Sport and migraines: How regular moderate endurance exercise can help

The recommendation to engage in regular moderate endurance exercise is something few patients can ignore, regardless of whether they suffer from high blood pressure, diabetes, depression, or migraines (1-4). Who doesn't remember the ubiquitous health campaign "Trimming 130 – Exercise is the best medicine" from the 1980s fitness movement (5)? ​​Resisting mainstream pressure and answering the question about the secret to his long life like Winston Churchill with "No sports!" requires a certain amount of self-confidence (6).

Nevertheless, the question remains: what is the basis for the categorical recommendation of endurance exercise for migraine? In evidence-based medicine, studies in which a new therapeutic concept is tested double-blind against placebo or standard therapy are considered the gold standard. This can even lead to innovative surgical therapies being tested against placebo procedures involving only anesthesia, an incision, and sutures (7). Regardless of ethical considerations in such a procedure, the effectiveness of a non-pharmacological therapy like endurance exercise can never be proven with the same level of evidence. Blinding the patient is simply not possible in endurance exercise. The idea of ​​endurance exercise that the active patient wouldn't even recognize as such would be practically idyllic. At best, exercise therapy can be compared openly (from the patient's perspective) with other forms of therapy.

Does exercise help against migraines?

Two studies from recent years will be presented as examples of the current state of research. In 2014, a Brazilian research group compared treatment with the tricyclic antidepressant amitriptyline alone with a combination of amitriptyline plus an aerobic exercise program in patients with chronic migraine (8). Given the severity of the patients' condition (at least 15 migraine days per month, supposedly without, but in reality with, medication overuse!), the chosen amitriptyline dose of 25 mg was very low. The German treatment guidelines of the DGN (German Society for Neurology) recommend a daily dose of 50–150 mg (4). The exercise program also represented a rather moderate level of exertion: 40 minutes of brisk walking three times a week for three months. Fifty of the 60 patients who started the program completed it (26 of 30 in the amitriptyline group and 24 of 30 in the amitriptyline + exercise group). The result was remarkable. Amitriptyline 25 mg alone reduced migraine frequency after 3 months from an initial average of 25 days per month to 13 days per month. When brisk walking was added, migraine frequency decreased from 23 days per month to 5 days. The reduction in painkiller use was even more pronounced. In the amitriptyline group, painkillers were taken on only 3 days per month (instead of 20 days = overuse!), and in the combination group of amitriptyline + exercise, only on one day per month instead of 16 days = overuse. The effectiveness of the combination of exercise and amitriptyline was significantly superior to amitriptyline alone. Furthermore, exercise counteracted weight gain caused by the appetite-stimulating effect of amitriptyline (BMI +1 in the amitriptyline group), and the combination group of amitriptyline + exercise even experienced weight loss (BMI -1)! These results exceeded the wildest expectations of any headache therapist. Generally, a 30% reduction in migraine frequency is considered a desirable (and often unmet) goal for chronic migraine. Never before in a controlled study has such a low dose of amitriptyline been able to improve (chronic) migraine (with medication overuse) to such an extent. The results contradict all experience and thus undermine the credibility of the entire study, rendering it hardly a valid argument for exercise in migraine treatment.

The results of a Swedish research group from 2011, which tested endurance exercise against relaxation training and topiramate in 91 migraine patients, appear considerably more realistic (9). Unlike the aforementioned amitriptyline study, no fixed dose of topiramate was prescribed; instead, the dose was individually selected between 25 and 200 mg according to tolerability. The exercise program consisted of a 40-minute workout three times a week, with a 15-minute warm-up, 20 minutes of ergometer training, and a 5-minute cool-down. After three months, the frequency of attacks had decreased by an average of one attack per month (-25%) in all three groups, with virtually identical results. Adverse events occurred only in the topiramate group (33% of patients), where, in addition to the known appetite-suppressing effect, weight loss (-1.3 kg) was also greater than in the exercise group (-0.5 kg), while weight actually increased in the relaxation group (+1.0 kg). This small but carefully conducted study demonstrated that two non-drug therapies can achieve similar success to a potent but also side-effect-prone medication. However, endurance sports, in particular, required not only genuine endurance but also a considerable time commitment to achieve this result.

Can exercise trigger migraines?

The recommendation for endurance sports is not accepted without question by all patients. The argument is often heard that, on the contrary, exercise is a trigger for migraine attacks that should be avoided. A Dutch research group investigated this argument in 2013, retrospectively surveying 103 patients at a headache clinic about their experiences with exercise as a trigger for migraine attacks (10). No fewer than 38% of the patients had experienced migraine attacks that began within 48 hours of physical activity; in more than half of the cases, the headache started during the exercise itself. Running and tennis were cited as the most problematic sports. As a result of this experience, half of the patients gave up more intensive physical activity. However, the majority of patients reported that lower-intensity exercise was unproblematic.

conclusion

Even though the available studies are not entirely convincing, primarily due to methodological issues, there is considerable evidence to suggest that endurance exercise can prevent migraine attacks. In many studies, the effect is comparable to standard medication for migraine prophylaxis. However, the advantage of avoiding medication side effects comes at the cost of a significant time commitment. The studies typically involved 30 to 40 minutes of exercise three times a week.

When choosing a sport, it's important to consider the possibility that unusually intense exercise could have the opposite effect and trigger migraine attacks. Studies have typically examined untrained patients, as they were the most likely group to show positive effects. For the sake of standardization, the training was most often conducted on a stationary bike. However, cycling might actually be the ideal compromise for newcomers to exercise, providing sufficient but not overly intense, readily available endurance training.

Dr. Axel Heinze, Dr. Katja Heinze-Kuhn & Prof. Dr. Hartmut Göbel