Recommending Exercise for Migraine: Just Do It

Dr. Johannes W. Woldeamanuel

New research suggests that strength training is the most effective form of exercise for reducing migraine headaches, with high-intensity aerobic exercise coming in a close second, and beating both migraine medications topiramate and amitriptyline.

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The new findings should encourage clinicians to recommend that patients with migraines engage in strength training whenever possible, study author Johannes W. Waldmanuel, MD, physician, scientist, and instructor, department of neurology and neurosciences, Stanford University School of Medicine, California, tells WebMD. Medscape Medical News.

“Exercise is something that patients can do throughout their lives and use to prevent migraine attacks rather than taking daily medications or frequent injections that have many adverse effects.”

The results were published online on October 13 Journal of Headache and Pain.

head-to-head comparison

Several clinical trials have shown exercise to be effective in managing migraines, Waldmanuel said, but so far, there are no direct comparisons between strength training and aerobic exercise.

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

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

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

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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 weight lifting, with resistance training. Both methods target muscles, while aerobic exercise targets cardiovascular health.

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

The analysis showed that all of the exercise interventions were more effective than the 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.

Next were 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 probably because it targets strengthening muscles, especially the major muscles in the neck and shoulder region, which can be a source of the pain trigger, Woldmanuel said. He added that neck pain is strongly associated with migraines.

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Interestingly, patients who did exercises that focused on uninjured muscles — for example, squats — still got the benefits of a lower migraine burden, Woldmanuel said.

Training recommendations

Strength training also increases or maintains lean muscle mass, which has been associated with lower migraine frequency. Research shows that maintaining lean body mass combats central sensitivity in various pain syndromes, Waldmanuel said.

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

The most common pathways are the opioid and intra-cannabinoid systems, Woldmanuel said, although other systems may be involved. He noted that migraines have been linked to a deficiency of both opioid and endocannabinoidergic signaling.

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

However, the two studies in which moderate-intensity aerobic exercise was performed exclusively on chronic migraine patients showed a significant effect of volume (Cohen’s). Dr) of 0.80 and 1.10 in reducing monthly headache frequency.

Based on these new findings and their own experiences, the researchers recommend starting strength training at 50% of your repetition maximum (RM) with 2-3 sets of 12-15 repetitions three times per week along with a 10-minute warm-up, stretching, and cool-down, for a total of 45- 60 minutes per session. The weight/resistance load may then be increased weekly by 5% of the RM if the patient is able to successfully complete three sets.

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

For high-intensity aerobic exercise, the authors recommend starting with interval training at 55% VO2 max (maximal respiratory capacity), or 50% HRthe above (maximum heart rate) for 45-60 minutes per session, including a 10-minute warm-up and cool-down, three times a week. The intensity can then be increased by 5%-10% each week to reach the maximum target of 80%-90% by week 12.

It’s best for patients to start with a trainer to guide and supervise, but once they’ve mastered the routine, they can do the exercises independently, Woldmanuel said.

Seizure management

Headaches are normal during exercise, which may be due to “boom-and-bust cycles” — exercising excessively when feeling good and then stopping completely when feeling bad, Woldmanuel said. He pointed out that these seizures do not mean “there is something wrong with the brain or that some muscles are injured.”

The investigators indicated that the best way to manage such disorders was to use a pacing strategy that included “not overdoing it on good days and avoiding excessive resting on bad days.”

Woldeamanuel noted that exercise is a lifestyle intervention; Not only does it help reduce migraine attacks, but it also helps control other known comorbidities such as obesity and high blood pressure.

Comment on Medscape Medical News, Elizabeth Lauder, MD, vice president for academic affairs, division of neurology, Brigham and Women’s Hospital, and professor of neurology, Harvard Medical School, Boston, Mass. Understand the potential value of different types of exercise.

The review was “well done,” Lauder said, adding that the researchers “carefully looked at the quality of the included studies.”

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

Headache pain. Published online Oct 13, 2022. Full text

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