Lifestyle Advice for Pediatric Migraine: Blaming the Patient, or Evidence Based?

Amy A. Gelfand, MD, MAS; Samantha L. Irwin, MBBS


Semin Neurol. 2020;40(3):277-285. 

In This Article

Section 2: "Regular Exercise"

What is the Evidence?

In a cross-sectional survey study of 1,619 adolescents in Spain (aged 12–18 years), those without headaches (n = 1,125) were more likely to exercise regularly than those without headaches (n = 494): odds ratio (OR), 1.4; 95% CI, 1.1–1.8. In the multivariate analysis, a more sedentary lifestyle was associated with a small but statistically significant increase in odds of recurrent headaches: OR, 1.05; 95% CI, 1.0–1.1. Similarly, in a cross-sectional study of 5,847 participants aged 13 to 18 years in Norway, low physical activity was associated with increased prevalence of migraine, tension-type headache, and other headaches.[15]

There is a correlation between body fat percentage, body mass index (BMI), and migraine in children.[16–19] In adults, obesity is a risk factor for progression from episodic to chronic migraine.[18] In a study of obese adolescents with migraine who underwent a 12-month multidisciplinary weight loss program that included physical training, reduction in headache frequency was seen, and a greater decrease in BMI was a predictor of improved headache frequency.[20] However, there was no control group and cognitive behavioral therapy (CBT) was a cointervention. An observational study of patients attending pediatric headache centers found that BMI was associated with headache frequency at the initial visit, and that for overweight patients, a change in BMI correlated with a change in headache frequency at follow-up visits.[16] To the extent that exercise can influence body fat percentage and BMI, exercise could conceivably be a mediator in the relationship between obesity and migraine frequency. In the Norwegian adolescent study noted earlier, however, both low physical activity and being overweight were independently associated with recurrent headache; hence, each may have an independent effect on migraine frequency.[15]

In a recent trial involving 13- to 18-year-olds with sport-related concussion, those assigned to aerobic exercise (n = 52) recovered more quickly than those assigned to stretching (n = 51): median of 13 (interquartile range [IQR], 10–18.5) days versus 17 (IQR, 13–23) days to recover (p = 0.009). Given that headache is a common postconcussive symptom, this is empiric evidence to suggest that exercise may improve recovery from posttraumatic headache in youth.

There are also data suggesting that exercise may be useful in managing mood disorders in children and adolescents.[21,22] Hence, if a mood disorder is a pertinent comorbidity for a young person with migraine, one could recommend exercise to target improving their mood disorder.

In adults, there is more evidence to suggest a role for exercise in decreasing migraine frequency. In one study of adults with episodic migraine, participants were randomized to treatment with (1) topiramate (n = 31), (2) a relaxation program (n = 30), or (3) aerobic exercise three times a week (n = 30). The exercise program consisted of 15 minutes of warm-up, 20 minutes of aerobic activity, and a 5-minute cool down. Migraine frequency decreased equally in all groups, suggesting that exercise may be as effective as topiramate for decreasing migraine frequency.[23] Given that topiramate has Level A evidence for migraine prevention in adults, these are encouraging results.[24]

In an adult trial of those with chronic migraine, participants were randomized to either exercise (40 minutes of "fast" walking outdoors three times a week for 12 weeks) plus 25 mg of amitriptyline a day (n = 30) or amitriptyline alone (n = 30). In the combined treatment group, headache frequency came down from 23 ± 6.1 day/month at baseline to 5 ± 2.2 at 3 months, versus a decrease from 25 ± 6.3 day/month to 13 ± 6.4 at 3 months in the amitriptyline-alone group (p = 0.001), for an improved therapeutic gain of approximately −6 day/month.[25]

In a third trial of exercise for episodic migraine prevention in adults (n = 36), after a 4-week run-in, participants were randomized to either (1) high-intensity interval training (HIT): four rounds of 4 minutes of exercise at 90% maximum heart rate, followed by 3 minutes of active rest at 70% maximum heart rate, or (2) moderate continuous aerobic training (MCT): maintaining 70% maximum heart rate for 45 minutes on a treadmill or (3) the control group: instructed to maintain usual daily activities after receiving education regarding standard physical activity recommendations. Both exercise interventions took place twice a week for 12 weeks. In addition, cardiopulmonary exercise testing and retinal vessel analyses were completed. Importantly, the interventions were well tolerated by all migraine patients. Although not significant, HIT led to a greater reduction in mean (SD) migraine days per month: 3.8 (3.0) during run-in to 1.4 (1.2) after the intervention, compared with 3.2 (2.4) to 2.0 (1.6) in the control group and 4.5 (2.1) to 3.2. (3.0) in the MCT group (p = 0.12 analysis of covariance).[26]

Two meta-analyses have pooled trial results to try to estimate the effect of exercise on migraine frequency in adults. In one study, aerobic exercise was concluded to yield a mean (SD) reduction of −0.6 (0.3) migraine days per month.[27] In the other, 10 randomized clinical trials were analyzed. All found headache frequency decreased compared with preexercise implementation; and in five studies, this change was greater than that in the comparison group. The authors highlighted the absence of adverse events and the potential of exercise to be a safe treatment for migraine prevention.[28]

In relation to the earlier-mentioned points, some people with migraine perceive exercise to be a migraine trigger. However, when tested 12 adults who perceived strenuous exercise to be a trigger, only a third (n = 4/12) had migraine when they exercised in an experimental setting, wherein they reached at least 80% of their maximal heart rate and exercised for an hour.[29] It may be that exercise is a trigger only under certain circumstances, or alternatively that other factors that tend to accompany exercise play a migraine-activating role—such as heat, light, or high altitude—and the patient perceives exercise to be the trigger.

Recommendations for the Clinician

Counseling. "Adolescents who exercise regularly may be less likely to have headaches. In adults with migraine, exercising three times per week seems to help decrease migraine frequency as much as taking a prescription medication." And, if relevant, "there is also some evidence that exercise may improve mood in young people."

Facilitating Implementation. Those with migraine sometimes find it difficult to exercise due to heat, movement sensitivity, light sensitivity, etc. They can be encouraged to exercise during cooler times of the day, or in shaded or air-conditioned environments if available. Hats and sunglasses may help mitigate photophobia, and having the option to wear these during physical education classes can be included in their 504 plans. The chaos of doing exercise with 20+ peers during physical education classes can also sometimes be overstimulating for someone with migraine; if so, medical excusal from physical education class may be reasonable, as long as there is an alternate plan for getting regular exercise. For those with significant movement sensitivity, lower-impact exercise such as walking, swimming, and biking may be better tolerated. Those experiencing frequent migraine might be deconditioned if there has been a prolonged period of sedentary living while in pain. Encouraging adolescents to start with just a 5- to 10-minute walk, 3 to 5 days a week, with the intention of "breaking a sweat," may be an achievable starting point. The duration and intensity can then be titrated up as tolerated.

Recommendations for Research

Randomized controlled trials are needed to determine whether exercise can decrease migraine frequency in children and adolescents, and if so, what is the appropriate "dose" and format of exercise for this indication.