I Hate Drinking Water. Who’s with me?
There. I said it. I am a registered dietitian who nearly shudders at the thought of drinking a big glass of water. Warding-off a dehydration headache and triggering a migraine is often on my mind. My challenge is getting my good intentions to translate to healthy imbibing on a regular basis.
In social media, it’s not uncommon to see rants like “if one more person tells me to drink more!” Or the sarcastic, “Gee, why didn’t I think of that. A glass of water to cure me of this disease I’ve had for 30 years.” When well-intentioned friends or family members suggest drinking more water as a remedy to our aching heads and neurological weirdness, I think most of us just bite our tongues while a few others may fire off a flippant response.
I think I nearly bit through my tongue when I was given the same unwelcomed advice when I felt like a failure for not being able to successfully breastfeed my daughter. Hormones, c-section pain, feeling like a blob, sore boobs, a hungry and screaming newborn, surrounded by witnesses. Those were the days! So, I understand the desire to assault the person giving advice.
Back to migraine- Of course, we have heard that drinking more water helps our aching heads. But, does science back that up? Can dehydration cause headaches and migraine attacks? How about extra hydration? Is it part of preventing attacks or treating the attacks? How much water do we need? For those of us who are resistant to this advice and can’t stand drinking unless seriously thirsty, what can we do? Might increasing our fluids help with other aspects of managing this complex and often debilitating condition?
Are we more prone to dehydration or do we just need more fluids than others?
While researching this topic, I came across a bit of info I hadn’t heard before. Some doctors and researchers think that diuresis may be part of prodrome. Diuresis is when the kidney increases the amount of urine made.
Prodrome is the phase that some of us experience in the hours (or days) before the actual attack becomes obvious. American Migraine Foundation’s graphic and description of the stages of migraine provides a great visual.
If nausea is part of your prodrome it’s not a surprise that keeping hydrated to fend off the attack or abort the attack would be especially hard. Who wants to keep drinking when you have the queasies? (More on specific tips to help nausea later in this article)
I had heard anecdotal stories of people saying that they need to pee a lot and/or seem thirstier before migraine, but I had not seen it mentioned in any studies before. A few weeks ago, this symptom became apparent to me. I was not at home so I became more aware of needing to search for public bathrooms.
I didn’t just have an uptick in the sensation of needing to go. My bladder kept filling up even though I didn’t feel especially thirsty nor was I drinking much more. Diuresis! Sure enough, later that evening I sensed familiar head pain followed by jaw pain and knew a migraine was on the way.
So, if you consider possible diuresis, plus the common complaint of gastrointestinal issues before migraine is in full swing, it seems logical that some people would be more prone to dehydration headache and migraine.
Do we need to just avoid dehydration or do people with migraine benefit from additional fluids?
It turns out that there is a nice but small study that suggests increased water intake improves migraine pain symptoms AND occurrences. In this study, there was a reduction in intensity and frequency of migraine headache. It is well-accepted that there is a relationship between dehydration and migraine. Perhaps this study plus lots of anecdotal experience of emergency room doctors, neurologists and headache specialists suggests that keeping a steady flow of additional water may be helpful in reducing our frequency and intensity of migraine. The study supports increasing water by 1.5 liter/day as a preventative strategy.
Can fluids help treat an active migraine attack?
The standard of care in many emergency departments is for giving lots of intravenous fluids for people with migraine. The authors of an often referred to guide on acute migraine treatment said, “fluid replacement is arguably an underappreciated aspect of acute migraine therapy.”
So, it looks like the answers to both questions above is YES. Having migraine makes us more prone to dehydration headache and migraine attacks. And, people with migraine benefit from additional fluids to prevent and treat attacks.
As annoying as it is to hear the nagging advice to drink more water, it’s an important piece of the Treatment Pie that we discuss often in our closed Facebook group. And, even though we are looking to our doctors to come up with something less mundane than drinking more water, they know it helps. I find it refreshing when a doctor takes the time to talk about something besides more medications that are expensive, require jumping through hoops for approval and may potentially have significant side effects. What if it helps you feel 30% better? You may already be drinking all that you need to help your head, but many of us do not, present company included.
What the experts say- Does dehydration cause headache and migraine?
After scouring the internet, I found very little satisfying research about the relationship between hydration and migraine. Fortunately, the body of evidence from experts and people who get frequent dehydration headaches and migraine cannot be denied.
Many or most doctors certified in headache medicine will tell you that dehydration is a top trigger. Dehydration is probably sited shortly after stress and poor sleep as a trigger for a headache that starts the cascade into the usual migraine symptoms. It’s not a cause, but a trigger.
According to Dr. Cynthia Armand, assistant professor of neurology at the Montefiore Headache Center at Albert Einstein College of Medicine, “The final key component of good headache hygiene is consistent hydration. We know dehydration is the biggest, most potent trigger for migraine, so hydrate, hydrate, hydrate!” Dr. Armand’s video about “headache hygiene” on the American Migraine Foundation’s site is quite good. I’m sure most of her patients get the message about dehydration headache and migraine. The woman is on a mission!
During this year’s Migraine World Summit there were several mentions of dehydration as a trigger as well as a session entitled “How Fasting, Weight and Dehydration Affect Your Brain,” by Dr. Elizabeth Leroux, director of the Montreal University Headache Center. The doctors acknowledge that hearing “drink more water” can be infuriating to a struggling patient, but the advice is important to the overall management of migraine.
How much water do we need to prevent dehydration headache and migraine?
The information in this video from NutritionFacts.org has lots of interesting information about the current water recommendations for men and women. The recommendation is for 4-7, 8 ounce cups per day for women and 6-11, 8 ounce cups for men assuming ambient temperature and moderate activity levels. For many of us, this amount of fluid may seem daunting. Couple that info with the information from the study suggesting the benefit of adding another 1.5 liters of water to your day and you just might stop reading this article here. Please don’t get overwhelmed. Baby steps! My tips at the end of this article will help you get on the right track if you have camel-like tendencies.
First, let’s go over some challenges specific to migraine and hydration.
Hydration when you have GI distress
Nausea, vomiting, diarrhea and constipation are all common complaints for those of us with migraine. Often, these symptoms are part of the migraine attack and resolve when the attack lifts. Other times these symptoms are frequent nuisances or incapacitating. Let’s explore how hydration and dehydration impact common GI symptoms.
Nausea and Vomiting
Did you know that nausea can be a symptom of dehydration? Yes, it can be both a symptom as well as a cause.
When nausea is a symptom of dehydration – While researching studies for this article, I came across a few studies with athletes looking at dehydration and GI distress. The nausea associated with exercising while dehydrated was attributed to delays in gastric emptying time. Since it is already known that some people with migraine have delayed gastric emptying during and sometimes in between migraine attacks, perhaps even mild dehydration may contribute to nausea for people prone to migraine attacks. This is conjecture on my part.
According to the American Heart Association, another possible reason for dehydration causing nausea is that being dehydrated may cause a decrease in blood pressure. A common symptom of low blood pressure is nausea. Anecdotally, I know many people with migraine with low blood pressure or normal blood pressure that tends to be in the lower range. It would be interesting to measure blood pressure to see if it’s comparatively low in a significant number of people experiencing nausea with migraine.
When nausea causes dehydration the reason is obvious. Not many people feel like eating or drinking when they feel green about the gills. It can be a vicious cycle leading to worsening migraine symptoms.
What to do about nausea
If you have a long history of migraine with nausea and vomiting you may have figured out a few things that help you. I highly recommend reading this thorough article with with 15 tips from Jennifer Bragdon. I promise that she will have at least one tip that you haven’t tried before.
If home remedies and over-the-counter drugs don’t help there are good medications for nausea and vomiting (antiemetics). Consider asking your doctor to prescribe the suppository form if you have concerns about keeping the medication down.
Dehydration will only make you feel worse and prolong getting back to feeling normal. A BIG bonus of the anti-nausea meds is that they not only act on neurochemistry associated with nausea relief, but also pain and other symptoms of migraine. Anti-nausea meds double as abortives for migraine and they are not associated with rebound. These medications are valuable tools in your migraine toolbox. Different nausea meds work on different chemicals in your brain, so you might need to try meds from different classes to find relief. For example, Zofran is a serotonin antagonist while Compazine and Phenergan are dopamine antagonists. If one doesn’t work for your nausea the other might. Ask your doctor for help with different medications. Remember, we might benefit from more fluid each day than the typical person who doesn’t have migraine.
Some people have a natural tendency toward being constipated. For them, increasing fluid is important to stimulate the GI tract to move things along. Water is also important to keeping the things soft and movable as it passes through the colon. One job our colon has is the removal of water from stool. So, if your colon is an over-achiever, you need to give your body more water.
Since the new anti-CGRP meds like Aimovig became available, relieving constipation has been a hot topic in doctor’s offices and social media. Read this article for more in-depth information on the subject of constipation.
There is an association of irritable bowel syndrome with migraine. For many, that means frequent bouts of diarrhea both associated with migraine attacks and in between migraine attacks. Finding the right beverage to replace fluids and electrolytes flushed down the toilet is critically important in keeping you healthy overall as well as keeping a dehydration headache or migraine attack from starting or worsening. You may find that room temperature or slightly warm beverages are tolerated better if your GI tract is especially sensitive.
For those with significant GI distress from vomiting and/or diarrhea, IV fluids and electrolytes may be the only solution to help replace what you’ve lost. Of course, emergency departments provide this as well as some doctor’s offices and urgent care centers. In some areas of the US there are private IV hydration sites that may be a solution to get you back on your feet.
11 Tips for staying hydrated
Here’s what I do plus some tips from people who successfully drink enough each day:
- Set a jug or pitcher aside each day with what you will drink that day (i.e. a full, gallon jug). Make sure half is consumed by lunch time. If this amount is too intimidating, start smaller and work up to a larger amount. This nifty gallon jug has motivation sayings on it to keep you going.
- Drink a full glass of water as soon as you get up in the morning and before you have your customary drink (i.e. tea, decaffeinated coffee)
- Make the water more tasty and interesting by adding strawberries, cucumber slices, ginger or mint leaves in the pitcher.
- Experiment with different types of non-sugary beverages that aren’t common migraine triggers.
- Experiment with carbonation and temperature. You may like mild carbonation but not super-bubbly seltzer. Personally, I like drinking Pellegrino from glass bottles as the bubbles are tiny and give me a pleasant sensation. Some bubbles are too perky for me. You may like iced drinks when it’s over 70 degrees outside and room-temperature drinks when it’s cooler. Be mindful of what seems to work better for you.
- Experiment with containers. Below is a picture of my Yeti thermal cup and bubbly water but there are many other great vessels to try. Drinking is so much easier for me if it’s in my thermal cup and without ice. I like cool, not cold.
- Try some electrolyte replacement drinks like Propel, unflavored. Beware – some of these drinks contain ingredients that if some people are sensitive to like citric acid and artificial sweeteners.
- Try one of several smartphone apps that will remind you to drink and track your intake
- When you feel a migraine attack coming on, set a timer for every 30 minutes and chug 4 ounces of water until you hit your goal
- Keep a container of water near you at home and/or at work so you can sip it throughout the day
- Keep a container of water in the car. Consider keeping an insulated tote in the car if you prefer your beverages cold. Here’s a another good option for the car.
Might increasing your hydration help you? You won’t know until you try.
A note about water toxicity
It happens rarely, but there have been instances when individuals drank too much water than their body could handle and became ill with water intoxication. In general, our body can properly handle a lot of water over the course of a day. In order to avoid water intoxication symptoms, do not exceed more than 27-33 ounces of water per hour, on average.