Sport and migraines: How regular, moderate endurance sport can help

Hardly any patient can avoid the recommendation to regularly engage in moderate endurance sports, regardless of whether they suffer from high blood pressure, diabetes, depression or migraines (1-4). Who can't remember the ubiquitous health campaign “Trimming 130 – exercise is the best medicine” by the Trimm Dich movement (5) from the 80s? To withstand the mainstream pressure and, like Winston Churchill, answer the question about the secret recipe for a long life: “No sports!” requires a lot of self-confidence (6).

Nevertheless, the question remains: what is the apodictic recommendation of endurance sports for migraines based on? In evidence-based medicine, studies in which a new therapeutic concept is tested in a double-blind manner against placebo or standard therapy are considered the ultimate. This can lead to innovative surgical therapy procedures being tested against placebo procedures that only involve anesthesia, skin incisions and sutures (7). Regardless of ethical considerations in such an approach, the effectiveness of a non-drug therapy method such as endurance sports will never be able to be proven with the same level of evidence. Blinding the patient is simply not possible in endurance sports. The idea of ​​an endurance sport that would not be perceived as such by the active patient would be almost paradisiacal. Sports therapy can only 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 study situation. In 2014, a Brazilian working 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 patient's condition (at least 15 migraine days per month, supposedly without, but actually with overuse of medication!), the chosen dose of amitriptyline was very low at 25 mg. The German DGN therapy guidelines recommend a daily dose of 50-150 mg (4). The sports program also represented a rather moderate strain: 40 minutes of fast walking 3 times a week for 3 months. 50 of 60 patients who started continued to the end (26 of 30 in the amitriptyline group and 24 of 30 in the amitriptyline + exercise group). The result was amazing. Amitriptyline 25 mg alone reduced migraine frequency from the original average of 25 days/month to 13 days/month after 3 months. If you also “went fast,” the frequency of migraines per month fell from 23 days to 5 days. The decrease in the use of painkillers was even more noticeable. In the amitriptyline group, painkillers were only taken on 3 days per month (instead of 20 days = overuse!) and in the amitriptyline + exercise combination group, painkillers were only taken 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. In addition, sport counteracted weight gain caused by the appetite-increasing amitriptyline (BMI +1 in the amitriptyline group) and there was even a weight reduction in the combination group amitriptyline + sport (BMI -1)! These results exceeded the wildest expectations of any headache therapist. In general, a 30% reduction in migraines in chronic migraines is considered a desirable (and often missed) goal. Never before in a controlled study has such a low dose of amitriptyline been able to improve (chronic) migraines (with medication overuse) to such an extent. The results contradict every experience and thus undermine the credibility of the entire study, so that it is hardly suitable as a plea for exercise for migraines.

The results of a Swedish working group from 2011, which tested endurance sports against relaxation training and against topiramate in 91 migraine patients, appear much more realistic (9). In contrast to the aforementioned amitriptyline study, no fixed dose was specified for topiramate, but the dose was chosen individually depending on tolerability between 25 and 200 mg. The sports program consisted of 40 minutes of training three times a week with 15 minutes of warm-up, 20 minutes of ergometer training and 5 minutes of cool-down. After 3 months, the frequency of attacks had decreased by an average of one attack per month (-25%) in all 3 groups. Adverse events only occurred in the topiramate group (33% of patients), in which the known appetite-reducing effect and the weight reduction (-1.3 kg) were greater than in the sports group (-0.5 kg), while in the relaxation group the weight even increased (+1.0 kg). This small but carefully conducted study showed that similar success can be achieved with two non-drug therapy methods as with one potent drug that also has side effects. However, endurance sports in particular required not only actual endurance to achieve this result, but also a not inconsiderable amount of time.

Can exercise trigger migraines?

However, not all patients accept the recommendation for endurance sports without objection. You often hear the argument that, on the contrary, exercise is a trigger for migraine attacks that should be avoided. A Dutch working group investigated this argument in 2013 and retrospectively surveyed 103 patients at a headache clinic about their experiences with exercise as a trigger for migraine attacks (10). As many as 38% of patients were aware of migraine attacks that began within 48 hours of exercise; In more than half of those affected, the onset of the headache occurred during exercise. Running and tennis were particularly cited as problematic sports. At least half of those affected gave up more intensive sporting activity because of this experience. However, the majority of patients reported that lower-intensity physical activity was unproblematic.

conclusion

Even if the studies are not entirely convincing, mainly due to methodological problems, there is still a lot to suggest that endurance sports can prevent migraine attacks. In many studies, the effect is on a par with standard medical prophylactics. However, the advantage of the lack of medication side effects comes at the expense of a considerable amount of time. In the studies, exercise was usually scheduled for 30 to 40 minutes three times a week.

When choosing a sport, the possibility should be taken into account that unusually intense sport can have the opposite effects and trigger migraine attacks. In studies, untrained patients were usually examined because it was hoped that positive effects would be most likely to be demonstrated in them. For the sake of easy standardization, the training was then most often carried out as a bicycle ergometer training. It is possible that cycling is actually the ideal compromise in everyday life for sufficient, but not too intensive, endurance sports that are available everywhere for new athletes.

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