Nutritional interventions for migraines often focus on adding something to one’s diet or supplements. For example magnesium feverfew and rosemary are just a handful of the nutrients and compounds that are effective for helping to reduce the frequency and severity of these debilitating attacks—at least in some people. Other strategies to ward off migraines or at the very least make them more bearable involve taking things out of the diet. “It’s genetic.”

People vary in what triggers their migraines but common culprits include beer wine cheese and chocolate. (As if having migraines wasn’t bad enough!) Sulfites and MSG are other potential triggers so perhaps the migraine reaction is related to a histamine or tyramine sensitivity as aged and fermented foods contain high levels of these compounds. (It’s a matter of debate whether tyramines induce migraines in susceptible individuals.) Then of course there are changes in barometric pressure but no matter how diligently someone controls their diet they can’t do much about the weather.

But what about taking something else out of the diet—something that has the potential to fundamentally alter brain energy metabolism and excitability? Removing gluten might be a good place to start—migraines are more prevalent in individuals with celiac disease gluten sensitivity and IBD. Gluten-free diets may improve a host of physical and psychological ailments but for many people going gluten-free might not be enough. If someone replaces the missing gluten with gluten-free bread crackers cookies pasta and cereal that’s still a pretty big load of carbohydrates. So what if going a couple steps further—removing almost all starch and sugar from the diet—could have a more powerful effect?

Remove almost all starch and sugar? Yep you guessed it: we’re talking about the ketogenic diet. Considering how effective this strategy is for a host of neurological conditions might it have a potential therapeutic role for migraines? In addition to epilepsy for which this dietary therapy has been used effectively for nearly a century this high-fat low-carbohydrate diet may be helpful for Parkinson’s disease ALS and multiple sclerosis so it wouldn’t be a complete surprise if it’s also beneficial—even mildly—in migraine another condition whose specific origins are unknown and that lacks a reliably effective intervention. To the extent that migraines might be triggered by a brain energy deficit or an over-excitability the ketogenic diet could do very well.

There isn’t a mountain of evidence on ketogenic diets for migraines but there’s enough supportive and promising data that this strategy would be worth giving a try for someone who’s incapacitated by these terrible occurrences. (What have they got to lose? They’ll have to go without some of their favorite foods for a while but the flipside is they’d likely have lower blood glucose and blood pressure higher HDL lower triglycerides and they might lose a couple pounds if they’re struggling with fat loss.)

A group of Italian researchers became interested in the potential for a ketogenic diet to be effective for migraines after two patients—twin sisters—reported a significant reduction in frequency and severity of migraines after implementing the diet for weight loss—talk about a nice unintended consequence! The patients were 47 years old and according to detailed “headache diaries” they kept experienced “5–6 attacks/month of severe throbbing headache of up to 72 hours’ duration; the severity was increased by movement and the attacks were accompanied by photophonophobia nausea and very occasionally vomiting.” In both cases the remission of migraines coincided with following the diet (headaches disappeared within three days) and they returned during the periods of following the habitual higher-carb diet. (Although even then the migraines were reduced in frequency intensity and duration.)

An interesting thing to note about this case study is that the subjects did not avoid potential dietary triggers such as phenylethylamine tyramine aspartame MSG nitrates nitrites and caffeine. They took several nutritional supplements but at levels much lower than would be considered to have a pharmacological effect. Additionally tests for celiac disease were negative in these patients although that doesn’t rule out non-celiac gluten sensitivity. So the study authors dismissed some of the potential reasons for migraine remission during the ketogenic periods writing “we attribute the improvement observed in these patients to ketogenesis the sole event found to be time-locked to the disappearance (and recurrence) of their migraine attacks.”

This promising result prompted a larger study this one involving 96 overweight female migraine sufferers. In the intervention group 45 subjects followed a very-low-calorie ketogenic diet (KD) for one month followed by a 5 month standard low-calorie diet. (The other 51 subjects followed the standard diet for all 6 months.) According to the study “In the KD group the baseline attack frequency (2.9 attacks per month) number of days with headaches (5.11 days per month) and tablet intake (4.91 doses per month) were significantly reduced after the first month of diet (respectively 0.71 0.91 0.51; overall KD versus baseline P < 0.0001.)” In the group following the standard diet the number of days without headaches was only decreased after 3 months and significant decrease in attack frequency wasn’t observed until 6 months in. It would have been interesting if the KD group had followed the KD for all six months.

Some individuals can take the better part of a month (if not longer) to become fully “keto-adapted” so a study during which subjects spent only a month on the diet is a nice start but even better would be to see what happens in migraine sufferers who follow a KD for a longer period of time. (In the researchers’ defense this was a proof-of-concept study so hopefully they have plans to recreate this and have subjects in the KD arm stay on the diet for the duration.)

There are numerous mechanisms by which the KD could be reducing the frequency and severity of migraines. As Dr. Richard Veech a pioneer in research on the therapeutic implications of ketone bodies wrote “ketones deserve the designation of a superfuel” for the brain. Their metabolism generates fewer reactive oxygen species than that of glucose and ketogenic diets are highly anti-inflammatory. Ketogenic diets also help normalize neuronal membrane potential and reduce excitotoxicity. This dietary intervention has powerful and wide-ranging effects and the multiple mechanisms by which it works point toward it potentially helping to alleviate crippling migraines. At the very least it’s worth trying. If someone experiences no relief after some period of time of genuinely sticking to the diet they can easily switch back to their usual foods.