Migraine is a debilitating neurovascular condition characterized by severe headaches, often accompanied by photophobia, phonophobia, nausea, vomiting, and heightened sensitivity to movement (1). It is frequently associated with mental health conditions, including depression and anxiety, sleep disturbances, chronic fatigue, and cardiovascular risk factors such as hypertension, diabetes, hyperlipidemia, and obesity (2–4). It is among the most common neurological disorders, with an estimated 14–15% of headache sufferers receiving a diagnosis of migraine (5). A recent meta-analysis found that the prevalence of migraine in the general population of Iran is 15.1% (6). The economic burden is significant; a systematic review reported annual healthcare costs ranging from £6,443 to £53,446 in some countries (7).

While the mechanisms underlying migraines remain unclear, environmental, hormonal, psychological, and dietary factors are potential contributors (8, 9). Certain foods, such as chocolate, caffeine, cheese, and alcoholic beverages, have been identified as common triggers (10–12). Dietary components may influence migraine pathophysiology through mechanisms involving neuropeptides, receptors, ion channels, inflammation, nitric oxide release, and vasodilation (13).

Although the evidence is limited, certain dietary interventions such as the ketogenic diet (14), elimination diets, and diets rich in anti-inflammatory foods show potential as effective approaches to managing migraines (15). However, individuals typically consume a variety of foods and nutrients simultaneously rather than in isolation, emphasizing the need to explore the combined effects, interactions, and cumulative impacts of diverse dietary components on migraines. Analytical methods, such as dietary pattern analysis and evaluations of overall diet quality, provide a more holistic understanding of the relationship between diet and migraines (13, 16).

Recent studies have examined the relationship between diet quality or dietary diversity and migraine attacks, finding that lower diet quality or diversity is associated with a higher frequency of attacks (17, 18).

However, to date, no studies have evaluated the combined effects of the LLDS and HEI on migraine severity and frequency. This study aims to address this gap by investigating the relationship between diet quality, lifestyle factors, and HEI with the severity and frequency of migraines.

The mean age of participants was 35.19 ± 6.92 years, and the mean weight was 74.55 ± 16.52 kg. None of the participants were following a specific diet. As shown in Table 1, participants’ baseline characteristics and dietary intake varied across the tertiles of the LLDS and HEI. Additionally, the mean daily water intake among participants was 4.61 ± 2.69 glasses. Most participants (54.7%) were female, and 58.87% were married. Employment status varied, with 37.15% of participants being homemakers, 27.86% self-employed, and 34.99% either employed or students. About 49.65% of participants had never smoked, while 30% were current smokers. Physical activity levels were predominantly low, with 43.92% reporting low activity, 37.5% moderate, and 18.58% high. No significant differences in age, weight, BMI, or physical activity levels were found across the tertiles of the LLDS and HEI scores (p > 0.05). However, individuals in the highest tertile of both the LLDS and HEI reported significantly better sleep quality compared to those in the lowest tertile (p < 0.001).

Table 2 presents the variations in baseline variables and dietary intake across the tertiles of the LLDS and HEI scores. The results show no significant differences in age, weight, BMI, or physical activity levels among the tertiles of LLDS and HEI scores (p > 0.05). However, individuals in the highest tertile of both LLDS (p < 0.001) and HEI (p < 0.001) reported significantly better sleep quality compared to those in the lowest tertile.

There were no significant differences in caloric intake across the LLDS (p = 0.17) and HEI (p = 0.12) tertiles. Regarding dietary intake, participants in the higher tertiles of LLDS and HEI had significantly higher protein and fiber intake, along with lower fat and saturated fat intake, even after adjusting for energy intake. Additionally, participants in the higher tertiles of LLDS and HEI had significantly lower intake of carbohydrates and monounsaturated fatty acids (MUFA) after adjusting for energy (p < 0.05).

Table 3 shows the relationship between LLDS and HEI scores and MIDAS using logistic regression analysis. As shown in Table 3, in the fully adjusted models, higher scores of LLDS and HEI were significantly associated with lower odds of migraine-related disability (OR = 0.68, 95% CI = 0.42–0.96, p = 0.02 for LLDS and OR = 0.58, 95% CI = 0.41–0.88, p = 0.025 for HEI).

Regarding the relationship between migraine pain intensity and diet quality, Table 4 presents the association between VAS and LLDS and HEI scores. In the fully adjusted model, participants in the highest tertile of LLDS had 45% lower odds of experiencing severe migraine pain compared to those in the lowest tertile (OR = 0.55, 95% CI: 0.38–0.75, p = 0.026). Similarly, those in the highest tertile of HEI exhibited a 38% reduction in the odds of severe migraine pain (OR = 0.62, 95% CI: 0.45–0.85, p = 0.03).

Participants in the highest tertile of LLDS and HEI scores exhibited lower odds of migraine-related disability and intensity. These findings suggest an association between diet quality and migraine outcomes, although the cross-sectional design of the study limits the ability to infer causality.

This cross-sectional study found that higher diet quality, as measured by the LLDS and HEI, was associated with reduced severity and frequency of migraine symptoms. However, given the observational nature of the study and the relatively small sample size, these findings should be interpreted with caution. The results highlight a potential link between dietary improvements and migraine management, but they do not establish causality. Future research, including longitudinal studies and clinical trials, is necessary to confirm these associations and explore the underlying mechanisms.

Diet plays a crucial role in influencing health outcomes and the risk of chronic conditions, such as migraines (29, 30). Numerous studies have assessed the impact of individual nutrients or combinations of dietary components on the occurrence and intensity of migraines (13, 31–35). However, few studies have comprehensively assessed overall dietary patterns and their cumulative effects on migraine risk and management. By focusing on dietary quality as a whole, our study provides valuable insights into how a balanced and nutrient-rich diet can mitigate the debilitating effects of migraines.

The HEI-2015 defines high-quality diets as those that emphasize greater intake of nutrient-dense foods, including fruits, vegetables (particularly greens and beans), whole grains, dairy products, total protein sources, seafood, plant-based proteins, and healthy fatty acids (36). It also emphasizes limiting the consumption of sodium, refined grains, added sugars, and saturated fats. Such a diet not only provides essential nutrients required to maintain normal neural function but may also be associated with a reduction in the severity of migraine attacks (37). Similarly, the LLDS is a dietary assessment tool based on food-based principles aligned with the Dutch Dietary Guidelines (27). It evaluates diet quality by assessing adherence to these guidelines, offering insights into how specific dietary patterns may reduce migraine severity and frequency.

Recent studies have consistently shown a significant association between poor diet quality and the prevalence of migraines (29). Supporting our findings, one study demonstrated that healthy women with normal body weight had higher diet quality scores (HEI-2005) compared to those suffering from migraines (38). Similarly, Bakirhan’s research aligns with our results, revealing a negative correlation between total HEI-2015 scores and VAS scores, suggesting that better diet quality is associated with lower migraine severity (39).

Furthermore, another study reported that individuals with migraines tend to consume more pro-inflammatory foods and exhibit lower overall diet quality compared to those without migraines (40). In line with these findings, Ghoreishy et al. observed that individuals with diets high in pro-inflammatory properties had a significantly greater risk of severe headaches compared to those with diets rich in anti-inflammatory foods, which were inversely associated with the frequency and severity of migraine attacks (41).

While the precise mechanisms underlying migraine attacks remain unclear, evidence suggests that inflammation plays a crucial role in their development (42). Additionally, an imbalance between oxidants and antioxidants is believed to contribute to the pathogenesis of migraines, potentially prompting the brain to initiate a homeostatic and neuroprotective response to oxidative stress (37). The association between higher diet quality and reduced migraine symptoms observed in our study may be explained by the presence of antioxidants, unsaturated fatty acids, and dietary fiber in nutrient-dense foods. These components help mitigate oxidative stress and reduce neuroinflammation, potentially preventing or alleviating migraine episodes (39).

From an alternative perspective, it is worth noting that the HEI and LLDS share similarities with dietary patterns such as the DASH (Dietary Approaches to Stop Hypertension) and Mediterranean diets, particularly in their emphasis on fruits, vegetables, and legumes (43, 44). Previous studies have found that greater adherence to the DASH diet is associated with reduced headache severity and shorter headache duration per episode, highlighting the potential benefits of these dietary patterns in managing migraine symptoms (17, 18). Furthermore, studies have shown that the neuroprotective effects of the Mediterranean diet in preventing neurodegeneration are largely attributed to its abundance of bioactive compounds, phytochemicals, and phenolic substances (45–48). These components play a critical role in mitigating inflammation and oxidative stress, which are significant contributors to the development of neurodegenerative conditions and play a key role in the severity of migraine-related disability, as measured by the MIDAS.

As mentioned previously, a possible underlying mechanism for the findings of our study may involve the balance between antioxidants and oxidants, which could be linked to the occurrence of migraines and headaches. Neuroinflammation can result in vasodilation and sensitization of pain-sensitive neurons, primarily through the activation of nociceptors in the trigeminal system. When the trigeminal ganglion is stimulated, it triggers the release of neuropeptides such as substance P, neurokinin, and calcitonin gene-related peptide (CGRP) (49). CGRP plays a critical role in various physiological processes, including the dilation of cerebral and dural blood vessels and the release of inflammatory mediators. Elevated levels of these neuropeptides have been detected in the cerebrospinal fluid of individuals with chronic migraines (50). Additionally, inflammatory markers such as interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α have been observed to increase, particularly during migraine attack phases (51).

Fruits and vegetables, rich in antioxidants, have potential therapeutic effects on migraines due to their bioactive compounds. For instance, indole-3-carbinol and sulforaphane, found in vegetables such as cabbage, broccoli, beets, parsley, spinach, and carrots, may act as CGRP antagonists, demonstrating effectiveness comparable to some medications in certain patients (52). Additionally, diets high in fiber can help reduce inflammation by modulating glucose absorption rates, altering gut microbiota, and decreasing the production of inflammatory cytokines (53). The fermentation of fiber by gut microbiota produces short-chain fatty acids (SCFAs), including butyrate, propionate, and acetoacetate. Among these, butyrate plays a critical role in regulating T-cell function, maintaining gut barrier integrity by enhancing the expression of tight junction proteins, and stabilizing hypoxia-inducible factor (HIF), which supports gut health and reduces toxin permeability (54).

Magnesium also plays a significant role in migraine pathophysiology. Fruits, vegetables, and legumes are excellent sources of magnesium, a mineral often found to be deficient in the plasma and brain tissue of individuals experiencing migraines. Magnesium is essential for mitochondrial energy production and contributes to various physiological processes, including vasoconstriction, inhibition of platelet aggregation, and regulation of serotonin secretion all of which are relevant for managing migraine symptoms (55).

This study is the first to present evidence of an association between the HEI, the LLDS, and migraine-related factors. Dietary data were collected using a validated FFQ, and participants with implausible calorie intakes (>4,000 or < 600 kcal) were excluded from the analysis. To ensure accuracy, interviews were conducted by three trained researchers.

Despite its strengths, this study has several limitations. First, its cross-sectional design precludes establishing causal relationships between diet quality and migraine outcomes. While the findings suggest associations, the temporal relationship between dietary intake and migraine symptoms cannot be determined. Second, the sample size, although sufficient for initial exploratory analyses, was relatively small and drawn from a single clinical setting. This may limit the generalizability of the findings to broader populations, particularly those with different sociodemographic or cultural backgrounds. Third, potential biases, such as recall bias, may have influenced the dietary data collected through the FFQ. Although the FFQ has been validated for the Iranian population, self-reported dietary intake is inherently prone to inaccuracies. Finally, while multivariable logistic regression models were used to adjust for confounders, the number of adjustment variables was limited. This raises the possibility of residual confounding from unmeasured variables, such as other dietary or lifestyle factors, genetic predisposition, or environmental influences. Future studies should aim to include a broader range of confounding factors and employ more robust statistical techniques to minimize bias.

Based on the findings of our study and the underlying mechanisms, managing overall diet quality, rather than focusing solely on individual macronutrients or micronutrients, appears to be a promising strategy for improving the prognosis and overall condition of individuals with migraines. However, further research is needed to validate the findings of the present study.