Recommending Exercise for Migraine: Just Do It

Dr Yohannes W. Woldeamanuel

Strength training is the most effective form of exercise for reducing migraine, with high-intensity aerobics coming in second, and both beating top-line migraine medications topiramate and amitriptyline, new research suggests.

The new results should encourage clinicians to recommend patients with migraine engage in strength-training exercise whenever possible, study investigator Yohannes W. Woldeamanuel, MD, a physician-scientist and instructor, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, California, told Medscape Medical News.

"Exercise is something patients can do all their lives and use it to prevent migraine attacks instead of taking daily medications or repetitive injections that have several adverse effects."

The findings were published online October 13 in The Journal of Headache and Pain.

Head-to-Head Comparison

Several clinical trials have shown exercise is effective for migraine management, but to date, there have been no head-to-head comparisons of strength training and aerobic exercise, said Woldeamanuel.

This new study used a systematic review with network meta-analysis (NMA), which compares multiple interventions and ranks the efficacy of each one.

After a literature search, researchers included 21 clinical trials with an exercise regimen arm and a comparison control arm. All study data reported monthly frequency of migraine at baseline and at the end of the intervention.

The total combined sample size was 1195 patients with migraine, who were a mean age of 35.5 years, with a female-to-male ratio of 6.7:1. All studies used International Classification of Headache Disorders (ICHD) criteria for migraine diagnosis.

The NMA provided 27 pairwise comparisons and eight indirect comparisons. The pairwise comparisons provided direct evidence between the different interventions.

Researchers combined strength training, including weightlifting, with resistance training. Both modalities target muscles, while aerobic exercise targets cardiovascular health.

The average number of weeks was 9.3, 9.3, and 10.7, and the average number of hours per session for strength/resistance training, high-intensity aerobic exercise, and moderate-intensity aerobic exercise interventions was 50, 56, and 45.3, respectively.

The analysis showed all exercise interventions were more effective than the placebo groups in reducing the frequency of migraine. In terms of ranking, strength training came out on top, with a mean difference in monthly migraine days of −3.55 (95% CI, −6.15 to −0.95) between the active and placebo groups.

Next was high-intensity aerobic exercise (−3.13; 95% CI, −5.28 to −0.97) and moderate-intensity aerobic exercise (−2.18; 95% CI, −3.25 to −1.11]), followed by topiramate, placebo, and then amitriptyline.

Strength/resistance training was superior possibly because it targets muscle strengthening, particularly major muscles in the neck and shoulder area, which can be a source of the pain trigger, said Woldeamanuel. He added neck pain is highly comorbid with migraine.

Interestingly, patients doing exercises that focus on unaffected muscles — for example, squats — still get the benefits of less migraine burden, said Woldeamanuel.

Training Recommendations

Strength training also increases or preserves lean muscle mass, which is associated with reduced migraine frequency. Research shows preservation of lean body mass combats central sensitization in various pain syndromes, said Woldeamanuel.

The superior effects of high versus moderate-intensity aerobic exercise may be due to recruitment of endogenous molecules involved in exercise-mediated hypoalgesia (pain reduction).

The most common pathways are the opioid and endocannabinoid systems, although other systems are also likely involved, said Woldeamanuel. He noted migraine has been linked to a deficiency of both opioidergic and endocannabinoidergic signaling.

Woldeamanuel commented on the difficulty of comparing exercise interventions for patients with chronic versus episodic migraine, as many studies include both.

However, the two studies with moderate-intensity aerobic exercise exclusively involving patients with chronic migraine showed large effect sizes (Cohen's d) of 0.80 and 1.10 in reducing monthly headache frequency.

Based on these new results and their own experience, the researchers recommend strength training start with 50% of repetition maximum (RM) with 2-3 sets of 12-15 repetitions three times a week along with 10 minutes of warm-up, stretching, and cool-down, totaling 45-60 minutes per session. Weight/resistance load can then be increased weekly by 5% of RM if the patient is capable of successfully completing three sets.

They also recommend including active recovery days (low-intensity exercise) between training days. All major muscles, including neck, shoulder, and upper limb muscles, should be trained in a rotation.

For high-intensity aerobic exercise, the authors recommend starting with interval training at 55% VO_2max (maximum respiratory capacity), or 50% HR_max (maximal heart rate) for 45-60 minutes per session, including 10 minutes of warm-up and cool-down, three times per week. The intensity can then be increased by 5%-10% each week to reach a maximum target of 80%-90% by week 12.

It is best for patients to start with a trainer for guidance and supervision, but once they master the routines, they can do the exercises independently, said Woldeamanuel.

Managing Flare-Ups

Headache flare-ups are normal during exercise, which may be caused by "boom and bust cycles" — exercising excessively when feeling good then completely stopping when feeling bad, said Woldeamanuel. He noted these flare-ups don't mean "there’s something wrong with the brain or there's some injury to muscles."

The best way to manage such flare-ups is to use a pacing strategy that involves "not going overboard on good days and avoiding excessive rest on bad days," the investigators note.

Woldeamanuel noted exercise is a lifestyle-based intervention; it not only helps reduce migraine attacks but also helps control other known comorbidities such as obesity and hypertension.

Commenting for Medscape Medical News, Elizabeth Loder, MD, vice-chair, academic affairs, Department of Neurology, Brigham and Women's Hospital, and professor of neurology, Harvard Medical School, Boston, Massachusetts, said, "it's useful to collect and summarize all of these studies, and to focus on helping patients and doctors understand the possible value of different kinds of exercise."

The review was "well done" said Loder, adding the researchers "have looked carefully at the quality of included studies."

The study received support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health. Woldeamanuel has reported no relevant financial relationships.

J Headache Pain. Published online October 13, 2022. Full text

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