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

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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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Self-citation
Association of Personal Protective Equipment with De Novo Headaches in Frontline Healthcare Workers during COVID-19 Pandemic: A Cross-Sectional Study
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Efficacy of Cognitive-Behavioral Therapy for the Prophylaxis of Migraine in Adults: A Three-Armed Randomized Controlled Trial
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An Integrative Cognitive Behavioral Therapy Program for Adults With Migraine: A Feasibility Study
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Perceived stress and pain severity in individuals with chronic migraine: A longitudinal cohort study using daily prospective diary data
Vives‐Mestres, M., Casanova, A., Hershey, A. D., & Orr, S. L. (2021) · Headache The Journal of Head and Face Pain · doi:10.1111/head.14199 · Cited by 22
Effect of a Craniosacral Therapy Protocol in People with Migraine: A Randomized Controlled Trial
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“However, in addition to such variables, our approach includes the emotional disability variable, an essential aspect in patients with primary headaches [48,49] and chronic pain [50].”
Background
Cognitive or daily stress association with headache and pain induction in migraine and tension-type headache patients: a systematic review
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“physiologic mechanisms of these painful conditions [14].”
BackgroundInfluential
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Sebastianelli, G., Atalar, A. Ç., Cetta, I., Farham, F., Fitzek, M. P., Karataş, H., Kholodova, M., Kukumägi, K.-H., Montisano, D. A., Onan, D., et al. (2024) · Cephalalgia · doi:10.1177/03331024241287224 · Cited by 22
“Furthermore, shedding light on this topic might lead to the development of new drugs to treat migraine attacks in their earliest phase, when they have more chances to be effective (9).”
Attention deficit hyperactivity disorder and risk of migraine: A nationwide longitudinal study
Hsu, T., Chen, M., Chu, C., Tsai, S., Bai, Y., Su, T., Chen, T., & Liang, C. (2022) · Headache The Journal of Head and Face Pain · doi:10.1111/head.14306 · Cited by 22
Triggers of Primary Headaches: Issues and Pathways Forward
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“The meta-analysis referred to earlier was based on 85 studies of headache triggers and 420 triggers were identified, which they proceeded to group into 15 categories.(13) A strength of this study was that the authors also looked at classifying triggers into fewer categories (4) or more categories (30), and conducted s…”
BackgroundMethodResultInfluential
Hallmarks of primary headache: part 3 – cluster headache
Coppola, G., Arruda, M. A., Ashina, M., Barloese, M. C. J., Belin, A. C., Bottiroli, S., Chowdhury, D., Icco, R. D., Lorenzo, C. D., Stefano, G. D., et al. (2025) · The Journal of Headache and Pain · doi:10.1186/s10194-025-02145-6 · Cited by 20
Migraine triggers in Asian countries: a narrative review
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An observational study of headaches in children and adolescents with functional abdominal pain
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“Daily stress due to school work, and lack of adequate sleep, among other factors, precipitate the burdens of these disorders in school-age children and the adult population (Visudtibhan et al., 2010; Houle et al., 2012; Pellegrino et al., 2018).”
Background
Assessing attack‐related fear in headache disorders—Structure and psychometric properties of the Fear of Attacks in Migraine Inventory
Klan, T., Bräscher, A., Klein, S., Diezemann, A., Guth, A., Gaul, C., & Witthöft, M. (2022) · Headache The Journal of Head and Face Pain · doi:10.1111/head.14272 · Cited by 17
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“…(13), evidence of therapist training in treatment modalities administered (8), randomization by a third party (11), reduction of allocation bias (9), reduction of measurement bias (10), equivalence in treatment expectations (10), Consolidated Standards of Reporting Trials (CONSORT)– consistent…”
BackgroundSelf-citation
Relation and Treatment Approach of Migraine in Pregnancy and Breastfeeding
Turankar, T. B., Sorte, A. G., Wanjari, M. B., Chakole, S. V., & Sawale, S. R. (2023) · Cureus · doi:10.7759/cureus.36828 · Cited by 15
“There are several documented causes of migraine, including stress and hormonal shifts [36].”
Background
Whether Weather Matters with Migraine
Denney, D. E., Lee, J., & Joshi, S. (2024) · Current Pain and Headache Reports · doi:10.1007/s11916-024-01216-8 · Cited by 15
“In a meta-analysis performed by Pellegrino et al., 27,122 participants rated weather as one of the top 4 triggers for their primary headache [2].”
Method
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A Micro-Longitudinal Study of Naps, Sleep Disturbance, and Headache Severity in Women with Chronic Migraine
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“Poor sleep has been found to precede migraine headaches (Andress-Rothrock et al., 2010; Boardman et al., 2006; Kelman & Rains, 2005; Odegard et al., 2011; Pellegrino et al., 2018) but other studies have found inconsistent or contrary results (Bertisch et al.”
ResultSelf-citation
Appraisal of Headache Trigger Patterns Using Calendars
Turner, D. P., Leffert, L. R., & Houle, T. T. (2019) · Headache The Journal of Head and Face Pain · doi:10.1111/head.13703 · Cited by 14
Self-citation
Types of Triggers in Migraine – Factor Structure of the Headache Triggers Sensitivity and Avoidance Questionnaire and Development of a New Short Form ( HTSAQ‐SF )
Caroli, A., Klan, T., Gaul, C., Kubik, S. U., Martin, P. R., & Witthöft, M. (2020) · Headache The Journal of Head and Face Pain · doi:10.1111/head.13896 · Cited by 14
“In a meta-analysis on perceived triggers of primary headache disorders, 420 unique triggers were reported across 27,122 total participants.(2) The most frequently cited triggers were related to stress (eg, mental stress, conflict), sleep (eg, fatigue, too much sleep), and emotion (eg, anger, fear).”
Background
Effectiveness of Tai Chi on Blood Pressure, Stress, Fatigue, and Sleep Quality among Chinese Women with Episodic Migraine: A Randomised Controlled Trial
Wang, S., Tian, L., Ma, T., Wong, Y. T., Yan, L. J., Gao, Y., Zhang, D., Hui, S. S., & Xie, Y. J. (2022) · Evidence-based Complementary and Alternative Medicine · doi:10.1155/2022/2089139 · Cited by 14
“In a recent metaanalysis involving 85 retrospective studies from 1958 to 2015 with a total of 27,122 participants, stress (58%) and sleep (41%) were the most common triggers indicated by patients with migraine [9].”
Background
Clinical Characteristics of Headache in Multiple Sclerosis Patients: A Cross-Sectional Study
Rościszewska-Żukowska, I., Galiniak, S., & Bartosik-Psujek, H. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12103518 · Cited by 13
“%) and sleepless nights (41.9%), which is consistent with migraine triggers identiﬁed in the general population [50].”
BackgroundInfluential
Primary headaches during the COVID-19 lockdown in Germany: analysis of data from 2325 patients using an electronic headache diary
Raffaelli, B., Mecklenburg, J., Scholler, S., Overeem, L. H., Gonçalves, A. S. O., Reuter, U., & Neeb, L. (2021) · The Journal of Headache and Pain · doi:10.1186/s10194-021-01273-z · Cited by 13
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Background
Sleep Symptoms and Disorders in Episodic Migraine: Assessment and Management
Vgontzas, A., Pavlovic, J. M., & Bertisch, S. M. (2023) · Current Pain and Headache Reports · doi:10.1007/s11916-023-01160-z · Cited by 13
Calcitonin Gene-Related Peptide (CGRP) and Pituitary Adenylate Cyclase-Activating Polypeptide (PACAP) in Migraine Pathogenesis
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Background
Association Between Electronic Diary–Rated Sleep, Mood, Energy, and Stress With Incident Headache in a Community-Based Sample
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“This approach acknowledges the potential variation in the influence of different trigger factors, recognizing that not all triggers affect patients equally (Supplement 1).”
Unraveling the directional relationship of sleep and migraine-like pain
Vizin, R. C. L., Kopruszinski, C. M., Redman, P. M., Ito, H., Rau, J. C., Dodick, D. W., Navratilova, E., & Porreca, F. (2024) · Brain Communications · doi:10.1093/braincomms/fcae051 · Cited by 11
“13,14 The nature and possible causal direction of interactions of migraine and sleep therefore remain uncertain.”
Background
Presenteeism in Non-Academic Staff in a Public University Context: Prevalence, Associated Factors, and Reasons to Work While Sick during the COVID-19 Pandemic
Magalhães, S. I. C., Barbosa, J., & Borges, E. M. D. N. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192214966 · Cited by 11
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Background
Predicting the Future of Migraine Attack Prediction
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“Premonitory features are the initial manifestation of an attack, generally preceding the onset of pain.(7)”
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Physical Activity is Associated with Less Analgesic Use in Women Reporting Headache—A Cross-Sectional Study of the German Migraine and Headache Society (DMKG)
Müller, B., Gaul, C., Glass, A. S., Reis, O., Jürgens, T. P., Kropp, P. A., Ruscheweyh, R., Straube, A. M., Brähler, E., Förderreuther, S., et al. (2022) · Pain and Therapy · doi:10.1007/s40122-022-00362-4 · Cited by 10
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Understanding the gaps in headache and migraine treatment with psychological and behavioral interventions: A narrative review
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Recruitment, retention, and adherence in a randomized feasibility trial of mindfulness-based stress reduction for patients with migraine
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Clinical-Epidemiology of Tension-Type Headache among the Medical and Dental Undergraduates of King Khalid University, Abha, Saudi Arabia
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Sleep, Work Stress and Headache in Printing Business: An Actigraphy Study
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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
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 › Clinical Neurology › Migraine and Headache Studies
Health Sciences › Dentistry › Oral Surgery › Temporomandibular Joint Disorders
Health Sciences › Medicine › Clinical Neurology › 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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