Amitriptyline and aerobic exercise or amitriptyline alone in the treatment of chronic migraine: a randomized comparative study

Advances in Exercise in the Clinical Trials of Migraine: A Scoping Review

PURPOSE OF REVIEW

This review aimed to investigate emerging evidence regarding the effectiveness of exercise for migraines, focusing on the results of recent trials. Additionally, it explored the possibility of exercise as a treatment for migraines.

RECENT FINDINGS

Between 2020 and 2023, five, four, one, and two trials were conducted regarding the effect of aerobic exercise, anaerobic exercise, Tai Chi, and yoga, respectively, on migraine; all studies showed significant effects. Two trials on aerobic exercise showed that high-intensity exercise was similar to or slightly more effective than moderate-intensity exercise as a treatment for migraines. Three trials on anaerobic exercise reported its effectiveness in preventing migraines. Regarding efficacy, side effects, and health benefits, aerobic exercises and yoga are potentially beneficial strategies for the prevention of migraines. Further studies are needed to develop evidence-based exercise programs for the treatment of migraines.

The Effect of OnabotulinumtoxinA on Headache Intensity and Number of Monthly Headache Days in Individuals with Chronic Migraine with Different Levels of Neck Disability

One of the treatment methods used in chronic migraine is OnabotulinumtoxinA. The effects of OnabotulinumtoxinA on headache intensity (HI) and number of monthly headache days (NMHD) in chronic migraine (CM) patients classified according to neck disability levels are unknown. Our aim was to investigate the effect of OnabotulinumtoxinA on the HI and the NMHD in individuals with CM with different levels of neck disability. One hundred sixteen patients were enrolled in the study. The OnabotulinumtoxinA protocol was administered as per Follow-the-Pain PREEMPT. The Neck Disability Index was used to evaluate neck disability. Primary outcome measures were headache intensity, assessed with the Visual Analogue Scale, and the number of monthly headache days recorded from patients' diaries. Secondary outcome measures were migraine disability, assessed with the Migraine Disability Assessment Test, and quality-of-life, assessed with the Headache Impact Test-6. All assessments were made at baseline and end of the treatment. The OnabotulinumtoxinA treatment showed a greater improvement effect in the number of monthly headache days (p = 0.000) and migraine disability (p = 0.000) parameters in the severe and complete disability groups. CM patients with complete and severe neck disability received the most benefit in reducing the NMHD at 3 months after OnabotulinumtoxinA treatment, but the HI decreased at a similar level in all neck disability groups.

A Descriptive Review of Medication-Overuse Headache: From Pathophysiology to the Comorbidities

PURPOSE OF REVIEW

Medication-overuse headache (MOH) is an important problem worldwide, with different areas of controversy regarding its entity. This article reviews the risk factors, comorbidities, pathophysiology, clinical presentation, effective management, and prognosis of MOH by summarizing and integrating the results and findings from previously performed more than 15,000 studies (from 2010 to 2023) available from the scientific database of the University Medical Library in the University Clinical Center of Niš, which aimed to investigate and define the complexity of this type of headache.

RECENT FINDING

It has been proposed that all acute migraine medications can lead to MOH, with differences in the propensity of different agents to cause the problem. Early data suggests that triptans and other painkillers used for the acute treatment of migraine may be an exception. Recent studies show that practitioners and the general public are still largely unaware of the problem of medication overuse and its damaging effects.

SUMMARY

Although it is likely that MOH does occur, restricting the number of acute medications is necessary to prevent it. It is also possible that increasing amounts of acute medications are simply a reflection of poorly controlled headaches rather than a cause. Further research needs to be developed to identify more precise mechanisms for effective MOH management and its evolution.

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.

Comment regarding: what is the efficacy of aerobic exercise versus strength training in the treatment of migraine? A systematic review and network meta‑analysis of clinical trials

In Woldeamanuel and Oliveira (2022)’s article about the efficacy of exercise in the treatment of migraine, the ranking of the efficacy of strength training (mean difference, − 3.55), aerobic exercise (mean difference, − 2.18 to − 3.13), topiramate (mean difference, − 0.98), and amitriptyline (mean difference, 3.82) using network meta-analysis can mislead readers. First, the inclusion criteria were reported at a monthly frequency of migraine and the end of the intervention, but some article did not meet the inclusion criteria or had data inconsistency. Second, there was an inconsistency in the placebos used in the included studies, which can be problematic in network meta-analysis. Third, all three articles on strength training were rated as high-risk or exhibited some risk of bias. Finally, the effectiveness of this statistical method is questionable for assessing physical activities because strength training, aerobic exercise, and preventive medications can be simultaneously recommended for possible synergistic effects in the prevention of migraine.

What is the efficacy of aerobic exercise versus strength training in the treatment of migraine? A systematic review and network meta-analysis of clinical trials

Background

Multiple clinical trials with different exercise protocols have demonstrated efficacy in the management of migraine. However, there is no head-to-head comparison of efficacy between the different exercise interventions.

Methods

A systematic review and network meta-analysis was performed involving all clinical trials which determined the efficacy of exercise interventions in reducing the frequency of monthly migraine. Medical journal search engines included Web of Science, PubMed, and Scopus spanning all previous years up to July 30, 2022. Both aerobic and strength/resistance training protocols were included. The mean difference (MD, 95% confidence interval) in monthly migraine frequency from baseline to end-of-intervention between the active and control arms was used as an outcome measure. Efficacy evidence from direct and indirect comparisons was combined by conducting a random effects model network meta-analysis. The efficacy of the three exercise protocols was compared, i.e., moderate-intensity aerobic exercise, high-intensity aerobic exercise, and strength/resistance training. Studies that compared the efficacy of migraine medications (topiramate, amitriptyline) to exercise were included. Additionally, the risk of bias in all included studies was assessed by using the Cochrane Risk of Bias version 2 (RoB2).

Results

There were 21 published clinical trials that involved a total of 1195 migraine patients with a mean age of 35 years and a female-to-male ratio of 6.7. There were 27 pairwise comparisons and 8 indirect comparisons. The rank of the interventions was as follows: strength training (MD = -3.55 [− 6.15, − 0.95]), high-intensity aerobic exercise (-3.13 [-5.28, -0.97]), moderate-intensity aerobic exercise (-2.18 [-3.25, -1.11]), topiramate (-0.98 [-4.16, 2.20]), placebo, amitriptyline (3.82 [− 1.03, 8.68]). The RoB2 assessment showed that 85% of the included studies demonstrated low risk of bias, while 15% indicated high risk of bias for intention-to-treat analysis. Sources of high risk of bias include randomization process and handling of missing outcome data.

Conclusion

Strength training exercise regimens demonstrated the highest efficacy in reducing migraine burden, followed by high-intensity aerobic exercise.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-022-01503-y.

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.

Headache in the Pediatric Population: Focus on Migraine

Pediatric headache is a common condition with significant impact on quality of life and ability to function in academic, social, and extracurricular activities. Most pediatric patients seen in primary care and neurology clinics with headache have primary headache disorders. Diagnosis is largely based on clinical history. Imaging is rarely needed in the absence of red flag features. Careful diagnosis is important to guide appropriate treatment. Treatment focuses on a biopsychosocial model integrating lifestyle, pharmacologic and nonpharmacologic treatment modalities. As few therapies are approved in the pediatric population, treatments are often used off-label based on evidence extrapolated from adult studies. Outcomes vary over time but are generally favorable when headache disorders are diagnosed promptly and managed in a multidisciplinary setting.

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.

Effects of Different Therapeutic Exercise Modalities on Migraine or Tension-Type Headache: A Systematic Review and Meta-Analysis with a Replicability Analysis

The primary aim of this study was to review the effect of exercise in comparison with a non-active treatment on pain intensity, frequency of headache episodes, headache duration, quality of life, medication use, and psychological symptoms, in patients with migraine or tension-type headache (TTH). A systematic search was conducted in various electronic databases to identify all relevant studies: Medline (PubMed), PEDro, EBSCO and Google Scholar. Clinical trials assessing the effects of exercise interventions in patients with primary headaches were selected. Methodological quality was evaluated using the Cochrane Risk of Bias Tool and PEDro scale and qualitative analysis was based on classifying the results into levels of evidence according to the GRADE. 19 studies (2776 participants; 85% female) were included. The meta-analysis showed statistically significant differences in pain intensity for aerobic training in patients with migraine (SMD = -0.65; 95% CI = -1.07 to -0.22, very low certainty evidence) and for strength training in patients with TTH (SMD = -0.84; 95% CI = -1.68 to- -0.01, very low certainty evidence). Statistically significant differences were also found in the medication use (SMD = -0.51; 95% CI = -0.85 to -0.17, low certainty evidence). Low transparency, replicability and high risk of bias were found. Aerobic training has a small to moderate clinical effect on pain intensity and medication use on migraine patients, with very low to low certainty of evidence. Strength training showed a moderate clinical effect with very low quality of evidence in patients with TTH. Exercise could be considered as clinically relevant for the management of patients with primary headaches, but the presence of low certainty of evidence and low transparency and replicability limited its clinical application. PERSPECTIVE: This article presents current evidence about exercise interventions in patients with primary headaches, including migraine and tension-type headache. Existing findings are reviewed, and relevant data are provided on the effectiveness of each exercise modality, as well as its certainty of evidence and clinical applicability.

Revised guidelines of the French headache society for the diagnosis and management of migraine in adults. Part 3: Non-pharmacological treatment

The French Headache Society proposes updated French guidelines for the management of migraine. This article presents the third part of the guidelines, which is focused on the non-pharmacological treatment of migraine, including physical exercise, dietary supplements and plants, diets, neuromodulation therapies, acupuncture, behavioral interventions and mindfulness therapy, patent foramen ovale closure and surgical nerve decompression.

Comprehensive management of adults with chronic migraine: Clinical practice guidelines in Mexico

Introduction:

Migraine is a polygenic multifactorial disorder with a neuronal initiation of a cascade of neurochemical processes leading to incapacitating headaches. Headaches are generally unilateral, throbbing, 4–72 h in duration, and associated with nausea, vomiting, photophobia, and sonophobia. Chronic migraine (CM) is the presence of a headache at least 15 days per month for ≥3 months and has a high global impact on health and economy, and therapeutic guidelines are lacking.

Methods:

Using the Grading of Recommendations, Assessment, Development, and Evaluations system, we conducted a search in MEDLINE and Cochrane to investigate the current evidence and generate recommendations of clinical practice on the identification of risk factors and treatment of CM in adults.

Results:

We recommend avoiding overmedication of non-steroidal anti-inflammatory drugs (NSAIDs); ergotamine; caffeine; opioids; barbiturates; and initiating individualized prophylactic treatment with topiramate eptinezumab, galcanezumab, erenumab, fremanezumab, or botulinum toxin. We highlight the necessity of managing comorbidities initially. In the acute management, we recommend NSAIDs, triptans, lasmiditan, and gepants alone or with metoclopramide if nausea or vomiting. Non-pharmacological measures include neurostimulation.

Conclusions:

We have identified the risk factors and treatments available for the management of CM based on a grading system, which facilitates selection for individualized management.

Genetics, pathophysiology, diagnosis, treatment, management, and prevention of migraine

Migraine is a neurological ailment that is characterized by severe throbbing unilateral headache and associated with nausea, photophobia, phonophobia and vomiting. A full and clear mechanism of the pathogenesis of migraine, though studied extensively, has not been established yet. The current available information indicates an intracranial network activation that culminates in the sensitization of the trigemino-vascular system, release of inflammatory markers, and initiation of meningeal-like inflammatory reaction that is sensed as headache. Genetic factors might play a significant role in deciding an individual's susceptibility to migraine. Twin studies have revealed that a single gene polymorphism can lead to migraine in individuals with a monogenic migraine disorder. In this review, we describe recent advancements in the genetics, pathophysiology, diagnosis, treatment, management, and prevention of migraine. We also discuss the potential roles of genetic and abnormal factors, including some of the metabolic triggering factors that result in migraine attacks. This review will help to accumulate current knowledge about migraine and understanding of its pathophysiology, and provides up-to-date prevention strategies.

Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study

BACKGROUND

Though a large amount of research on the management of headache has been conducted, the clinical effectiveness of these treatments remains unclear.

OBJECTIVES

To reach consensus among international musculoskeletal experts on what the most appropriate management is in patients that suffer from headache.

DESIGN

Expert group and Delphi-study.

METHODS

A total of 11 experts participated in the expert panel groups, where the role of physiotherapy in the management of headache was discussed. Afterwards, 14 of the initial 25 participants in the field of headache completed the whole Delphi study, which was conducted over 4 rounds. The first round aimed to identify clinical indicators and treatments that are useful in patients with headache. These questions were then categorized and ranked during the second, third, and fourth rounds. Consensual agreement was set at ≥ 80%.

RESULTS

After the final round, 9 interventions were rated as useful by the participants. In the final extra round, 14 clinical indicators were retrieved as important to decide whether or not to start one of the consensual treatments. The top 3 management strategies were (1) upper cervical spine mobilisations in cervivogenic headache, (2) active mobilisation exercises of the cervical spine in cervivogenic headache, and (3) lifestyle advice in tension-type headache and migraine.

CONCLUSION

International experts agreed that most scientifically established effective treatments are useful in cervicogenic headache. Consensual agreement on treatments for migraine and tension-type headache were only reached for specific treatments. Their recommendations provide a framework for further research and the clinical management of headache.

Exercise in Treatment of Migraine Including Chronic Migraine

PURPOSE OF REVIEW

With this review, we aimed to investigate the effect of exercise on migraine and explored the possibility of exercise as a treatment option for migraine.

RECENT FINDINGS

A close association of physical activity and exercise with migraine has been reported in clinical and population-based studies. Recent randomized controlled trials investigating the effect of aerobic exercise as a migraine-preventive treatment have revealed a notable improvement in migraine symptoms. Data on the effect of anaerobic exercise and exercise for flexibility, coordination, and relaxation on migraine are currently insufficient to make any recommendations. Possible pathways for the attenuation of migraine by exercise include the endogenous opioid and cannabinoid systems, brain-derived neurotrophic factor, inflammation, and behavioral/psychological factors. Regarding efficacy, side effects, and health benefits, aerobic exercise is a potentially beneficial strategy in the preventive treatment of migraine. Further studies are needed to delineate an evidence-based exercise program for migraine treatment.

Prospective cohort study of routine exercise and headache outcomes among adults with episodic migraine

OBJECTIVE

To evaluate the association of routine exercise with headache frequency, intensity, and duration among adults with episodic migraine (EM).

BACKGROUND

A comprehensive management plan for EM must aim at reducing disability and cost of care; to do so requires optimizing acute and preventive medications, and behavior changes. Prophylactic medication use is associated with adverse events and contraindications with comorbidities. Aerobic exercise is reported to decrease migraine frequency. However, no study has evaluated a potential synergistic relation between regular exercise and preventive medication use among patients with EM.

DESIGN AND METHODS

This was a secondary analysis of data from a prospective cohort study of adults with EMs. In that study, adults with EM (using International Classification of Headache Disorders-3 criteria confirmed by study physicians) were recruited from three academic medical centers in Boston, MA. At baseline, participants provided information on exercise, clinical and demographic characteristics, and lifestyle behaviors. We prospectively collected daily information on headaches and health behavior over at least 6 weeks using electronic questionnaires from 94 participants. We assessed the association between baseline self-reported moderate-vigorous exercise at least three times per week, at baseline, and prospectively recorded headache frequency, intensity, and duration. We further assessed whether these associations differed by the prevalent use of prophylactic migraine medication.

RESULTS

Data from 94 of 98 eligible participants were used in the analysis as 4 participants had missing data on routine exercise frequency or intensity at baseline. On average, patients who reported moderate-vigorous exercise at least three times per week at enrollment had 1.5 fewer headache days per month (-1.5 headache days/month; 95% confidence interval [CI] -3.1 to 0.1) compared to less exercise; this was not statistically significant (p = 0.066). The association between exercise and headache days per month varied by baseline use of migraine prophylaxis (p-value of interaction = 0.009). Among those who reported regular use of migraine prophylaxis, a report of moderate-vigorous exercise at least three times per week was associated with 5.1 fewer headache days (-5.1: 95% CI -8.2 to -2.0; p = 0.001) compared to those who reported lower levels of exercise. However, among those not using migraine prophylaxis, we observed only 0.4 fewer headache days per month (-0.4: 95% CI -2.2 to 1.3; p = 0.636) associated with moderate-vigorous exercise at least three times/week, a result that was not statistically significant. There was no association of self-reported moderate-vigorous exercise at least three times a week with headache intensity or duration.

CONCLUSION

In patients with EM, those who reported moderate-vigorous exercise at least three times per week had fewer headache days per month, though not statistically significant. This association was significantly stronger in those who used prophylactic medication for migraines. Exercise appeared not to be associated with the severity or duration of headaches. Routine moderate-vigorous exercise may be an important adjunctive strategy for improving headache burden in patients eligible for migraine prophylaxis.

Headache Hygiene in Pediatrics: Brushing Up on the Basics

Headache hygiene refers to self-management behaviors and practices aimed at reducing headache-related disability and improving self-efficacy. Although self-management interventions have an established place in the management of a wide range of chronic conditions, there is still not a standardized approach to this in pediatric headache. In this article, we focus on headache hygiene approaches including education, lifestyle interventions, and psychologic interventions. We also present our center's resource compilation, made available to patients by quick response code technology, as an example of a structured approach to headache hygiene. Further work should explore a standardized approach to headache hygiene and strategies to support adherence, including the use of technology as an innovative health care delivery pathway.

Anandamide Is Related to Clinical and Cardiorespiratory Benefits of Aerobic Exercise Training in Migraine Patients: A Randomized Controlled Clinical Trial

Introduction: Since endocannabinoids have been implicated in migraine pathophysiology, we conducted a randomized, controlled clinical trial to test the effects of a 12-week aerobic exercise intervention on plasma anandamide (AEA) and its relation with clinical, psychological, and cardiorespiratory outcomes. Materials and Methods: Episodic migraine patients taking no preventive drugs and nonheadache individuals were recruited from Hospital São Paulo and a tertiary headache clinic between March 2012 and March 2015. Participants were randomly assigned to receive aerobic exercise or enter the waitlist. Primary outcome was changes in plasma AEA; secondary outcome was number of days with migraine/month; and other clinical variables, mood scores, and cardiorespiratory fitness were chosen as tertiary outcomes. Measurements were taken on headache-free days. Data were analyzed by generalized linear models. Discussion: Fifty participants concluded the study (mean±SD age=36.2±10.9, and BMI=26.5±4.5). The plasma AEA reduced in migraine exercise (p<0.05) and control exercise groups (p<0.01). The number of days with migraine (p<0.01), migraine attacks (p<0.05), and abortive medication used (p<0.05) reduced in the migraine exercise group, whereas cardiorespiratory fitness increased in migraine exercise and control exercise groups (both p<0.05). Anxiety, depression, anger, and fatigue scores improved in the migraine exercise group (p<0.05 for all). Significant correlations between reduction in abortive medication used and cardiorespiratory fitness (r=-0.81 p<0.001), and reduced AEA (r=0.68 p<0.05) were found. Conclusions: This study suggests that peripheral AEA metabolism may be partly linked to the clinical and cardiorespiratory benefits of regular aerobic exercise in migraine patients. Trials registration: #NCT01972607.

Consensus of the Brazilian Headache Society on the treatment of chronic migraine

Chronic migraine poses a significant personal, social and economic burden and is characterized by headache present on 15 or more days per month for at least three months, with at least eight days of migrainous headache per month. It is frequently associated with analgesic or acute migraine medication overuse and this should not be overlooked. The present consensus was elaborated upon by a group of members of the Brazilian Headache Society in order to describe current evidence and to provide recommendations related to chronic migraine pharmacological and nonpharmacological treatment. Withdrawal strategies in medication overuse headache are also described, as well as treatment risks during pregnancy and breastfeeding. Oral topiramate and onabotulinum toxin A injections are the only treatments granted Class A recommendation, while valproate, gabapentin, and tizanidine received Class B recommendation, along with acupuncture, biofeedback, and mindfulness. The anti-CGRP or anti-CGRPr monoclonal antibodies, still unavailable in Brazil, are promising new drugs already approved elsewhere for migraine prophylactic treatment, the efficacy of which in chronic migraine is still to be definitively proven.

Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment

Patients with pelvic pain suffer from psychological conditions at a disproportionately high rate compared with their peers. We review environmental, genetic, inflammatory, and neurobiological factors that increase vulnerability to developing both of these conditions. We review treatment strategies for chronic pelvic pain in patients who have comorbid psychological conditions, including both nonpharmacologic and pharmacologic options.

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 .

Sports, physical activity and headache in the classical age: historical descriptions from the first sports textbook, "De arte gymnastica", by Girolamo Mercuriale

BACKGROUND AND OBJECTIVES

The relationship between physical activity, sports and headache presents a growing interest, testified by numerous papers recently published. The correlation between headache and sporting activities or physical exercise dates back to the classical age. We aim at promoting the development of more studies focused on the relationship between headache and physical activity.

METHODS

We analysed the book "De arte gymnastica", written by Girolamo Mercuriale (Forlì, Italy, 1530-1606), and considered the first "sports medical textbook". We discuss these classical literature findings in the light of the International Classification of Headache Disorders, 3rd edition.

RESULTS

The Author's work derives from the systematic revision of Greek, Roman and Arabic literatures about the matter. Despite some references to inveterate headaches or cold-related pains, Mercuriale does not gather specific clinical characterisations of different types of headache. However, interestingly, he reports detailed descriptions of how the same sport, or the same physical activity, could cause or give relief from head pain, depending on the precise way of practising. Mercuriale summarises 18 sports or physical activities that can give relief from headache; conversely, running or heavy activities, such as boxing, appear among the 12 contraindicated sports for people suffering from headache.

CONCLUSIONS

"De arte gymnastica", by Girolamo Mercuriale, is the first textbook on sports medicine. Headache if often cited along the treatise: different sports and physical activities, or various ways of practising the same action could produce opposite effects for people suffering from headache.

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.

Intentional avoidance of physical activity in women with migraine

Given the benefits of habitual physical activity for migraine management and overall health, it is important to understand the reasons for low physical activity levels in those with migraine. Beliefs that physical activity can trigger and/or worsen migraine pain may contribute to low physical activity levels via intentional avoidance of physical activity, particularly of higher intensities. This study evaluated intentional avoidance of physical activity at varying intensity levels and its association with (a) leisure-time physical activity levels, (b) beliefs that physical activity will trigger and/or worsen migraine, and (c) migraine characteristics. Participants were women ( n = 100) who screened positive for migraine on the IDMigraine and completed an online survey on physical activity and migraine. The majority of the sample (78%) reported avoiding physical activity to manage migraine attacks at least once in the past month, and most reported avoidance of both moderate- and vigorous-intensity activity. Among those who reported avoidance, moderate- and vigorous-intensity physical activity was avoided on an average of 4.0 ± 2.0 and 4.1 ± 2.2 days/week, respectively. More frequent avoidance of vigorous-intensity physical activity (but not moderate-intensity) was significantly correlated with lower vigorous-intensity physical activity indicated by fewer days/week ( r = −0.28, p = 0.016) and fewer minutes/day ( r = −0.29, p = 0.011). The frequency of physical activity avoidance was significantly correlated with stronger expected likelihood that physical activity, at both intensity levels, will both trigger ( r = 0.39–0.43, p < 0.01) and worsen ( r = 0.24–0.25, p < 0.05) migraine attacks. Individuals who avoided physical activity reported a significantly higher number of migraine attacks in the past month and were more likely to have chronic migraine, compared to those who did not report avoidance. Intentional avoidance of moderate- and vigorous-intensity physical activity is a common migraine management strategy that is associated with lower levels of vigorous-intensity physical activity, stronger beliefs that physical activity will trigger or worsen migraine, and more frequent migraine attacks. Individuals with migraine who avoid physical activity may benefit from targeted intervention to address beliefs about physical activity and migraine, which has the strong potential to improve both migraine and health outcomes.

The role of nonpharmacologic therapies in management of chronic pelvic pain: what to do when surgery fails

PURPOSE OF REVIEW

To provide an update on nonsurgical and nonpharmacologic strategies for the management of chronic pelvic pain (CPP).

RECENT FINDINGS

Effective treatment of patients with CPP requires a multifaceted approach, with thoughtful consideration of surgical, pharmacologic, and nonpharmacologic strategies. Evidence for physical therapy and trigger point injections for treatment of myofascial components of CPP is increasing. Neuromodulation techniques, such as percutaneous tibial nerve stimulation and transcutaneous electrical stimulation, have limited but favorable preliminary data in patients with CPP. Behavioral strategies, such as exercise, cognitive behavioral therapy, and mindfulness, have demonstrated significant improvements in pain, function and quality of life in patients with a variety of chronic pain conditions and are promising avenues for future research in CPP.

SUMMARY

Nonpharmacologic therapies are important adjuncts to surgical and pharmacologic treatment for CPP and should be considered integral to a comprehensive treatment approach.

Has aerobic exercise effect on pain perception in persons with migraine and coexisting tension-type headache and neck pain? A randomized, controlled, clinical trial

BACKGROUND

A large subset of persons with migraine suffers from coexisting tension-type headache and neck pain which may adversely affect the prognosis of migraine. Aerobic exercise has been shown to decrease migraine burden in these persons. Therefore, the aim of this study was to investigate whether the effect of aerobic exercise in persons with migraine and coexisting tension-type headache and neck pain can be explained by changes in pain perception.

METHOD

Seventy consecutively recruited persons with migraine and coexisting tension-type headache and neck pain were randomized into exercise group or control group. Aerobic exercise consisted of bike/cross-trainer/brisk walking for 45 min, three times/week for 3 months. Controls continued their usual daily activities. Pericranial tenderness, pain thresholds, supra-thresholds and temporal summation were assessed at baseline, after treatment and at follow-up (6 months from baseline).

RESULTS

Fifty-two persons with migraine and coexisting tension-type headache and neck pain completed the study. Aerobic exercise did not induce consistent changes in nociceptive pathways measured by pericranial tenderness, pressure pain thresholds and sensitivity to electrical stimulation.

CONCLUSION

The effect of aerobic exercise cannot be explained by measurable effects on the pain modulation system. Thus, the positive effect on migraine burden may rather be explained by positive alteration of avoidance behaviour. Aerobic exercise can be recommended as a safe and inexpensive migraine treatment strategy.

SIGNIFICANCE

This study adds further knowledge about the positive effect of aerobic exercise for persons with migraine and coexisting tension-type headache and neck pain. This effect cannot be measured by changes in pain modulation, but may rather be explained by positive alteration of avoidance behaviour.

Potential Mechanisms Underlying Centralized Pain and Emerging Therapeutic Interventions

Centralized pain syndromes are associated with changes within the central nervous system that amplify peripheral input and/or generate the perception of pain in the absence of a noxious stimulus. Examples of idiopathic functional disorders that are often categorized as centralized pain syndromes include fibromyalgia, chronic pelvic pain syndromes, migraine, and temporomandibular disorder. Patients often suffer from widespread pain, associated with more than one specific syndrome, and report fatigue, mood and sleep disturbances, and poor quality of life. The high degree of symptom comorbidity and a lack of definitive underlying etiology make these syndromes notoriously difficult to treat. The main purpose of this review article is to discuss potential mechanisms of centrally-driven pain amplification and how they may contribute to increased comorbidity, poorer pain outcomes, and decreased quality of life in patients diagnosed with centralized pain syndromes, as well as discuss emerging non-pharmacological therapies that improve symptomology associated with these syndromes. Abnormal regulation and output of the hypothalamic-pituitary-adrenal (HPA) axis is commonly associated with centralized pain disorders. The HPA axis is the primary stress response system and its activation results in downstream production of cortisol and a dampening of the immune response. Patients with centralized pain syndromes often present with hyper- or hypocortisolism and evidence of altered downstream signaling from the HPA axis including increased Mast cell (MC) infiltration and activation, which can lead to sensitization of nearby nociceptive afferents. Increased peripheral input via nociceptor activation can lead to “hyperalgesic priming” and/or “wind-up” and eventually to central sensitization through long term potentiation in the central nervous system. Other evidence of central modifications has been observed through brain imaging studies of functional connectivity and magnetic resonance spectroscopy and are shown to contribute to the widespreadness of pain and poor mood in patients with fibromyalgia and chronic urological pain. Non-pharmacological therapeutics, including exercise and cognitive behavioral therapy (CBT), have shown great promise in treating symptoms of centralized pain.

The effects of aerobic exercise for persons with migraine and co-existing tension-type headache and neck pain. A randomized, controlled, clinical trial

Aim To evaluate aerobic exercise in migraine and co-existing tension-type headache and neck pain. Methods Consecutively recruited persons with migraine and co-existing tension-type headache and neck pain were randomized into an exercise group or control group. Aerobic exercise consisted of bike/cross-trainer/brisk walking for 45 minutes, three times/week. Controls continued usual daily activities. Pain frequency, intensity, and duration; physical fitness, level of physical activity, well-being and ability to engage in daily activities were assessed at baseline, after treatment and at follow-up. Results Fifty-two persons completed the study. Significant between-group improvements for the exercise group were found for physical fitness, level of physical activity, migraine burden and the ability to engage in physical activity because of reduced impact of tension-type headache and neck pain. Within the exercise group, significant reduction was found for migraine frequency, pain intensity and duration, neck pain intensity, and burden of migraine; an increase in physical fitness and well-being. Conclusions Exercise significantly reduced the burden of migraine and the ability to engage in physical activity because of reduced impact of tension-type headache and neck pain. Exercise also reduced migraine frequency, pain intensity and duration, although this was not significant compared to controls. These results emphasize the importance of regular aerobic exercise for reduction of migraine burden.

An update on behavioral treatments in migraine - current knowledge and future options

INTRODUCTION

Besides pharmacological and interventional treatments a variety of non-medical therapeutic options exist for migraine, which has largely been derived from behavioral therapy. Areas covered: For our update we collected available studies via PubMed searches. This review highlights that already consulting of the patient is able to reduce the frequency of migraine attacks. Relaxation techniques, especially progressive muscle relaxation, and various types of biofeedback are effective, as is the implementation of cognitive behavioral therapy. However, recent reviews also point to some existing inconsistencies and methodological limitations. The advent of modern information technology based approaches (e.g. online therapy, smartphone applications) further advanced the arsenal of behavioral treatment regimes. The combination of behavioral treatment options and the combination with pharmacotherapy lead to additive effects. In modern multidisciplinary treatment approaches, behavioral therapy is an indispensable component. Expert commentary: Behavioral treatment in prophylaxis of migraine is as effective as pharmacological treatment with additional effects when pharmacological and behavioral treatment is applied in combination. Novel treatment approaches using online technology and electronic devices offer interesting options that will spread more in the future.

Real-life use of onabotulinumtoxinA for symptom relief in patients with chronic migraine: REPOSE study methodology and baseline data

Background

Migraine is a debilitating neurological disorder that affects 14.1% of the US and 14.7% of the European populations. Chronic migraine (CM) is broadly defined as headache occurring on ≥15 days per month for ≥3 months, and has an estimated worldwide prevalence of 1.4% to 2.2%. OnabotulinumtoxinA is currently approved for the treatment of CM in most European countries, and is the only preventative treatment approved for adults with CM, based on results from the PREEMPT clinical trial programme. The ongoing prospective, observational REal-life use of botulinum toxin for the symptomatic treatment of adults with chronic migraine, measuring healthcare resource utilisation, and Patient-reported OutcomeS observed in practice (REPOSE) Study aims to describe real-world healthcare resource utilisation and patient-reported outcomes over a 2-year period in Germany, Italy, Norway, Russia, Spain, Sweden, and the United Kingdom, among patients with CM prescribed onabotulinumtoxinA.

Methods

Herein, methodology and baseline characteristics of patients who participated for ≥6 months in REPOSE are reported. No outcomes data are presented, although the methods for collecting these data are detailed. In REPOSE, onabotulinumtoxinA is administered at baseline and each follow-up visit (approximately every 3 months) during the 24-month treatment period, according to the treating physician’s best clinical judgment and standard of care, guided by the terms of the marketing authorisation described in the Summary of Product Characteristics. Outcome assessments include Migraine-Specific Quality of Life Questionnaire (MSQ), EuroQol Group Questionnaire (EQ-5D), headache-day frequency, treatment satisfaction, headache-related healthcare resource utilisation (ie, healthcare professional visits, hospital admissions, medication use), onabotulinumtoxinA utilisation (ie, dose, sites), and safety/tolerability.

Results

As of the interim assessment date for this analysis, the study has enrolled 644 patients from 78 sites throughout Europe, and baseline data are available for 336 patients from 61 sites who participated in the study for ≥6 months. Baseline measures indicate substantial disease burden and healthcare resource utilisation.

Conclusions

Final results from the REPOSE Study will provide the largest real-world, long-term analysis of the clinical use of onabotulinumtoxinA for the treatment of CM and will add important information to existing real-world findings. Future analyses will assess the long-term safety and efficacy of onabotulinumtoxinA in this population.

The Experience of Adolescents Living With Headache

There is little qualitative literature that addresses the adolescent experience of living with headache. The purpose of this study was to determine the dimensions of the health challenge of adolescent headache; the high points, low points, and turning points of living with headache; and the approaches used to resolve the challenge of living with headache. Story theory was used as the qualitative framework to guide data collection, and story inquiry provided the structure for analyzing the data. The Pediatric Migraine Disability Scale (PedMIDAS) quantitatively measured the impact of headaches on daily functioning. Of the 8 participants, 6 reported moderate to severe disability. From the stories, a theme for the complicating health challenge of living with adolescent headache was "an enduring distress manifested by pain, uncertainty, distancing self from family and friends, challenges with school, and not knowing how to resolve." Themes descriptive of the high points, low points, and turning points included "Contentment with school achievement, supportive relationships, and comforting engagement"; "Interruption in pursuing sports/exercise, time with others, and family relationships"; and "A developing realization, through hope and insight, of the possibilities for moving toward resolution." Stories revealed approaches used to resolve the challenge of living with headache, which included self-management through medication, sleep, and transcendence. The findings offer insight into the challenges faced by adolescents with headache and provide evidence of the importance for developing holistic plans of care that address the individual needs of the patient rather than relying on medication management alone.

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015

BACKGROUND

Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment.

OBJECTIVE

To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion.

METHODS

On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device.

RESULTS

A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%.

CONCLUSION

Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments.

ABBREVIATIONS

ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

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.