Does Exercise Make Migraines Worse and Tension Type Headaches Better?

The cervical spine in tension type headache

INTRODUCTION

The concept that headaches may originate in the cervical spine has been discussed over decades and is still a matter of debate. The cervical spine has been traditionally linked to cervicogenic headache; however, current evidence supports the presence of cervical musculoskeletal dysfunctions also in tension-type headache.

PURPOSE

This position paper discusses the most updated clinical and evidence-based data about the cervical spine in tension-type headache.

IMPLICATIONS

Subjects with tension-type headache exhibit concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, positive flexion-rotation test and also cervical motor control disturbances. In addition, the referred pain elicited by manual examination of the upper cervical joints and muscle trigger points reproduces the pain pattern in tension-type headache. Current data supports that the cervical spine can be also involved in tension-type headache, and not just in cervicogenic headache. Several physical therapies including upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling) and exercises targeting the cervical spine are proposed for managing tension-type headache; however, the effectiveness of these interventions depends on a proper clinical reasoning since not all will be equally effective for all individuals with tension-type headache. Based on current evidence, we propose to use the terms cervical "component" and cervical "source" when discussing about headache. In such a scenario, in cervicogenic headache the neck can be the cause (source) of the headache whereas in tension-type headache the neck will have a component on the pain pattern, but it will be not the cause since it is a primary headache.

Prescription of therapeutic exercise in migraine, an evidence-based clinical practice guideline

The main objective of this clinical practice guideline is to provide a series of recommendations for healthcare and exercise professionals, such as neurologists, physical therapists, and exercise physiologists, regarding exercise prescription for patients with migraine.This guideline was developed following the methodology and procedures recommended in the Appraisal of Guidelines for Research and Evaluation (AGREE). The quality of evidence and strength of recommendations were evaluated with the Scottish Intercollegiate Guidelines Network (SIGN). A systematic literature review was performed and an established appraisal process was employed to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology).The evaluation of the current evidence, the elaboration of the grades of recommendation, and their validation show a B grade of recommendation for aerobic exercise, moderate-continuous aerobic exercise, yoga, and exercise and lifestyle recommendations for the improvement of symptoms, disability, and quality of life in patients with migraine. Relaxation techniques, high-intensity interval training, low-intensity continuous aerobic exercise, exercise and relaxation techniques, Tai Chi, and resistance exercise obtained a C grade of recommendation for the improvement of migraine symptoms and disability.

Effects of eight weeks of aerobic exercise and vitamin D supplementation on psychiatric comorbidities in men with migraine and vitamin D insufficiency: A randomized controlled clinical trial

BACKGROUND

High prevalence of psychiatric comorbidities associated with migraine increases the risk of evolution from episodic migraine to chronic migraine. This study investigated the effects of eight weeks of aerobic exercise and vitamin D supplementation on psychiatric comorbidities in men with migraine and vitamin D insufficiency.

METHODS

Forty-eight participants took part in this randomized controlled clinical trial and were allocated into four groups: aerobic exercise and vitamin D (AE + VD), aerobic exercise and placebo (AE + Placebo), vitamin D (VD), and Placebo. AE + VD and AE + Placebo groups performed three aerobic exercise sessions per week for eight weeks and received a vitamin D supplement and placebo, respectively. The VD group received a vitamin D supplement, and the Placebo group received a placebo for eight weeks. The depression severity, quality of sleep, and physical self-concept were measured at baseline and after eight weeks.

RESULTS

The results showed that depression severity was significantly lower in AE + VD compared to AE + Placebo, VD, and Placebo at the post-test. Our results demonstrated that in the post-test, the mean score of sleep quality in AE + VD was significantly lower than AE + Placebo, VD, and Placebo. Finally, the results revealed that after eight weeks of intervention, the physical self-concept in AE + VD was significantly higher than in VD and Placebo groups.

LIMITATIONS

Not having complete control of sun exposure and the diet were the limitations.

CONCLUSION

The results indicated that the concomitant application of AE and VD supplementation could provoke synergistic effects leading to additional psycho-cognitive health benefits in men with migraine and vitamin D insufficiency.

Migraine management: Non-pharmacological points for patients and health care professionals

Migraine is a highly prevalent disorder with an enormous burden on societies. Different types of medications are used for controlling both acute attacks and prevention. This article reviews some non-pharmacological recommendations aiming to manage migraine disorder better and prevent headache attacks. Different triggers of migraine headache attacks, including environmental factors, sleep pattern changes, diet, physical activity, stress and anxiety, some medications, and hormonal changes, are discussed. It is advised that they be identified and managed. Patients should learn the skills to cope with the trigger factors that are difficult to avoid. In addition, weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients' knowledge about the disease are recommended to be parts of migraine management. In addition, using neuromodulation techniques, dietary supplements such as riboflavin, coenzyme Q10 and magnesium, and acupuncture can be helpful. Non-pharmacological approaches should be considered in migraine management. Furthermore, the combination of pharmacological and non-pharmacological approaches is more effective than using each separately.

Exercise interventions in migraine patients: a YouTube content analysis study based on grades of recommendation

Background

Migraine is the second leading cause of disability worldwide, engendering a high economic cost in developed countries. The adverse events related to pharmacological treatment use have increased interest in non-pharmacological interventions such as exercise. YouTube offers a public source of information for migraine patients regarding exercise interventions for migraine improvement. However, this information has not been validated to ensure the quality and validity of its content.

Objective

This qualitative content analysis study aims to review and evaluate YouTube videos regarding exercise for migraine.

Methods

A systematic review of the current evidence regarding exercise for migraine was performed to establish evidence classification and grades of recommendation with the Scottish Intercollegiate Guidelines Network tool. The data sources were PubMed, PEDro, Cochrane, EBSCO, Google Scholar and Web of Science. The quality of YouTube videos on exercise in migraine was reviewed using the Global Quality Scale and DISCERN scale. Finally, the classification in grades of recommendation was used to evaluate the included videos in terms of the various exercise modalities.

Results

The classification into recommendation grades showed a grade B for aerobic exercise, yoga and changes in lifestyle behavior regarding exercise. A total of 129 videos were included. The healthcare and exercise professional authors produced higher quality videos with a significant statistical difference, although the alternative therapists and patients' videos had a greater impact and a higher viewership based on correlation analysis. The evaluation of the videos based on the recommendation grades could only include 90 videos. 71% of these videos showed a B grade of recommendation, which corresponded to fewer than half of the total included videos.

Conclusions

YouTube needs higher quality videos on exercise for migraine, and healthcare and exercise professional authors need to improve their scoping strategies to acquire more views. The authors of YouTube videos should have better access to the best current evidence regarding exercise interventions in migraine.

Physical Activity is Associated with Less Analgesic Use in Women Reporting Headache-A Cross-Sectional Study of the German Migraine and Headache Society (DMKG)

INTRODUCTION

The aim of this analysis is to determine whether regular physical activity is associated with less analgesic use in men and women suffering from headache disorders based on population-based cross-sectional data.

METHODS

We used data from a random general population sample in Germany that comprised 2477 participants aged ≥ 14 years. A standardized questionnaire addressing headache and headache treatment was filled in during the face-to-face survey.

RESULTS

Thirty-nine percent of the participants reported headache. Of these, 37.5% of men and 33.6% of women were physically active. Of the participants with headache, 43.3% reported taking analgesics on < 2 days a month, 40.7% on 2-5 days a month, 10.1% on 6-10 days a month, and 5.9% on > 10 days a month. Frequent headache, severe impact of headache on daily life, and depressive symptoms were associated with higher analgesic use in both men and women. For women, physical inactivity was associated with the frequency of analgesic use adjusted for sociodemographic and headache-related variables. For men, results did not suggest any association between physical inactivity and frequency of analgesic use.

CONCLUSIONS

There are both sex-unspecific and sex-specific factors associated with analgesic use among men and women with headache. In women with increased analgesic use, promoting physical activity may reduce analgesic use. For men, education about the therapeutic effects of physical activity for headaches is an important resource.

Neck-specific strengthening exercise compared with placebo sham ultrasound in patients with migraine: a randomized controlled trial

BACKGROUND

Migraine patients have musculoskeletal disorders and pain in the cervical. And, despite the pathophysiology demonstrating the relationship between migraine and the cervical spine, the effectiveness of craniocervical exercises in these patients has not been verified. So, the aimed of this study was verify the effectiveness of craniocervical muscle-strengthening exercise (CMSE) in reducing the frequency and intensity of headache in migraine patients.  METHODS: A two-armed, parallel-group randomized controlled trial with a 3-month follow-up was performed. For eight weeks, the volunteers in the intervention group (n = 21) performed a protocol of CMSE, while those in the sham ultrasound group (n = 21) received the application of disconnected therapeutic ultrasound in the upper trapezius and guideline for home-stretching. The primary outcomes were the frequency and intensity of the headache. The secondary outcomes were questionnaires about migraine and neck disability, and satisfaction with the treatment, cervical range of motion, the pressure pain threshold, craniocervical flexion test (CCFT), cervical muscle strength and endurance test, and the cervical muscle activity during the physical tests.

RESULTS

No differences were observed for the changes observed in primary outcomes after eight weeks and at the 3-months follow up (p > 0.05). For the secondary outcomes, craniocervical exercises improved the sensitivity of the frontal muscle (p = 0.040) and promoted a reduced amplitude of muscle activity of the anterior scalene and upper trapezius in the last stages of CCFT (p ≤ 0.010). There was also reduced muscle activity of the anterior scalene and splenius capitis in the endurance test (p ≤ 0.045), as evaluated by surface electromyography.

CONCLUSION

CMSE were insufficient in reducing the frequency and intensity of headache, improving the performance of the cervical muscles, or reducing migraine and neck pain-related disabilities. This was found despite a decreased electromyographic activity of the cervical muscles during the last stages of CCFT and increased median frequency during the endurance test.

TRIAL REGISTRATION

Accession code RBR-8gfv5j , registered 28/11/2016 in the Registro Brasileiro de Ensaios Clínicos (ReBEC).

Physical inactivity and headache disorders: Cross-sectional analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

BACKGROUND

Physical inactivity has been linked to headache disorders but estimates based on the current World Health Organization physical activity guidelines are unknown.

OBJECTIVE

To test the associations between headache disorders and physical inactivity in the ELSA-Brasil cohort.

METHODS

In a cross-sectional analysis, linear (continuous variables) and logistic regression models (categorical variables) tested the associations of physical activity levels in the leisure time, commuting time, and combined leisure time physical activity + commuting time physical activity domains with headache disorders, adjusted for the effects of sociodemographic data, cardiovascular risk variables, psychiatric disorders, and migraine prophylaxis medication.

RESULTS

Of 15,105 participants, 14,847 (54.4% women) provided data on physical activity levels and headache. Higher physical activity levels (continuous values) in the leisure time physical activity domain associated with lower migraine and tension-type headache occurrence and lower headache attack frequency, while in the commuting time physical activity domain it associated with more frequent headache attacks. Compared to people who met World Health Organization physical activity levels in the leisure time physical activity or combining leisure time physical activity + commuting time physical activity domains (i.e. ≥150 min.wk^-1 of moderate and/or ≥75 min.wk^-1 of vigorous physical activity), physical inactivity associated with higher migraine occurrence, while somewhat active (i.e. not meeting World Health Organization recommendations) associated with higher migraine and tension-type headache occurrence. Physical inactivity in the commuting time physical activity domain associated with higher tension-type headache in men and lower migraine in women. Physical inactivity within vigorous leisure time physical activity intensity, but not moderate leisure time physical activity, associated with higher migraine, mostly in women. Finally, physical inactivity associated with higher headache attack frequency regardless headache subtype.

CONCLUSION

Physical inactivity and unmet World Health Organization physical activity levels associate with primary headaches, with heterogeneous associations regarding headache subtype, sex, physical activity domain/intensity, and headache frequency in the ELSA-Brasil study.

The effects of two different intensities of aerobic training protocols on pain and serum neuro-biomarkers in women migraineurs: a randomized controlled trail

OBJECTIVES

We have a weak understanding of how aerobic training may influence migraine, and the optimal parameters for exercise regimens as migraine therapy are not clear. The objectives of this study were to assess, first, effects of two different intensities of aerobic exercise on migraine headache indices; second, serum neuro-biomarker in women migraineurs.

METHODS

A total of 45 non-athlete female migraine patients were selected by a neurologist and randomly divided into three groups: control (CON), moderate-intensity aerobic training (MOD T), and high-intensity aerobic training (HIGH T). Before and after the training protocol, body composition factors, migraine pain indices, VO₂max, and serum Adenylate-Cyclase Activating Polypeptide (PACAP) and Substance P (SP) were measured. Exercise training protocol includes two different intensities of aerobic exercise: Moderate (13-15 Borg Scale, 60-80% HRmax) and High (15-17 Borg Scale, 65-95% HRmax).

RESULTS

Moderate-intensity aerobic training (MOD T) reduced headache intensity, frequency, and duration in women with migraine (p < 0.001, for all). Also, high-intensity aerobic training (HIGH T) reduced headache intensity, frequency, and duration (p < 0.001, for all). However, for headache intensity and duration, MOD T was effective rather than HIGH T (p < 0.001; p ≤ 0.05, respectively). In addition, neither MOD T nor HIGH T could not alter PACAP and SP contents (p = 0.712; p = 0.249, respectively).

CONCLUSIONS

Our results demonstrated that either MOD T or HIGH T could modify migraine pain indices but neither MOD T nor HIGH T could not alter the PACAP and SP contents in women with migraine.

Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review

Headache is the clinical syndrome most commonly observed by neurologists in daily practice. Pharmacological and non-pharmacological treatments are commonly used for the management of headaches; however, the clinical reasoning behind these interventions is not properly applied. We conducted a narrative literature review using as data sources for academic PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PEDro, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, and SCOPUS. This narrative literature review mainly considered systematic reviews, meta-analyses, randomised clinical trials, and expert opinions published after the year 2000 discussing clinical reasoning for application of non-pharmacological interventions in individuals with tension-type, migraine, and cervicogenic headaches. After the data extraction, we organized the literature thematically as follows: (1) mapping of theoretical aspects of non-pharmacological interventions; (2) summarizing most updated literature about effectiveness of non-pharmacological interventions grouped by targeted tissue and headache; (3) identifying research gaps in the existing literature and proposing hypotheses for better understanding of current clinical reasoning. We found that there are many non-pharmacological treatment strategies used for headaches, including beyond the tissue-based impairment treatments (bottom-up) and strategies targeting the central nervous system (top down). Bottom-up strategies include joint-biased, soft-tissue biased, or needling interventions, whereas top-down strategies include exercise and cognitive interventions. Evidence shows that the effectiveness of these interventions depends on the application of proper clinical reasoning, since not all strategies are effective for all headaches. For instance, evidence of non-pharmacological interventions is more controversial for migraines than for tension-type or cervicogenic headaches, since migraine pathogenesis involves activation of sub-cortical structures and the trigemino- vascular system, whereas pathogenesis of tension-type or cervicogenic headaches is most associated to musculoskeletal impairments of the cervical spine. We conclude that current literature suggests that not all non-pharmacological interventions are effective for all headaches, and that multimodal, not isolated, approaches seem to be more effective for patients with headaches. Most published studies have reported small clinical effects in the short term. This narrative literature review provides some hypotheses for discrepancies in the available literature and future research. Clinical reasoning should be applied to better understand the effects of non-pharmacological interventions.

Current perspectives on sex differences in tension-type headache

INTRODUCTION

Clinical and experimental evidence supports the presence of several gender differences in the pain experience.

AREAS COVERED

The current paper discusses biological, psychological, emotional, and social differences according to gender and their relevance to TTH. Gender differences have also been observed in men and women with tension-type headache and they should be considered by clinicians managing this condition. It appears that multimodal treatment approaches lead to better outcomes in people with tension-type headache; however, management of tension-type headache should consider these potential gender differences. Different studies have observed the presence of complex interactions between tension-type headache, emotional stress, sleep, and burden and that these interactions are different between men and women.

EXPERT OPINION

Based on current results, the authors hypothesize that treatment of men with tension-type headache should focus on the improvement of sleep quality and the level of depression whereas treatment of women with TTH should focus on nociceptive mechanisms and emotional/stressful factors. Future trials should investigate the proposed hypotheses.

The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis

BACKGROUND

In patients with frequent migraine, prophylactic treatments are used. Patients often request non-pharmacological alternatives. One treatment option can be aerobic exercise. The value of aerobic exercise as prophylactic treatment however needs to be determined.

METHODS

A systematic review and meta-analysis was performed to investigate the result of aerobic exercise on the number of migraine days, duration and pain intensity in patients with migraine. After screening three online databases, PubMed, Cochrane library and Web of Science, using predefined in- and exclusion criteria, six studies were retained. Pooling of data was performed when possible.

RESULTS

Significant reductions in the number of migraine days after aerobic exercise treatment were found with a mean reduction of 0.6 ± 0.3 migraine days/month. Other outcomes were too variable to pool due to heterogeneity of outcome measurements. Unpooled data revealed small to moderate reductions in attack duration (20-27%) and pain intensity (20-54%) after aerobic exercise intervention. Various exercise intensities are applied.

CONCLUSION

There is moderate quality evidence that in patients with migraine aerobic exercise therapy can decrease the number of migraine days. No conclusion for pain intensity or duration of attacks can be drawn. Effect sizes are small due to a lack of uniformity. For future studies, we recommend standardized outcome measures and sufficiently intense training programs.

TRIAL REGISTRATION

CRD42018091178 .

The association between migraine and physical exercise

BACKGROUND

There is an unmet need of pharmacological and non-pharmacological treatment options for migraine patients. Exercise can be used in the treatment of several pain conditions, including. However, what exact role exercise plays in migraine prevention is unclear. Here, we review the associations between physical exercise and migraine from an epidemiological, therapeutical and pathophysiological perspective.

METHODS

The review was based on a primary literature search on the PubMed using the search terms "migraine and exercise".

RESULTS

Low levels of physical exercise and high frequency of migraine has been reported in several large population-based studies. In experimental studies exercise has been reported as a trigger factor for migraine as well as migraine prophylaxis. Possible mechanisms for how exercise may trigger migraine attacks, include acute release of neuropeptides such as calcitonin gene-related peptide or alternation of hypocretin or lactate metabolism. Mechanisms for migraine prevention by exercise may include increased beta-endorphin, endocannabinoid and brain-derived neurotrophic factor levers in plasma after exercise.

CONCLUSION

In conclusion, it seems that although exercise can trigger migraine attacks, regular exercise may have prophylactic effect on migraine frequency. This is most likely due to an altered migraine triggering threshold in persons who exercise regularly. However, the frequency and intensity of exercise that is required is still an open question, which should be addressed in future studies to delineate an evidence-based exercise program to prevent migraine in sufferers.

Sports Neurology in Clinical Practice: Case Studies

With regard to persistent posttraumatic headache, there is legitimate concern that duration of symptoms may have an impact on the efficacy of future treatment attempts. Without neuropathologic confirmation, a clinical diagnosis of chronic traumatic encephalopathy cannot be made with a high degree of confidence. Sport-related headaches are challenging in a return-to-play context, because it is often unclear whether an athlete has an exacerbation of a primary headache disorder, has new-onset headache unrelated to trauma, or is in the recovery phase after concussion. Regular physical exercise may prove beneficial to multiple neurologic disease states.

Physical therapy for headaches

Background Headache is the medical problem most commonly observed by neurologists. Non-pharmacological treatments are commonly demanded by individuals with headaches, but their evidence of effectiveness is conflicting. Aim The current review provides an updated discussion on what is supported by current scientific evidence about physical therapies for tension-type headache (TTH), migraine, and cervicogenic headache (CeH), and which gaps there still may be in our understanding of the interventions. Methods PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, PEDro, and SCOPUS were searched from their inception through March 2015. Results/Discussion Several physical therapies including spinal joint manipulation/mobilization, soft tissue interventions, therapeutic exercises and needling therapies are proposed to be effective for the management of headaches. Current evidence has shown that the effectiveness of these interventions will depend on proper clinical reasoning since not all interventions are equally effective for all headache pain conditions. For instance, evidence of physical therapy in migraine is more controversial than in TTH, since migraine pathogenesis involves activation of sub-cortical structures and the trigemino-vascular system, whereas pathogenesis of TTH is more associated with musculoskeletal disorders, e.g. muscle pain. It seems that multimodal approaches including different interventions are more effective for patients with TTH, migraine and CeH.

Aerobic Exercise for Reducing Migraine Burden: Mechanisms, Markers, and Models of Change Processes

BACKGROUND

Engagement in regular exercise routinely is recommended as an intervention for managing and preventing migraine, and yet empirical support is far from definitive. We possess at best a weak understanding of how aerobic exercise and resulting change in aerobic capacity influence migraine, let alone the optimal parameters for exercise regimens as migraine therapy (eg, who will benefit, when to prescribe, optimal types, and doses/intensities of exercise, level of anticipated benefit). These fundamental knowledge gaps critically limit our capacity to deploy exercise as an intervention for migraine.

OVERVIEW

Clear articulation of the markers and mechanisms through which aerobic exercise confers benefits for migraine would prove invaluable and could yield insights on migraine pathophysiology. Neurovascular and neuroinflammatory pathways, including an effect on obesity or adiposity, are obvious candidates for study given their role both in migraine as well as the changes known to accrue with regular exercise. In addition to these biological pathways, improvements in aerobic fitness and migraine alike also are mediated by changes in psychological and sociocognitive factors. Indeed a number of specific mechanisms and pathways likely are operational in the relationship between exercise and migraine improvement, and it remains to be established whether these pathways operate in parallel or synergistically. As heuristics that might conceptually benefit our research programs here forward, we: (1) provide an extensive listing of potential mechanisms and markers that could account for the effects of aerobic exercise on migraine and are worthy of empirical exploration and (2) present two exemplar conceptual models depicting pathways through which exercise may serve to reduce the burden of migraine.

CONCLUSION

Should the promise of aerobic exercise as a feasible and effective migraine therapy be realized, this line of endeavor stands to benefit migraineurs (including the many who presently remain suboptimally treated) by providing a new therapeutic avenue as an alternative or augmentative compliment to established interventions for migraine.

Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis

AIM

We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH).

METHODS

We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality.

RESULTS

Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH ( ITALIC! p < 0.0001; mean reduction -1.11 on a 0-10 visual analog scale (VAS); 95% CI -1.64 to -0.57) and CGH ( ITALIC! p = 0.0002; mean reduction -2.52 on a 0-10 VAS; 95% CI -3.86 to -1.19) pain intensity, CGH frequency ( ITALIC! p < 0.00001; mean reduction -1.34 days per month; 95% CI -1.40 to -1.28), and migraine ( ITALIC! p = 0.0001; mean reduction -22.39 hours without relief; 95% CI -33.90 to -10.88) and CGH ( ITALIC! p < 0.00001; mean reduction -1.68 hours per day; 95% CI -2.09 to -1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity ( ITALIC! p < 0.00001; mean reduction -1.94 on a 0-10 VAS; 95% CI -2.61 to -1.27) and frequency ( ITALIC! p < 0.00001; mean reduction -9.07 days per month; 95% CI -9.52 to -8.62).

DISCUSSION

Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

Headache and peak oxygen uptake: The HUNT3 study

Background

Evidence on the association between headache and physical fitness is conflicting. The aim of this population-based study was to examine the relationship between peak oxygen uptake (VO2peak) and headache, including migraine and tension-type headache (TTH).

Methods

In the third Nord-Trøndelag Health study (HUNT3), VO2peak was measured by ergospirometry in a sample of 4631 healthy adult participants. Of these, 3899 (54% women) also answered headache questions. The cross-sectional association between headache and VO2peak was evaluated by logistic regression using a categorical approach based on quintiles. Scores in the upper quintile were used as reference.

Results

Participants age 20–50 years had significant trends of increasing prevalence of any headache ( p < 0.001), migraine ( p < 0.001), TTH ( p = 0.002) and unclassified headache ( p = 0.027) with lower VO2peak. The highest prevalence odds ratios (ORs) were found in those with VO2peak in the lower quintile: For any headache the OR was 2.3 (95% confidence interval (1.6–3.3), for TTH 1.8 (1.2–2.8), for unclassified headache 1.9 (1.1–3.8), and for migraine 3.7 (2.1–6.6). Similar results were also found among those who reported physical activity levels in accordance with current recommendations of the American College of Sports Medicine but nevertheless had low VO2peak. Being in the lowest VO2peak quintile was also strongly associated with migraine aggravated by physical activity (OR 4.1, 2.1–8.1). No significant association was found between VO2peak and headache for those 50 years or older.

Conclusions

In this large cross-sectional study, an inverse relationship was found between VO2peak and headache for adults younger than 50 years of age.

Headache in sports

Sports- and exercise-related headaches are not unusual. Despite their frequent occurrence in this context, there are little epidemiologic data concerning sports-related headache. The recent attention of concussive injuries and associated post-traumatic headache has renewed interest in the study of those headaches occurring after head trauma; however, any primary headache type can also occur in the setting of contact and/or collision sports. The nonspecific nature of headaches provides unique challenges to clinicians encountering this complaint. It is, therefore, imperative that physicians treating athletes are able to distinguish the various headache types and presentations often seen in this population.