Exercise and Migraine Prevention: a Review of the Literature

DOI: https://doi.org/10.1007/s11916- 020- 00868- 6

Abstract-Summary This review intends to characterize the recent literature pertaining to the role of aerobic exercise in the prevention of migraine.

The past decade has seen the publication of numerous high-quality studies that explore aspects of exercise’s effects on migraine prevention, including its success as a stand-alone prevention strategy, as well as its non-inferiority to some pharmaco- logic preventive measures.

Exercise often tops providers’ lists of recommended lifestyle modifications that

help reduce migraine burden.

Psychologically, there is evidence that exercise improves migraine self-efficacy

and internalizes the locus of control, leading to reduced migraine burden.

Randomized control trials have demonstrated that a sufficiently rigorous aerobic exercise regimen alone is sufficient to yield a statistically significant reduction in migraine frequency, intensity, and duration.

The addition of exercise to a traditional preventive regimen may provide added

benefit.

Exercise is a reasonable evidence-based recommendation for migraine prevention.

2.4 Lifestyle

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Introduction Aerobic exercise is often promoted to patients as an effective management strategy, either alone or in combination with medication, for the prevention of both episodic and chronic migraine [553].

Despite near-universal agreement that regular aerobic exercise should be included among the management strategies offered to patients with migraine, this consensus belies a paucity of agreement on specifics [554].

Additional questions include whether exercise is appropriate as a stand-alone preventive strategy, whether there is a synergistic benefit when it is combined with pharmacotherapy, and what biological and/or psychological mechanisms underlie the observed benefits.

Although patients with migraine have been found to exercise less than the gen- eral population, investigators have found that they are more likely to engage in complementary and alternative medicine practices, like yoga [555].

Mechanisms In a 2011 study, investigators crafted a 10-week aerobic exercise regimen for migraine patients in an effort to prove the preventive effects of exercise on migraine [556].

Noting the comorbid psychiatric factors that often exacerbate disability in migraine patients (like anxiety), a 2017 study examined whether the investigators’ prior findings regarding the elevation of the proinflammatory cytokine IL-12p70 in women with migraines could be tempered by engagement in a regular moderate aerobic exercise regimen [557].

Irby and colleagues subsequently use this study to suggest that exercise, which they note had previously been proven to improve self-efficacy among patients with depression, could similarly be harnessed to improve self-efficacy among patients with migraine, and potentially reduce migraine burden [554].

Exercise Alone for Migraine Prevention The investigators found nine studies and five case reports that pointed to exercise as an effective intervention for prevention of migraine.

This was a systematic review meta-analysis specifically designed “to investigate the result of aerobic exercise on the number of migraine days, duration and pain intensity in patients with migraine” [558].

Thanks to greater consistency in study design, unlike Busch a decade earlier, these investigators were ultimately able to conclude that there was moderate quality evidence that aerobic exercise decreases number of migraine days.

They also found low-quality evidence that exercise can shorten attack duration, noting a decrease by 20–27% on average, with one included study citing a decrease of 20 migraine hours per month post-treatment.

One of the studies included in the Lemmens meta-analysis studied exercise when

used as a prevention/treatment strategy for more than just migraine alone [559].

Exercise Compared with Traditional Preventive Therapy Investigators compared exercise with topiramate for prevention of migraine [560].

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2 Mechanisms

Patients were randomized into exercise, topiramate, and relaxation tech-

nique groups.

Investigators found a mean reduction in migraine attacks by 0.93 per month in the exercise group, a reduction by 0.97 per month in the topiramate group, and a reduction by 0.83 per month in the relaxation technique group [560].

Santiago and colleagues wondered whether aerobic exercise in combination with a standard preventive medication could yield improved migraine control in patients with chronic migraine [561].

Investigators ultimately found statistically significant improvement on nearly all measures among the amitriptyline plus exercise group, including headache fre- quency, duration, and intensity.

This study is noteworthy because many of the other studies mentioned in this review examined episodic and not chronic migraine; it lends credence to the notion that exercise is a worthy adjuvant to a standard pharmacologic prevention strategy for patients with chronic migraine.

Types of Exercise Few investigators have sought to compare the effectiveness of different types of exercise among subjects in the same study.

A future investigation may consider pooling studies by exercise type or intensity

and comparing improvement in migraine incidence based on those measures.

A 2018 study was one that sought to compare exercises of different intensities

and their effect on migraine prevention [562].

This study suggests that higher-intensity aerobic exercise may be more beneficial

for migraine prevention.

Darabaneanu used a jogging regimen (three times weekly, 50 min per session including a warmup and cooldown period) that increased in intensity over the course of the study as participants’ exercise tolerance increased, and found improvement in number of migraine days per month [556].

Köseoglu used a treadmill regimen tailored to the exercise tolerance of partici-

pants and found a significant decrease in migraine days per month [563].

Exercise as Migraine Trigger Some patients do anecdotally report that exercise may induce migraine attacks, and there have been some studies suggesting certain exercise may be considered a trig- ger for migraine-type attacks.

One study by Koppen and colleagues found that in a population of 103 patients,

the lifetime prevalence of migraine attacks triggered by exercise was 38% [564].

The study also found that neck pain was often an initial symptom described by these patients during their normal attacks as well as their exercise-induced migraines. The type of offending exercise was not well described in this study, but research- ers did report that almost half of those patients with exercise-induced migraine stopped playing the sport or participating in the exercise regimen [564].

There are some proposed mechanisms to why exercise may induce migraine

attacks.

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Low-Impact Exercise and Migraine Yoga, for example, is a low-impact exercise that has some data for prevention of primary headache syndromes, along with other conditions that are often comorbid with migraine, including fibromyalgia, anxiety, and depression.

Sixteen studies were included, and researchers concluded that overall yoga was found to have positive effects on pain and pain-related disability, most notably for patients with headache, back pain, muscle soreness, and irritable bowel syn- drome [565].

Focusing on one study included in the aforementioned meta-analysis, a random- ized controlled trial of seventy-two patients with migraine without aura assigned patients to either a self-care group or a yoga group for 12 weeks.

Researchers found that the patients in the yoga group had a reduction in head- ache frequency, pain intensity, and symptomatic medication use and lower anxiety and depression scores [566].

Conclusions Despite agreement about high-level findings regarding exercise and migraine pre- vention in the studies included in this review, a wide variety of research questions on numerous aspects of this topic remain incompletely answered.

Studies seem to suggest exercise may be useful in the treatment of episodic migraine, with some suggesting it can be helpful in patients with chronic migraine when incorporated as an adjunct to traditional pharmacotherapy.

This is an especially useful consideration for patients who may be subject to

exercise-induced migraine.

Additional research is needed to further clarify the underlying mechanisms by which exercise helps prevent migraine, as well as to explore which exercise regi- mens are most effective.

Most reassuringly, it means that when providers advise their patients that exer- cise will aid in the prevention of their migraines, the advice is not merely an informed suspicion, but rather an evidence-based recommendation.

Acknowledgement A machine generated summary based on the work of Barber, Mark; Pace, Anna 2020 in Current Pain and Headache Reports.

The association between migraine and physical exercise