Information-Theoretic Trigger Surprisal and Future Headache Activity

Importance: Identifying migraine triggers is a common goal for individuals with migraine but remains challenging due to the vast number of possible triggers and their fluctuating nature. A measurement system quantified through information-theoretic surprisal (ie, the negative logarithm of the probability of an observed exposure) could be valuable for evaluating the wide range of possible triggers for future migraine attacks. Objective: To evaluate the association between surprisal and future headache attacks. Design, Setting, and Participants: This cohort study conducted from April 2021 to December 2024 included 109 participants with migraine who completed diary entries of potential migraine triggers and migraine attacks within 12 and 24 hours after trigger exposure twice daily for up to 28 days. Exposure: Diary items captured exposure to potential behavioral, emotional, and environmental migraine triggers. To quantify the unexpectedness of a participant's daily experiences, total surprisal scores measured in bits of information was calculated using within-person empirical probability distributions to reflect how atypical each day's experiences were. Main Outcomes and Measures: The primary outcomes were occurrence of a headache attack within 12 and 24 hours (0, no attack; 1, attack) after trigger exposure. A headache attack was defined as any self-reported headache with pain greater than 0 on a 0 to 10 numeric rating scale where 0 was no pain and 10 was the worst pain, and any pattern of secondary symptoms (eg, photophobia and phonophobia). Intraclass correlation coefficients and variance components were calculated to quantify between-person differences in baseline risk and the strength of the surprisal association. Results: A total of 109 participants were included in the analysis. Participants' median age was 35 (26.0-46.0) years, and the majority were female (102 [93.5%]). One hundred and four participants had complete diaries (5176 diary entries) and experienced headaches on 1518 of 5145 days (29.5%). Higher surprisal was significantly associated with increased migraine risk within 12 hours (odds ratio [OR], 1.86; 95% CI, 1.12-3.08; P = .02) and 24 hours (OR, 2.15; 95% CI, 1.44-3.20; P < .001), with a higher OR indicating a stronger association observed at the longer interval. The association between current surprisal and migraine onset was moderated by recent surprisal history and exhibited nonlinear properties at 12 hours. Random-effects models revealed substantial between-person variability and, after adjustment, the association between total surprisal and headache attack risk was attenuated (OR, 1.56; 95% CI, 1.01-2.40; P = .04 for 12 hours and OR, 1.88; 95% CI, 1.27-2.79; P = .002 for 24 hours). Conclusions and Relevance: In this cohort study, surprisal offered a novel, individualized measure of trigger unpredictability that was associated with short-term migraine risk. Incorporating surprisal into digital tools may improve personalized prevention strategies, moving beyond static trigger lists to a dynamic, context-aware model of migraine self-management.