine.9,11,13,25-27 Moreover,
there is some evidence to indicate the positive effect of
1226
Table 5.—The Multiple Regression Model to Assess
the Relation Between HEI Scores and Migraine Type
Model β SE 95% CI P Value
Model 1 −2.30 0.96 −4.18 to −0.42 .02
Model 2 −2.29 0.97 −4.19 to −0.38 .02
Model 3 −2.03 0.98 −3.97 to −0.10 .04
Model 1: Unadjusted.
Model 2: Adjusted for energy intake, BMI category and WHR
category.
Model 3: Model 2  +  age, marital status, migraine type, pain
intensity, and family history.
high diet quality on migraine management.8,9,11-13 So,
this study compared the diet quality of women with CM
and EM.
In line with the previous studies, the findings of the
present study showed that the diet quality of most mi-
grainous women was “poor” or “needs improvement.”
Evans et al (2015) also reported the same results in a
study on migrounous women. Moreover, they showed
that the diet quality of migrainous women was lower
than women without migraine.8
Moreover, for the first time, we revealed that the
HEI score was significantly lower in women with CM
compared with that of women with EM and there
was a significant inverse association between CM
and the HEI score. In a case-control study, adherence
to DASH diet (a healthy diet with a higher consump-
tion of fruit, vegetables, beans, and whole grains and
a lower consumption fat) has been accompanied with
lower risk of CM in comparison to women with low-
est adherence.28 Furthermore, it has been shown that
migrainous patients with low diet quality (such as
adherence to a Western dietary pattern consisting of
high amounts of refined grains, saturated fats, full
fat dairies, and low amounts of whole grains, unsatu-
rated fats, low-fat dairies, and vegetables) were more
susceptible to higher migraine attack frequency and
duration.29
The negative association between the diet quality
and CM may be due to the higher anti-inflammatory
and antioxidant effect of high quality diets. In this
regard, Hann and colleagues (2001) in a case-con-
trol study, evaluated the association of HEI score
September 2019
and plasma concentration of carotenoids, folate, and
vitamin C (as biomarkers of long-term vegetable
and fruit intakes).30 They indicated that the women
with high HEI score had a higher concentration of
plasma biomarkers and a lower intake of fats and
saturated fats.30 Moreover, other studies introduced
the antioxidant and anti-inflammation effects of
these biomarkers which originate from the healthy
diets.31,32 Besides, the recent studies found strong
evidence which indicates inflammation and oxidative
stress might be implicated with migraine etiology.33,34
So, a high-quality diet with a higher amount of
antioxidant and anti-inflammatory nutrients might
be helpful to reduce migraine attack frequency and
duration. In line with these findings, the results of
this current study showed that the women with CM
had a lower intake of fruit, vegetables and beans and
a lower total HEI score in comparison to women
with EM.
In the current study, the women with CM had a
higher score of consuming dairy products. In various
studies of migraine precipitants, all kinds of dairy
products have been introduced as migraine trig-
gers.12,26,35,36 So, it seems that a higher consumption
of dairy products in women with CM is one of the
important dietary factors of their higher attack fre-
quency. Moreover, the women with CM had a higher
score of fatty acid ratio. But it doesn’t mean they had
healthier intakes in terms of fats in comparison to
women with EM. Based on the results, the women
with CM had a significantly higher percentage of
energy intake from the fats group. Ferrara and col-
leagues (2015) assessed the effect of a low-lipid diet
compared with a normal-lipid diet in migrainous
patients with 35% of energy from fat; they showed
a significant decrease in severity and frequency of
migraine attacks in both case and control groups but
a higher decrease in case group.25 Bic and colleagues
(1999) also reported the positive effect of a low-fat
diet on migraine duration and attack frequency.11 In
line with this evidence, in the present study, the total
amount of fat intake was higher in chronic migrain-
ous women and they had higher attack frequency per
month.
Some limitations should be explained in the cur-
rent study: First, we applied FFQ for evaluating the
Headache
diet quality; so, the limitation of FFQ for assessment
of dietary intakes (such as underreporting or over-
reporting of food intakes purposely or unintention-
ally) should be considered. Second, due to the use of
cross-sectional design for study, we could not mark
cause and effect association.
Migraine and aura status were diagnosed by a neu-
rologist that could be considered as a strength for the
current study.
In conclusion, based on the HEI recommended
categorization, the diet quality of most migrainous
women was not “good.” For the first time, we showed
that the women with CM had a lower diet quality
than the women with EM. Moreover CM had a neg-
ative association with diet quality. So, improving diet
quality may be a useful approach to manage migraine
attacks. However, from a research point of view, fur-
ther longitudinal studies are needed to confirm these
results.
Acknowledgments: The authors would like to thank all the
patients who eagerly participated in the current study. All
the authors declare that they have no conflicts of interest.
This article was extracted from the M.Sc. thesis of Samaneh
Hajjarzadeh.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Reza Mahdavi, Zeinab Nikniaz
(b) Acquisition of Data
Samaneh Hajjarzadeh, Maryam Behrouz, Davood
 sentative sample of women with and without severe
Shalilahmadi
(c) Analysis and Interpretation of Data
Zeinab Nikniaz, Samaneh Hajjarzadeh, Reza

Mahdavi
Category 2
(a) Drafting the Manuscript
Samaneh Hajjarzadeh
(b) Revising It for Intellectual Content
Reza Mahdavi, Zeinab Nikniaz, Davood Shalilahmadi,
Maryam Behrouz
Category 3
(a) Final Approval of the Completed Manuscript
Zeinab Nikniaz, Reza Mahdavi, Samaneh Hajjar­
 13. Shaik MM, Gan SH. Vitamin supplementation as
zadeh, Maryam Behrouz, Davood Shalilahmadi
1227
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