This study was conducted in Kuwait immediately after end of Ramadan in May 2020. The aim of this cohort study was to determine the impact of fasting during the month of Ramadan on the frequency and severity of migraine headaches. Fasting is well known trigger for migraine and this was established in the medical literature, especially with regard to short-term fasting and the first day of Ramadan. This exacerbation is likely due to associated with dehydration, caffeine withdrawal changes in life style and change in sleep habits. It is more common among sufferers of primary headaches (12).
Our study found that the mean number of days patients experienced migraine attacks was higher in the month of Ramadan compared to that of Shaban (the month before Ramadan). This is similar to the result found by Abu Salama et al (13), where participants had a three-fold increase in the frequency of migraine attacks during Ramadan. Our results is also in agreement with previous Indian study that reported higher rates of headache-related emergency room visits during Ramadan in Muslim communities in India (14).
One of the reasons suggested for these observations in our cohort are caffeine withdrawal while fasting, especially that Arabic coffee consumption in the Kuwaiti society is quiet high. Another factor contributing to this increase is dehydration, further amplified by the fact that Ramadan was during the summer, where temperatures in Kuwait are high during April and May and the day hours are long. Islamic calendar is lunar, the duration of the fast varies from year to year. Ramadan can happen in June, July or August where the temperature can go as high as 50 degree Celsius. Another possible theory is the sleep disturbance that occurs during this month because of night prayers and a change in the timings of meals. Increasing frequency and severity of migraine attacks could be explained by altered levels of serotonin and norepinephrine and dilation of blood vesels around the brain that are probable mechanisms of hunger-triggered headaches. Following hunger due to fasting hours, at sunset people usually break their fasting with large meals with different varieties and its quite common that deserts and sweets will follow which is a tradition in Ramadan in most of the countries. Such ingestion of an excessive carbohydrate load, may result in vascular headache may also occur in response to a rapid insulin secretion and reactive lowering of blood sugar (15). On the other hand, a study conducted in Saudi Arabia found that there was a significant decrease in the number of migraines during Ramadan, during which patients fasted for approximately the same duration of hours as those in our study (16). This may be due to differences in caffeine consumption levels and in sleep habits. This is important as it points towards the fact that there may be modifiable factors that are associated with migraines during fasting rather than just the inherit act of fasting itself.
Our study also found that the severity of headaches during the month of Ramadan was increased. One reason for this is that most patients will not break there fast in order to take analgesics, leading to more severe headaches. We also found that there was a significant increase in analgesic days in Ramadan, and this may be due to an increase in the number and severity of the headaches. However, Gabr et al (16), found that there was no difference in the severity of the attacks between Ramadan and the previous month. They also found that medication use was decreased, and they suggested that this was because the time of the headache usually occurred during the hours of fasting.
It is important to note that there is another type of headache in the international classification of headache disorder called a fasting-headache, which occurs when fasting lasts for more than 16 hours (17), whereas in our study participants only fasted for around 15 hours. As a result, we are not regarding these headaches as fasting-headaches. In addition, we only included patient that were already diagnosed with migraine headaches, in which the reported headaches in Ramadan were similar in character to those they experience when they have their usual migraine.
Another important finding was that the migraines interfered with the daily activities of 75 percent of the followed patients during the month of Ramadan, similar previous result (13), where migraines increasingly affected the quality of the patients’ lives and their ability to practice their religion. This further emphasizes the importance of finding appropriate treatment modalities for these patients.
In addition, 38% of patients broke their fast due to migraine attacks. However, when we take into account the number of patients whose lives were affected by migraines during fasting, this percentage may not accurately reflect the severity of frequency of the migraines, but rather may reflect the fact that most patients would not break their fast in order to take analgesics. This needs to be taken into account when discussing patients’ treatment plans and may limit the use of analgesics at the onset of the headache, as most patient would still be fasting.
Most patients with migraines will continue fasting regardless of how severe and frequent the headache get because of their strongly spiritual connection to this holy month, meaning they are extremely eager to fast despite their medical conditions. This makes the option of not fasting an unacceptable treatment plan resulting in a challenge for the physicians trying to find the best abortive and prophylactic therapy for these patients. As a result, different modalities in medical therapies should be further studied in patients with migraine attacks during the period of fasting, providing the best reduction in migraine attacks and severity. Botulinum toxin and monoclonal antibodies can be used as an effective preventive therapy and more research in using them in migraineurs during Ramadan is needed.
For these reasons it is very important to create a specialized management plan for migraine patients during the month of Ramadan. Firstly, patients should be educated about the effects of caffeine withdrawal, sleep disturbance and dehydration on their migraine attacks, and given appropriate ways to deal these problems. For example, drinking enough water during non-fasting hours and decreasing caffeine consumption gradually before the start of the month of Ramadan, as well as the importance of obtaining good sleep time and sleep pattern Reduction of caffeine consumption in the weeks preceding Ramadan is recommended. A cup of strong coffee just before the start of the fast may prevent the occurrence of fasting-Ramadan headache was recommended in previous publication(12). However, we really don’t recommend this if the person is planning to sleep since caffeine may disturb the sleep pattern and may result in frequent urination adding more sleep disruption
Another important factor is pyrophytic treatment. This has to be chosen carefully as some treatment options such as topiramate have long titration periods and a twice daily regimen, limiting it’s using during fasting (13). The use of botulinum toxin and monoclonal antibodies is are important possible options, however further research is needed in order to establish the best prophylactic regimens during fasting.