The occurrence of headache during fasting [4] is well known in the public and was established in the medical literature, especially with regard to short-term fasting such as the Yom-Kippur [6, 7] fast and the first day of Ramadan [8]. It seems to be associated with dehydration and caffeine withdrawal, and to be more common among sufferers of primary headaches. It is possible that other factors associated with changes in life style and stress also contribute to this phenomenon.
In the present cohort cross-over study; in which, we tried to evaluate the impact of Ramadan fast on the frequency of migraine attacks. We observed that a threefold increase in the frequency of migraine attacks during the entire month of Ramadan fasting, in a cohort of 30 episodic migraine patients treated in a neurological clinic. This phenomenon was associated with longer duration of migraine, lower frequency of migraine attacks, and migraine with aura. It seemed to be less pronounced in patients experiencing throbbing headaches and in married patients. Previous prophylactic therapy did not dampen this phenomenon.
Our study was preformed in 2009, in which Ramadan occurred in August, in the Negev desert area and dehydration is highly prevalent. Coffee and strong tea consumption is highly abundant in Bedouin culture and withdrawal is probably prominent. A previous [9] study has demonstrated higher rates of headache-related emergency room visits during Ramadan in Muslim communities in India. In addition, no epidemiological migraine surveys were preformed in the Bedouin community, our clinical experience is that migraine prevalence and characteristics are similar among Bedouins to the Jewish community. Therefore, we assume that increased frequency of migraine attacks among sufferers during the Ramadan is universal and also maybe to a lesser degree. Similar studies in cold weather and different lifestyles would provide us with further perspectives.
The International Classification of Headache, 2nd edition (ICHD-II, 2004) codes “Fasting headache” as a separated entity (10.5 of ICHD-II) [5]. Nevertheless, the ICHD-II criteria define fasting headache only when the patient was fasting for more than 16 h. The fasting time, during the time period between sunset and sundown in Israel during the study month is <14 h, making it impossible to consider the headache attacks “fasting headache”. However, it is possible that some of the headache attacks were similar to fasting headache in their pathophysiological mechanisms.
Our results raise an important clinical issue, involving the management of observant Muslim patients suffering from episodic migraine. Although none of our patients developed chronic migraine following the Ramadan fast, migraine suffering was dramatically increased and affected the patients’ quality of life and their ability to practice their religious fate.
Physicians treating Muslim migraine patients should discuss the issue with their patients and ask about the patients previous Ramadan experiences, and adapt the patient management accordingly.
Till today no trial results were reported, it seems reasonable to advice the patients (especially in hot weather) to consume high quantities of water each night, and to minimize the consumption of caffeine during Ramadan nights to avoid dehydration and withdrawal.
In high risk patients (especially those with a history of Ramadan-associated migraine exacerbations), pharmacological treatment should be discussed with the patients. The treatment should preferably be once daily (because of the Ramadan schedule) and without long titration periods. The drug should be discontinued immediately after the end of the Ramadan (The Islamic holiday of Eid ul-Fitr). In addition, there is no available data regarding the use of beta-blockers and tricyclic antidepressants during prolonged fasting. The potential for weakness, lightheadedness and hypotension [10] caused by these drugs could be aggravated during fasting and dehydration, which makes them bad choices for fasting patients. Topiramate requires a long titration and a twice daily regimen.
Rofecoxib (Vioxx®) was found [11] to be effective as a prophylactic treatment to Yom-Kippur headache. In addition, this drug is no longer available; other long-acting non-steroidal antiinflammatory drugs can be used, taken immediately after an early breakfast prior to sunrise.
Similarly long-acting triptan, such as naratriptan can be used; also caution must be drawn to the development of chronic daily headache.
Another option is the use of long-acting valproic acid preparation, taken once daily. This drug was used [12] successfully in a patient with episodes of hypoglycemia followed by attacks of migraine without aura.
Future studies should address the limitations of this preliminary study, looking into the circadian preponderance of the attacks, their relation to menstruation, or intercurrent illness in larger groups of migraine sufferers and non-sufferers.
Further studies are also needed to find effective ways to identify patient at risk and ways to manage the Ramadan-associated migraine exacerbation, which affects the lives of millions of Muslim migraine patients world wide, and many of them exacerbate 1 month each year.