Abstract / Summary
Abstract Background Ramadan fasting is practiced annually by a substantial portion of the global Muslim population. Migraine is a leading cause of disability; fasting-related physiological and behavioral changes may influence migraine occurrence and severity. This systematic review and meta-analysis (SRMA) aimed to synthesize the available evidence on the association between Ramadan fasting (RF) and migraine-related outcomes, including (the frequency, intensity, duration, number of migraine days, attacks, use of analgesics and medications, as well as fasting continuity) among adults with clinically confirmed migraine from inception until March 2026. Methods PubMed, Scopus, Web of Science, Embase, and the Cochrane Library were searched from inception through March 2026 in accordance with PRISMA 2020. Eligible studies included adults with clinically confirmed migraine undergoing Ramadan fasting and reporting relevant migraine outcomes. Risk of bias was assessed using the Newcastle–Ottawa Scale, and certainty of evidence was evaluated using GRADE. For studies comparing outcomes in the same participants during Ramadan and non-Ramadan periods, paired mean differences and standard errors were calculated and pooled using the generic inverse-variance method. Random-effects meta-analyses used the Sidik–Jonkman approach with Hartung–Knapp confidence interval. Sensitivity analysis examined assumed within-participant correlations of r = 0.3, 0.5, and 0.7. Results The search identified 450 records, of which five observational studies comprising 759 participants were included. All included studies were conducted in the MENA region between 2009 and 2025. Episodic migraine was the most common subtype. The pooled paired analysis showed no statistically significant difference in migraine days between Ramadan and the comparison periods (paired MD 3.28 days; 95% CI [− 1.54 to 8.10]; p = 0.1189), with considerable heterogeneity (I 2 = 98.3%, p < 0.001). Similarly, no statistically significant difference was observed in migraine attack count (paired MD 0.74; 95% CI [− 7.71 to 9.19]; p = 0.7418), with considerable heterogeneity (I 2 = 99.7%). In contrast, the pooled paired analysis of two studies showed a higher number of days of analgesic/medication use during Ramadan (paired MD 5.00 days; 95% CI [4.61 to 5.40]; p = 0.0040), with no detected statistical heterogeneity (I 2 = 0%). Conclusion Evidence from observational studies did not establish a consistent association between Ramadan fasting and most migraine outcomes. Although greater analgesic/medication use was observed during Ramadan, this finding was based on only two studies and requires cautious interpretation. Very high heterogeneity and very low certainty for several outcomes limit definitive conclusions. PROSPERO registration CRD420261359701.