Perceived triggers of primary headache disorders: A meta-analysis

Pellegrino, A Brooke Walters; Davis-Martin, Rachel E; Houle, Timothy T; Turner, Dana P; Smitherman, Todd A

doi:10.1177/0333102417727535

Cited by 288Migraine and Headache StudiesTemporomandibular Joint DisordersTraumatic Brain Injury Research

Perceived triggers of primary headache disorders: A meta-analysis

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Pellegrino, A Brooke Walters, Davis-Martin, Rachel E, Houle, Timothy T, Turner, Dana P, Smitherman, Todd A·2018·Cephalalgia

DOI 10.1177/0333102417727535PMC PMC8544028

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Abstract

Objective: To quantitatively synthesize extant literature on perceived triggers of primary headache disorders. Methods: A meta-analytic review of headache trigger survey studies was conducted. Endorsement rates, assessment method, and headache and sample characteristics were extracted from included articles. Separate random-effects models were used to assess trigger endorsement rates and post-hoc meta-regressions examined potential moderator variables. Results: 85 articles from 1958 to 2015 were included, involving 27,122 participants and querying 420 unique triggers (collapsed into 15 categories). Four-fifths (0.81; 95% CI .75 to .86) of individuals with migraine or tension-type headache endorsed at least one trigger. Rates increased with the number of categories queried (OR: 1.18, 1.08–1.30) and year of publication (OR: 1.04, 1.00–1.08). The triggers most commonly endorsed were stress (.58, .53–.63) and sleep (.41, .36–.47). Conclusions: Extreme heterogeneity characterizes the headache trigger literature. Most individuals with a primary headache disorder perceive their attacks to be triggered by one or more precipitants, the most common of which are stress and sleep. However, trigger endorsement is influenced by method of assessment. Enhancing methodological consistency and prioritizing experimental studies would improve our understanding of headache triggers.

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Emotional distress is regarded as the most important trigger in migraine attacks.
“since emotional distress is regarded as the most important trigger in migraine attacks (6).”
From Efficacy of Cognitive-Behavioral Therapy for the Prophylaxis of Migraine in Adults: A Three-Armed Randomized Controlled Trial (2022) · cites this paper as [6]
The Discussion says stress is the most common perceived headache trigger, which supports the claim’s central point. But the meta-analysis covers migraine and tension-type headache together, and it measures how often triggers are endorsed—not whether emotional distress is the most important trigger specifically for migraine attacks. (LLM, conf=0.82)
Experimental — accuracy not yet measured
Interoceptive awareness localizes to the insula, a brain area considered a hub of activity in migraine that plays a key role in integrating sensory, autonomic, cognitive, and emotional processes.
“Interoceptive awareness localizes to the insula,39 an area of the brain considered a “hub of activity” in migraine, playing a key role in integrating many of the dynamic processes of migraine (sensory, autonomic, cognitive, and emotional).40”
From Mechanisms of mindfulness in patients with migraine: Results of a qualitative study. (2023) · cites this paper as [40]
Citation 40 is attached to the claim that the insula is a migraine activity hub integrating sensory, autonomic, cognitive, and emotional processes. The Introduction and Discussion address migraine stimuli, perceived triggers, and stress-related autonomic effects, but our copy does not address the insula or its proposed integrative role. Searches for the insula, interoceptive awareness, and the stated processes found no relevant passage; citation 39, not this source, is attached to the separate localization claim. (LLM, conf=0.76)
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Authors: Pellegrino, A. B. W., Davis-Martin, R. E., Houle, T. T., Turner, D. P., & Smitherman, T. A.
Affiliations: Hartford HealthCare Headache Center, West Hartford, CT, USA
University of Massachusetts Chan Medical School (US)
Massachusetts General Hospital (US)
University of Mississippi (US)
Corresponding author: Smitherman, Todd A
ORCID: Pellegrino, A Brooke Walters
Davis-Martin, Rachel E
Houle, Timothy T
Turner, Dana P
Smitherman, Todd A
Venue: Cephalalgia
Publisher: SAGE Publications
Published: 2017-08-20
Volume: 38
Issue: 6
Pages: 1188-1198
ISSN: 0333-1024 (ISSN-L)
1468-2982
DOI: 10.1177/0333102417727535
PMC: PMC8544028
OpenAlex: W2746815301
Cited by: 288
References: 24
Citations by year: 2026: 16 · 2025: 37 · 2024: 75 · 2023: 29 · 2022: 25 · 2021: 34 · 2020: 25 · 2019: 24 · 2018: 16 · 2017: 5 · 2014: 1
FWCI: 2.91
Type: journal article
Language: en
Open access: green
europepmc.org
Licence: journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations: Cephalalgia (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: National Institute of Neurological Disorders and Stroke (R01NS065257)
Topics: Health Sciences › Medicine › Psychiatry and Mental health › Migraine and Headache Studies
Health Sciences › Health Professions › Complementary and Manual Therapy › Temporomandibular Joint Disorders
Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
Keywords: headache triggers, primary headache, migraine, tension-type headache, stress, sleep
MeSH terms: Humans, Headache Disorders, Primary

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Perceived triggers of primary headache disorders: A meta-analysis

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