To Exercise or Not to Exercise? The Migraine Paradox
To Exercise or Not to Exercise? The Migraine Paradox
Few things are as confusing as the relationship between exercise and migraine. Migraine as defined by the International Headache Society includes the phrase “aggravation by routine physical activity”. Yet so often we are told to include exercise as part of our treatment plan. Why is this? Does it even make sense?
This is one of my favorite topics. I was a competitive swimmer from first grade until college. Migraine and its associated symptoms ended my swimming career (of course back then I kept my migraine disorder a secret). I did not fully understand the association between migraine and the fact that I couldn’t turn my head to breathe anymore, or that I could only flip-turn a limited number of times before I would vomit. What was even more confusing for me was that when I didn’t swim, the pain was worse. Yet swimming under the direction of a coach and at the pace of a swim team had become impossible.
After some trial and error, I came to the realization that if I did not exercise each day, I had a much worse migraine by the afternoon than I would have had otherwise (my migraine pattern at the time was daily). But I had to spend a lot of time discovering the type and pace of exercise that worked for me. I also found that I had to figure all this out on my own. There did not seem to be anyone who understood the nuances of what caused my pain/migraine to flare up. It was not always what “made sense” to a trainer, coach, physical therapist, workout buddy, or even me.
WHY IS IT DIFFICULT FOR US?
Over 50% of those of us with migraine have something called kinesiophobia. I am opposed to the definition of this word. It is: “an excessive, irrational, and debilitating fear of physical movement…” essentially accompanied by avoiding movement so as to not “provoke pain”1. The reason I am against this definition is I do not think there is anything irrational about it. For many of us, it hurts.
WHAT ARE SOME REASONS EXERCISE MIGHT TRIGGER OR EXACERBATE MIGRAINE?
Although there have been some possible mechanisms suggested, there is not a medically-agreed upon physiological explanation. Two possible hypotheses for how exercise may induce migraine are through two separate neuropeptides: hypocretin and CGRP. Hypocretin is produced by the hypothalamus and helps regulate patterns of sleep and arousal. It is often thought to be involved in certain symptoms associated with the premonitory phase of migraine such as yawning, fatigue, and food cravings. It is believed that exercise affects this pathway2. Exercise can also cause CGRP levels to rise, and as we know CGRP plays a role in migraine. However, neither of these theories on exercise and migraine have been extensively studied.
Another thought on the acute pain felt while trying to exercise during migraine is related to the fact that the nerve afferents from the trigeminal nerve that surround vascular structures in the meninges (the membrane that encloses the brain) are activated during an attack. This leads to the release of pro-inflammatory substances. What this means for us is that pulsing sensations that we normally would not feel suddenly feel painful in our head. This becomes much worse if we try to exercise and increase our heart rate2.
WHY MIGHT EXERCISE MAKE US FEEL BETTER?
To answer why exercise might make someone with migraine feel better we must first clarify that we are usually referring to exercise as a preventive, or at least not exercise when you are feeling at your worst. Levels of beta-endorphin (an opioid produced in our bodies) have been found to be lower in migraine patients than in people without migraine2. In the peripheral nervous system beta-endorphin decreases transmission in pain pathways; in the central nervous system it is part of a pathway associated with pleasure. Beta-endorphin is increased through low threshold prolonged exercise (50 minutes) or high intensity exercise that exceeds the anaerobic threshold2.
In migraine patients a natural system within our bodies called the endocannabinoid reward system has also been reported to be dysfunctional when compared to people without migraine. Concentrations of the endocannabinoid ligand anandamide (AEA, thought to be responsible for the “runner’s high”) are lower in patients with migraine than in controls. This is hypothesized to contribute to the lowered pain threshold (sensitization) that contributes to migraine and its chronification. Levels of AEA increase after exercise2.
Research in this area is limited. However a recent literature review found that rigorous aerobic exercise alone can yield a significant reduction in migraine frequency, intensity, and duration. The authors also noted that more benefit was associated with high intensity exercise3.
What about yoga? So many of us love yoga and find it helpful, especially those of us who have found it challenging to add aerobic or high impact exercise into our exercise regimen. A recent clinical trial (the CONTAIN trial) set out to determine if yoga was beneficial as add-on therapy (in addition to prescribed medical therapy) for episodic migraine. The group of patients who included yoga as well as regular medical therapy experienced greater improvements in headache frequency and intensity, and used fewer rescue medications4.
HOW DO WE USE EXERCISE CORRECTLY FOR MIGRAINE?
What I have found personally, and in helping people with migraine who want to exercise, is this: People with migraine are highly diverse, as are the types of exercise they are able to do, and the types that help them. Some of us are not capable of jumping straight into a yoga class because using our upper body triggers a migraine. Many of these people start with walking or pool exercises. Others are unable to achieve relief without long bouts of strenuous exercise each day. It would be remiss to ignore the fact that exercise is also helpful for some of the things that can come along with migraine like insomnia, depression, and anxiety2. If you are not able to see results right away in your pain level or migraine frequency, perhaps pay attention to the effects exercise has on your other symptoms or comorbidities.
Step one is to find what types of exercise we can do without making our symptoms worse. Step two is to use exercise for migraine prophylaxis and to improve our general health and well-being. Happy trails (or wherever your journey takes you).
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1 Benatto MT, Bevilaqua-Grossi D, Ferreira Carvalho G, Mendes Bragatto M, Ferreira Pinheiro C, Straceri Lodovichi S, Dach F, Fernandez-de-Las-Penas C, Lima Florencio L. Kinesiophobia is associated with migraine. Pain Medicine. 20(4), 2019:846-851.
2 Amin FM, Aristeidou S, Baraldi C, Czapinska-Ciepiela EK, Ariadni DD, Di Lenola D, Fenech D, Kampouris K, Karagiorgis G, Braschinsky M, Linde M. The association between migraine and physical exercise. J Headache Pain. 2018 Sep 10;19(1):83.
3 Barber M, Pace A. Exercise and migraine prevention: a review of the literature. Curr Pain Headache Rep. 2020 Jun 11;24(8):39.
4 Kumar A, Bhatia R, Sharma G, Dhanlika D, Vishnubhatla S, Singh RK, Dash D, Tripathi M, Padma Srivastava MV. Effect of yoga as add-on therapy in migraine (CONTAIN): A randomized clinical trial. Neurology. 2020 May 26;94(21).
MEET THE AUTHOR
Dr. Lindsay Weitzel experienced chronic daily migraine from the time she was four years old until she was thirty. Her constant migraine attacks caused enough damage to give her complex regional pain syndrome (a ceaseless pain like burning fire) down the right side of her face, head, neck, and arm. Lindsay believes that having no memory without daily pain gave her a unique perspective on living with and fighting off her disease.