Recommend exercise for migraine: Just Do It
Strength training is the most effective form of exercise for reducing migraine, with high-intensity aerobics coming second, and both beating the top migraine medications topiramate and amitriptyline, according to new research.
The new findings should encourage clinicians to recommend that patients with migraine do strength-training exercises whenever possible, according to study researcher Yohannes W. Woldeamanuel, MD, physician-scientist and instructor, Department of Neurology and of Neurological Sciences, Stanford University School of Medicine, California, Told Medscape Medical News.
"Exercise is something that patients can do for a lifetime and use it to prevent migraine attacks instead of taking daily medications or repetitive injections that have multiple side effects."
The results were published online October 13 in The Headache and Pain Diary.
Direct comparison
Several clinical trials have shown exercise to be effective for migraine management, but to date there have been no direct comparisons between strength training and aerobic exercise, Woldeamanuel said.
This new study used a systematic review with network meta-analysis (NMA), which compares several interventions and ranks the effectiveness of each.
After a literature search, the researchers included 21 clinical trials with an exercise regimen arm and a comparison control arm. All study data reported monthly migraine frequency at baseline and end of intervention.
The total combined sample size was 1195 migraine patients, mean age 35.5 years, with a female to male ratio of 6.7:1. All studies used the International Classification of Headache (ICHD) criteria for the diagnosis of migraine.
The NMA provided 27 pairwise comparisons and eight indirect comparisons. Pairwise comparisons provided direct evidence between the different interventions.
The researchers combined strength training, including weightlifting, with resistance training. Both modalities target muscle, 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 of strength/resistance training, high-intensity aerobic exercise, and aerobic exercise moderate intensity was 50, 56 and 45.3, respectively.
The analysis showed that all exercise interventions were more effective than placebo groups in reducing migraine frequency. 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.
This is followed by 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 building, particularly the major neck and shoulder muscles, which can be a trigger for pain, Woldeamanuel said. He added that neck pain is strongly comorbid with migraine.
Interestingly, patients who do exercises that focus on unaffected muscles — for example, squats — still experience the benefits of less migraine burden, Woldeamanuel said.
Training recommendations
Strength training also increases or preserves lean muscle mass, which is associated with reduced migraine frequency. Research shows that preserving lean body mass combats central sensitization in various pain syndromes, Woldeamanuel said.
The greater effects of high intensity aerobic exercise compared to moderate intensity may be due to the 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, Woldeamanuel said. He noted that migraine was linked to impaired opioidergic and endocannabinoidergic signaling.
Woldeamanuel commented on the difficulty of comparing exercise interventions for patients with chronic and 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 to reduce monthly headache frequency.
Based on these new results and their own experience, the researchers recommend starting strength training at 50% maximum repetition (RM) with 2-3 sets of 12-15 repetitions three times a week with 10 minutes of warm-up, stretching, and cool-down, totaling 45 to 60 minutes per session. The weight/resistance load can then be increased each week by 5% RM if the patient is able to complete three sets.
They also recommend including active recovery (low-intensity exercise) days between training days. All major muscles, including the muscles of the neck, shoulders and upper limbs, should be trained in rotation.
For high-intensity aerobic exercise, the authors recommend starting with interval training at 55% VO2max (maximum breathing capacity), or 50% RHmaximum (maximum heart rate) for 45 to 60 minutes per session, including 10 minutes of warm-up and cool-down, three times a week. The intensity can then be increased by 5% to 10% each week to reach a maximum goal of 80% to 90% at week 12.
It's best for patients to start with a trainer for guidance and supervision, but once they master the routines they can do the exercises independently, Woldeamanuel said.
Manage flare-ups
Headache flare-ups are normal during exercise, which can be caused by "boom and bust cycles" – exercising excessively when you feel good, then stopping completely when you you feel bad, Woldeamanuel said. He noted that these flare-ups do not mean "there is something wrong with the brain or that there is an injury to the 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 that exercise is a lifestyle intervention; it not only helps reduce migraine attacks, but also helps control other known co-morbidities such as obesity and hypertension.
Commenting for Medscape Medical News, Elizabeth Loder, MD, Vice President, Academic Affairs, Department of Neurology, Brigham and Women's Hospital, and Professor of Neurology, Harvard Medical School, Boston, Massachusetts, said, "It is helpful to bring together and summarize all of these studies, and focus on helping patients and physicians understand the possible value of different types of exercise."
The review was "well done," Loder said, adding that the researchers "carefully reviewed the quality of the included studies."
The study received support from the National Institute of Neurological Disorders and Stroke of the National Institutes of Health. Woldeamanuel has did not report any relevant financial relationships.
J Headache Pain. Published online October 13, 2022. Full text
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