The Fasting Headache

Written by Seymour Diamond, M.D., Executive Chairman and Founder of National Headache Foundation, Director Emeritus and Founder of Diamond Headache Clinic in Chicago.

Mary A. Franklin, Executive Director of National Headache Foundation in Chicago, Illinois.

As the Jewish high holidays approach in September this year, one becomes aware that some religious and traditional practices may pose a problem for the headache patient, and in particular the migraine sufferer. Fasting is often reported by patients, and cited in medical textbooks, as a headache trigger.

Throughout Judaism, there are two days of fasting. Most readers will recognize Yom Kippur (the Day of Atonement), which is the most holy day in the Jewish calendar. The other day of fasting is Tish B’av, a holiday beginning on the night of July 15, which commemorates the many tragedies that have befallen the Hebrew people.

In a 1995 study in Israel of hospital employees before and after a 25-hour fasting period for Yom Kippur, it was found that subjects with a history of headache were more likely to experience a fasting-induced headache than those without a headache history. The headaches were described as mild to moderate, of a nonpulsating quality and located bilaterally and frontally. The number of reported headache attacks was related to the duration of the fasting. The researchers noted that withdrawal from caffeine and nicotine did not seem to influence the occurrence of the headaches.

The International Classification of Headache Disorders divides headache into two classes – primary and secondary. Primary headaches, which include migraine and tension-type headache, have no underlying cause or disorder for the headaches. Secondary headaches can be traced to a specific cause – brain tumor, aneurysm or exposure to a substance, such as nitrites. The most frequent form of secondary headaches are due to a disorder of homeostasis – the internal system that regulates our bodily functions and maintains stability. Fasting headache would be an easily identifiable form of a disorder of homeostasis.

A new headache is considered to be a headache due to a disorder of homeostasis if it occurs for the first time in close relation to the disorder, and if the headache resolves or improves once the disorder is improved. Fasting headache would definitely improve, and hopefully disappear, after its victim eats or drinks.

Hypoglycemia (low blood sugar levels) has been linked to fasting headaches, especially migraine attacks associated with fasting. As early as 1933, the great British neurologist, MacDonald Critchley indicated that migraine attacks associated with fasting and strenuous exercise, might be relieved by food intake. It has been recommended that to avoid fasting headaches and those migraine attacks associated with fasting, the patient should maintain a regular meal schedule, even when dieting for weight loss. Missing or skipping a meal should be avoided in order to maintain your homeostasis.

However, for those adhering to religious rituals, a new set of problems arise. Rules vary throughout Judaism, For the migraine sufferer, the ultra-Orthodox may be less-stringent on Tish B’av but not on Yom Kippur. Eating even a little bit of food on Yom Kippur is a Torah prohibition, and that rule applies even to a person who is ill. In cases in which migraine could precurse a life-threatening event (chashash sakanat nefashot), such as a stroke, eating minimal amounts would be permitted. But of course, they would need to have a previous history of such events related to fasting. Guidelines have been established and were printed on www.israelnationalnews.com last year:

  1. The individual has been diagnosed with migraine that can be caused by fasting
  2. The migraine appears after an aura, and the aura lasts for over one hour
  3. No migraine medications (such as suppositories or sprays) can prevent the onset of the migraine

These religious dilemmas are not limited to Judaism. Christians, and particularly Catholics, may face the issue during the Lenten season. Catholic adults, from 18 to 59, are expected to refrain from eating between meals during the 40 days before Easter, and all those from age 14, until death, are to abstain from eating meats and meat products on Ash Wednesday and every Friday during Lent. Rules may be bent for medical reasons, and dispensations can be granted.

For Muslims, the fasting headaches are called “First-of-Ramadan” (FAR) headaches which are triggered as a result of the ritualistic fasting. Those with previous histories of headache, either migraine or tension-type, are more likely to develop a fasting headache. Hypoglycemia did not seem to be a factor for this religious group, as most Muslims seemed to eat a meal before dawn and then a second meal after dusk. However, caffeine withdrawal from coffee and tea, and dehydration may play a factor in the FAR headaches. Consumption of a caffeinated beverage or water seemed to relieve the headache symptoms. For the migraine sufferer who is observing Ramadan, use of an abortive agent prior to fasting, may be effective at thwarting the “fasting migraine attack.”

This article originally appeared in HeadWise, a publication of the National Headache Foundation.

Further reading

  1. Mosek A, Korczyn AD. Yom Kippur headache. Neurology 1995; 45:1953-1955.
  2. Torelli P, Evangelista A, Bini A, et al. Fasting headache: A review of the literature and new hypotheses. Headache 2009; 49:744-752.
  3. Melamed E. Yom Kippur Q&A: Revealing G-d’s kingdom in Israel. www.israelnationalnews.com; accessed 9/24/12.
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