Fasting-induced headache in Ramadan: a scoping review with implications for clinical practice

Introduction Headache attributed to fasting is a recognized secondary headache in the International Classification of Headache Disorders, 3rd edition (ICHD-3), defined as a diffuse, non-pulsating headache developing during fasting and relieved after eating. It is especially relevant during Ramadan, when large populations undergo predictable daily periods of food and fluid abstinence lasting up to 20 hours. Despite the high number of individuals potentially affected, the evidence on fasting-induced headache during Ramadan remains fragmented and has never been systematically summarized.Areas covered This scoping review maps the current literature on fasting-induced headache during Ramadan based on structured searches in PubMed and Embase. Twenty studies were included, comprising observational studies, surveys, case reports and a small number of clinical trials. Findings were organized thematically.Expert opinion Ramadan fasting reproducibly worsens migraine and triggers fasting headache, with dehydration, caffeine withdrawal, hypoglycemia, disrupted sleep and eating habits as the main proposed mechanisms. Worsening tends to be most pronounced in the early days of fasting and to attenuate thereafter. Preemptive pharmacological prevention is promising: pre-fasting etoricoxib has a preliminary evidence, while rimegepant shows a positive signal in migraine patients that awaits confirmation. Pharmacological interventions may offer the greatest benefit during the first week of Ramadan.