Regular Smoking, Drinking Linked to Headaches in Teenagers

Pauline Anderson
Authors and Disclosures

June 22, 2010 — Being physically active and abstaining from alcohol, caffeine, and tobacco could help prevent
headaches in adolescents, a new study suggests.

After controlling for socioeconomic variables, the study found that the prevalence of any headache was
doubled in those who reported regularly drinking cocktails, consuming at least 1 cup of coffee a day, and being
physically inactive and was almost doubled in those who smoked daily. Prevalence of migraine was more than
tripled in those drinking cocktails and more than doubled in those drinking coffee on a daily basis.

"The results of the study suggest that students should smoke less, drink less, and participate in more sports,
and in cases where they get migraines, they should also avoid coffee," said study author Rudiger von Kries
MD, PhD, professor of pediatric epidemiology at the Institute of Social Pediatrics and Adolescent Medicine,
Ludwig-Maximilians-University, Munich, Germany. "It's a very simple message."

However, contrary to the findings of other recent research, this study did not find an association between low
fluid intake and headache in teenagers.

The study was published online June 7 in Headache, a journal published by Wiley-Blackwell on behalf of the
American Headache Society.

Headache Classifications

The study included 1260 students in grades 10 and 11 at 11 public grammar schools in Munich who filled out
questionnaires on diet and lifestyle habits. Students were asked about how often they ate breakfast, had a
break meal at school, ate a wholesome lunch, got recommended amounts of fruits and vegetables, drank
alcoholic drinks and coffee, and smoked cigarettes and about the frequency, duration, and intensity of physical
activity.

The students were also asked about their headache history. If the students reported having headaches, they
were asked details about symptoms, duration, frequency, and intensity. Using the International Classification of
Headache Disorders Second Edition, researchers categorized headaches into migraine and its subgroups,
tension-type headache (TTH) and its subgroups, combined migraine plus TTH, and miscellaneous headache.

About 83% of the students reported having a headache at least once in the past 6 months, with 10.2%
reporting migraine, 48.7% reporting TTH, and 19.8% reporting combined migraine plus TTH. These figures are
much higher than in other studies, said Dr. von Kries. It's unclear why, but it could be that because of
increasing competition Munich students are stressed at school. As well, beer made in the German state of
Bavaria has a relatively high concentration of alcohol, which may contribute to headaches, he noted.

Beer and Headaches

Looking at beer consumption, the probability of having headache increased to 1.7 in students drinking at least 1
glass per week. "German teens drink more beer than wine," said Dr. von Kries. "You can interpret this by
saying there's a 70% on average increase if they drink beer."
In categories of headache, prevalence of migraine was increased in students who were physically less active
(OR, 4.2; 95% CI, 2.2 – 7.9) and drank at least 1 cup of coffee per day (OR, 3.4; 95% CI, 1.6 – 7.0). This, said
Dr. von Kries, was not surprising because other research has shown a link between caffeine and migraines.

Prevalence of TTH was increased in students who were physically less active (OR, 1.7; 95% CI, 1.1 – 2.7).
Prevalence of migraine plus TTH was increased in students who reported drinking cocktails regularly (OR, 3.4;
95% CI, 1.9 – 6.0), drank at least 1 cup of coffee per day (OR, 2.4; 95% CI, 1.3 – 4.8), smoked daily (OR, 2.7;
95% CI, 1.4 – 5.1), and were physically less active (OR, 2.2; 95% CI, 1.3 – 3.7).

Unlike previous research, the study did not find an association between headache and insufficient fluid intake.
"One explanation might be that it's become popular for youngsters to run about with a bottle of beer in the
evening and a bottle of water during the day," said Dr. von Kries. "These water bottles are very popular among
students."

Chemical Triggers

The study authors suggested that certain pathophysiologic mechanisms might explain how dietary factors
might trigger headache attacks. Chemical triggers of headache, for example, caffeine or tyramine, which are
associated with different food items, might play a role.

It is also possible that psychological factors, for example, reward- and sensation-seeking behaviors among
teens, are involved. Unhealthy behaviors, such as smoking, excessive alcohol intake, or a poor diet, appear to
be correlated, wrote the study authors. "It cannot be excluded that a general age-specific, sensation-seeking
behavior might account for both health-compromising behavior and unhealthy diet on one side and headache
and maybe other psychopathological symptoms on the other side."

An ideal next step would be to conduct a randomized trial in which some schools would introduce an
intervention that educates students about why they should avoid unhealthy lifestyle choices to see if that
reduces risks of headache, said Dr. von Kries.

Among the weaknesses of the study was that types of headache were based on a self-administered
questionnaire and were not validated by physicians, which might have resulted in comparatively high estimates
of headache prevalence. As well, because the study was cross-sectional rather than prospective, it cannot
answer the question of whether the differences in dietary and lifestyle habits caused the increased prevalence
of headache or were a consequence of the headache.

Dr. von Kries pointed out, however, that people do not usually start drinking or smoking because of a
headache. "In this context, you can't prove anything with epidemiology; you would have to do a randomized
trial where you tell people to stop drinking and then find out whether they really have fewer headaches."

Headache is one of the most frequently reported health concerns among adolescents. Other research has
reported that about 5% to 15% of teenagers have migraine and a further 15.25% have TTH.

Information, Not Intervention

For his part, Patrick Lavin MD, professor of neurology and ophthalmology and director of the Vanderbilt
Headache Clinic, Nashville, Tennessee, agrees that raising awareness of the association between unhealthy
lifestyle habits with headache is a good idea but he is not convinced that creating high school interventions is
the best way to do this.
"Students know about these associations already; they know, for example, that smoking is not good for you
irrespective of headaches," he told Medscape Neurology. "It's certainly a good idea to let students know about
the associations, but I don't know that funding a study to go into schools and talk to them would be any better
than just circulating pamphlets or publications."

Although habits are difficult to change, raising awareness about the association between headache and
lifestyle habits, he adds, "is definitely worthwhile, and if that can be done economically, fine."

Dr. Lavin did not think it surprising that 83% of students in the study reporting having a headache in the past 6
months. He said this is in line with the 78% to 80% of the general population in the United States who get
tension headaches.

The study did not have financial support. The study authors have disclosed no relevant financial relationships.

Headache. Published online June 7, 2010.