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avoiding eating chocolate due to that suspicion seems a minor one, but may be vital in terms of the conflicting study findings. Hanington has reported that, although 73% of a sample of 500 headache sufferers implicated chocolate as a trigger for them (7), only 5% of the patients in a headache clinic met the voluntary diet restriction criterion. Thus, the results of all of the studies reviewed here lead to the conclusion that chocolate is not a significant trigger of migraine, and that many migraine sufferers believe chocolate triggers their headache when in fact it does not.

Explanations for the Perceived Causal Relationship between Chocolate and Headache

If chocolate does indeed cause headaches, it is in a very limited percentage (5% or less) of headache sufferers. Given this finding, it is curious that many times that percentage of headache sufferers believe that chocolate is a trigger for them. Some of these individuals may have encountered educational materials identifying chocolate as a headache trigger and assumed that chocolate caused their headaches without a personal experience of that relationship. Others may have had an experience that led them to believe chocolate caused their headache when this was not the case. As chocolate is the most commonly craved food in the USA (45), there are ample opportunities to make false associations. This may be particularly true for women, who are three times more likely than men to suffer from migraine (1) and also crave chocolate more frequently than men (46). Sweet craving itself has been reported to be a prodromal symptom of migraine (47). Thus, craving and consuming chocolate may be a symptom rather than a cause of migraine.

The gender difference in headache prevalence is often explained by hormonal differences. Estrogen fluctuation associated with the onset of menses has been identified as a frequent migraine trigger, occurring regularly in about 60% of women (48). Headache diaries have demonstrated this association reliably (49). Interestingly, the onset of menses has also been associated with an increase in carbohydrate and chocolate craving (46, 50). Women may also become more sensitive to the effects of vasoactive chemicals such as tyramine and BPEA in the perimenstrum (51). Thus, the occurrence of a menstrual headache may be erroneously associated with chocolate ingestion, the craving of which is also associated with menses onset. Additionally, chocolate may actually contribute as a trigger, but only during the perimenstrum.

In addition, stress has been endorsed as a headache-triggering factor in almost three-quarters of headache sufferers (2), and has been reliably demonstrated to be associated with headache onset (5). Stress is also often associated with sweet craving. In addition, fasting or skipping meals has been linked to headache and is endorsed by almost half of chronic headache suffers (2). A candy bar from the

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