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the relationship between headache and diet by conducting prospective studies of various diets, with some eliminating foods rich in vasoactive amines (8), and others eliminating foods that may cause allergic reactions (30, 37, 38). The results of these studies have been mixed and have suffered from multiple methodological problems.
One problem with most diet restriction studies has been the lack of an adequate control group. Most studies (39, 40) have used the patient's usual diet as a baseline control, rather than offering a 'placebo' diet to control for expectation effects. These studies generally show positive effects in the form of decreased headaches on the restrictive diet. In contrast, Salfield et al. (41) placed subjects on both restrictive and control diets, and showed equal headache improvement on either diet. Medina and Diamond (8) also reported no significant difference in headache activity when subjects were placed on tyramine-rich or tyramine-free diets. It would appear from the results of these two studies that any type of dietary manipulation might result in headache improvement, regardless of the type of diet used.
A second problem with the majority of dietary challenge and restriction studies has been the wide interval from food ingestion to time of headache, with studies attributing headaches to foods consumed up to 72 hours before the headache (42). In addition, these studies have failed to control additional potential triggers such as menstruation, stress and excessive analgesic use. One case study (42) reported a patient with near daily headache and excessive aspirin use that was hospitalized for ulcer disease. Treatment included discontinuation of aspirin and dietary restriction, which resulted in a resolution of the chronic daily headache. This patient would now be recognized as suffering from analgesic overuse or drug rebound headache, and improvement in headache would be attributed to elimination of excessive aspirin. At the time, however, his headache improvement was attributed to the dietary restrictions.
Investigations of Chocolate as a Trigger of Headache
Three studies have investigated the relationship between chocolate and headache directly through placebo-controlled challenge studies. In one such study, Gibb et al. (43) selected 20 subjects from a headache clinic who believed chocolate was a trigger of their migraines and divided them into chocolate (n = 12) and carob 'placebo' (n = 8) groups. Subjects ate 40 g samples and were contacted by telephone 32 hours after ingestion. Five of the individuals who ate chocolate and none of the individuals who ate the placebo reported the development of a headache within 24 hours of eating the sample, a significant difference (P = 0.051).
In contrast to the findings of Gibb et al, two published studies have failed to find an association between chocolate and headache. Moffet et al. (44) selected
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