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Keywords:

  • chronic headache;
  • behavioral treatment;
  • exercise

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Statement of Authorship
  7. References

Background

Behavioral approaches have been found to be effective in managing chronic headache. Recently, attention has been given to the role of exercise in chronic headache management, although much of the literature addresses it as a monotherapy. The current review assesses the effectiveness of exercise as an adjunct to other behavioral treatments for chronic headache.

Objective

To evaluate the methodology and outcomes of studies using behavioral headache interventions with an aerobic exercise component.

Methods

A systematic literature review was conducted on PubMed and PsychInfo to identify studies that offered or recommended aerobic exercise as part of a multicomponent treatment for headaches. The search included only those articles that were written in English and published in academic journals.

Results

Nine studies met inclusion criteria, of which 2 were randomized controlled trials. Despite methodological limitations, results of existing studies suggest that the behavioral headache interventions that include aerobic exercise may be associated with positive outcomes for headache variables. Four single-group studies reported statistically significant improvements in at least 1 headache variable at the end of treatment. Both randomized controlled trials and 1 non-randomized trial reported statistically significant post-treatment improvement in at least 1 headache outcome variable in the intervention group compared with control groups.

Conclusions

Incorporating exercise into behavioral headache treatments appears to be promising, but as studies to date have not evaluated the individual contribution of exercise, its role in managing headache symptoms is unclear. Further work is needed to evaluate the unique role of exercise in such treatment programs. Recommendations for future research include adhering to published guidelines for clinical trial design and reporting, adhering to existing guidelines for headache research (such as reporting outcome data for multiple headache variables), developing exercise prescriptions based on public health recommendations, and reporting all aspects of exercise prescriptions.

Recurrent headaches, most prevalent among females, negatively impact family functioning, work productivity, and absenteeism, and are associated with increased emergency room visits and use of prescription and non-prescription medications.[1] While medications can be highly effective in the treatment of chronic headaches, they are not always well tolerated or significantly effective in providing headache relief.[2] Extensive research has found behavioral headache management techniques (eg, relaxation training, biofeedback, stress management training, cognitive behavior therapy) to have strong empirical support in the management of chronic head pain.[3]

Exercise has received a reasonable amount of consideration as another potential treatment option,[4, 5] as researchers have identified an association between low levels of physical activity and increased prevalence of migraine and non-migrainous headaches.[6] Engagement in regular physical activity has been associated with decreased functional disability related to migraines[7] and the transition of transformed (chronic) migraines to episodic migraines within 1 year.[8] In 2008, Busch and Gaul[9] summarized the status of research on the role of exercise on migraine outcomes, and concluded that exercise generally was associated with decreases in pain intensity, but not with changes in headache frequency or duration. However, they suggested that it is difficult to draw conclusions based on the studies they examined, owing to methodological limitations.

Aerobic exercise is of particular interest, as it is associated with improved cardiovascular fitness,[10, 11] which is hypothesized to be a mechanism of change in the improvement of headache symptoms.[4, 11] The exact mechanism of this relationship is unclear, although various hypotheses have been suggested, including sustained increased serotonin levels,[4] and moderation of the sympathetic and parasympathetic responses to stress.[11, 12] Since 2008, 3 additional publications have conducted systematic investigations of aerobic exercises as a treatment option for headache. Varkey et al administered a 40-minute aerobic exercise cycling intervention 3 times a week for 12 weeks.[13] Most of the exercise sessions were supervised, but patients had the option of completing 1 session per week at home. Among the 26 patients who completed the program, significant improvements at post-treatment were found in the quality of life, migraine frequency and intensity, and medication use, as well as in maximum oxygen intake (VO2 max), an indicator of physical fitness. Building on these findings, Varkey et al conducted a larger randomized controlled trial (RCT) in which participants received this exercise prescription, a relaxation treatment, or a course of daily topiramate treatment.[14] Those in the exercise group had higher VO2 max levels at post-treatments than those who received topiramate or a relaxation treatment. Participants in the topiramate group received a significantly greater improvement in headache intensity compared with the other groups. Otherwise, there were no differences between groups in terms of headache frequency or quality of life, prompting the authors to argue that exercise is just as effective at controlling migraines as relaxation training and topiramate – 2 well-established treatments. Another recent pilot study utilizing a similar exercise prescription (30 minutes of aerobic exercise, 3 times per week for 10 weeks) reported significant improvements in the number of migraine days per month, migraine intensity, fitness level, and stress level.[15] Collectively, these findings provide evidence regarding the utility of aerobic exercise in the treatment of chronic headaches.

The Busch and Gaul[9] report and the studies discussed above assess the effectiveness of exercise as a monotherapy for the management of chronic headache, and suggest that it may be a useful treatment option. Busch and Gaul[9] suggest, however, that multicomponent treatment packages, as opposed to individual treatment techniques, seem to be best for chronic headaches. At present, little is known regarding the use of aerobic exercise within these types of behavioral interventions, or the degree to which an exercise component uniquely contributes to the overall intervention effectiveness. The goals of this paper are to identify existing treatment outcome studies for interventions that include an exercise component, discuss general issues related to design and study characteristics, discuss the nature of exercise implementation within these studies, and put forth guidelines for future research and clinical practice.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Statement of Authorship
  7. References

Procedure

A systematic literature review was conducted on Medline and PsychInfo to identify studies that offered or recommended exercise as part of a multidisciplinary treatment. Abstracts were reviewed by the first author, who then categorized each result in accordance with prespecified criteria. If it was unclear from the abstract whether a study met criteria, the full article was reviewed. Inclusion and exclusion criteria, search terms, and search limits are specified in Table 1. Reference lists were also reviewed to identify studies that did not appear in literature search results.

Table 1. Results of Medline and PsychInfo Literature Review Search Terms and Inclusion/Exclusion Criteria
Inclusion criteria
  • Treatment outcome study
  • Intervention includes aerobic exercise component and at least 1 non-medication component
  • Aerobic exercise must be either prescribed or recommended as part of treatment (ie, not educational only)
  • Adults
  • English language
Search terms“headache” AND “multidisciplinary” AND “treatment”
Search limiters

Medline complete

  • Dates: Inception-July 2012
  • Language: English
  • Age: All Adult (19 + years)

PsychInfo

  • Dates: Inception-July 2012
  • Language: English
  • Age: Adulthood (18 years and older)
Total results6340
Included61
Reason for exclusion (number of studies)
  • •Pediatric headache
  • (2)
  • •Primary diagnosis of non-headache condition
  • (38)
  • •Utilized only non-aerobic exercise intervention (eg, postural, manual, physical therapy; stretching)
  • (6)
  • •Utilized intervention with no exercise component
  • (2)
  • •Non-intervention (eg,, conceptual papers, non-experimental studies)
  • (9)
  • •Pediatric headache
  • (5)
  • •Primary diagnosis of non-headache condition
  • (3)
  • •Utilized intervention with no exercise component
  • (1)
  • •Utilized intervention with aerobic exercise education only (without recommendation for treatment)
  • (1)
  • •Case study
  • (5)
  • •Non-intervention (eg, conceptual papers, non-experimental studies)
  • (5)
  • •Duplicates from Medline search
  • (19)

Study Characteristics and Outcomes Assessed

The study characteristics evaluated include study design, treatment setting, and whether a comparison group was included. Sample characteristics include sample size, average age at baseline, percent of participants who were female, and participant headache diagnoses. The intervention characteristics assessed include exercise dose (details about the exercise regimen, including number, frequency, and duration of exercise sessions), delivery format of the exercise intervention (ie, group classes, individual sessions, or a combination of group and individual sessions), session supervision (supervised sessions, unsupervised, or both), type of exercise (aerobic or a combination of aerobic and non-aerobic exercises), and non-exercise treatment components of the intervention and comparison groups. The outcome variables evaluated include headache frequency, headache intensity, number of headache days, disability, quality of life, depression, medication use, and doctor visits. Data for outcome variables were collected using standardized forms developed for the purpose of this literature review. In order to assess the quality of the included studies, quality ratings were assigned, using the Consolidated Standards of Reporting Trials (CONSORT) guidelines for RCTs, and the Newcastle-Ottawa Quality Assessment Scale for observational studies. The first and second authors independently reviewed each study and assigned a quality rating. Ratings were then compared and discrepancies resolved by revisiting the prespecified rating guidelines in the context of the study in question.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Statement of Authorship
  7. References

Study and Sample Characteristics

Table 2 displays details of study design and sample characteristics, while Table 3 identifies headache-specific characteristics. Literature searches identified 7 studies meeting inclusion criteria, while 2 additional studies were found after reference list reviews. While 7 of these studies specified the use of aerobic exercise in the intervention, 2 studies that included exercise did not indicate whether it was aerobic exercise. Given the small number of studies meeting inclusion criteria, the authors decided to include these 2 studies. Studies were published in academic journals between 1984 and 2012. Studies were generally of moderate to high quality.

Table 2. Reported Study and Sample Characteristics
StudyStudy DesignQuality RatingaSettingSample Size (n)Average Age at Baseline (years)% Female
InterventionControlInterventionControlInterventionControlInterventionControl
  1. a

    Quality ratings for RCTs were derived from adding the number of reported components described in CONSORT guidelines, with scores ranging from 0 to 44. Ratings for observational studies were derived from the Newcastle-Ottawa Quality Assessment Scale for cohort studies, with scores ranging from 0 to 9. For both measures, higher scores represent higher quality.

  2. nr = information not reported; RCT = randomized controlled trial; n/a = not applicable to this study.

Gunreben-Stempfle et al[18] (2009)Non-randomized experimental5Pain center (university-based)

Pain center (historical)

Primary care (historical)

42

Pain center: 46

Primary care: 80

41.3

Pain center: 41.2

Primary care: 45.5

84

Pain center: 74

Primary care: 65.6

Dittrich et al[16] (2009)RCT19Outpatient medical centerOutpatient medical center151533.732.1100100
Magnusson et al[19] (2003)Non-randomized experimental5Pain center headache programMedical center headache clinic (historical)377042417684
Lemstra et al[17] (2002)RCT35Community centerWait-list control443635.633.272.758.3
Blumenfeld and Tischio[20] (2003)Single group6Medical center headache programn/a497n/anrn/anrn/a
Hoodin et al[21] (1999)Single group8Inpatient unitn/a221n/a39.1n/a77n/a
Wallasch et al[22] (2012)Single group7Outpatient headache center; inpatient (as needed)n/a201n/a42.6n/a89n/a
Gaul et al[23] (2011)Single group6Outpatient headache centern/a295n/a41n/a89n/a
Gallagher and Warner[24] (1984)Single group5nrn/a18n/a27n/a61n/a
Table 3. Summary of Reported Headache Characteristics
StudyParticipant Headache Diagnoses (% of sample)Headache Diagnostic CriteriaHeadache-Related Inclusion Criteria Baseline Headache Frequency- Intervention Group Baseline Headache Frequency-Control Group(s)
  1. ICHD = International Classification of Headache Disorders; IHS = International Headache Society; nr = information not reported; n/a = not applicable to this study.[28, 29]

Gunreben-Stempfle et al[18] (2009)

Migraine without aura (nr)

Tension-type (nr)

Post-traumatic (nr)

Intervention:

ICHD

Controls:

nr

Intervention:

IHS diagnosis;

≥8 headaches/month for 1 year

Pain center control:

nr

Primary care control: migraine and/or tension-type headache diagnosis

9 ± 5.9 migraine days/month

17.5 ± 10.7 tension-type days/month

Pain center:

7.5 ± 5.2 migraine days/month

16.4 ± 9.9 tension-type days/month

Primary care:

6.9 ± 4.7 migraine days/month

15.7 ± 10.2 tension-type days/month

Dittrich et al[16] (2009)Migraine with aura (nr)ICHD-IInr

> 1/year: 5 patients

1/month: 5 patients

> 1/month: 3 patients

≥ 1/week: 2 patients

>1/year: 1 patient

1/month: 11 patients

> 1/month: 1 patient

≥ 1/week: 2 patients

Migraine without aura (nr) 
Magnusson et al[19] (2003)Migraine without aura (1%)nr

Intervention:

≥15 headache days /month; chronic daily headaches for ≥6 months

Control:

nr

nr23.4 headache days/month
Post-traumatic (3%)
Tension-type (5%)
Medication overuse (49%)
Cervical spine-related headache (5%)

New daily headache (3%)

Transformed migraine (84%)

Lemstra et al[17] (2002)

Migraine with aura (nr)

Migraine without aura (nr)

ICHD-I

Chronic migraines for

≥6 months

20.20 ± 8.07 pain days in past month21.08 ± 8.33 pain days in past month
Blumenfeld and Tischio[20] (2003)Migraine without aura (100%)Primary care physician diagnosisPrimary headache disorder diagnosisnrn/a
Hoodin et al[21] (1999)

Chronic daily headache (86%)

Post-traumatic (11.2%)

Cluster (1.8%)

Cluster and migraine variant (.5%)

nrEnrollment in headache inpatient programnrn/a
Wallasch et al[22] (2012)

Migraine (31%)

Tension-type (6%)

Migraine and tension-type (29%)

Medication overuse (34.3%)

ICHD-II

ICDH-II diagnosis;

Initially referred to Headache Center Berlin from March to September 2009

14.4 ± 8.2 days/monthn/a
Gaul et al[23] (2011)

Tension-type and migraine (23%)

Migraine without aura (78%)

Migraine with aura (22%)

Tension-type (6%)

Medication overuse (19%)

ICHD-IIMigraine, tension-type, and/or medication overuse diagnosis13 days/monthn/a
Gallagher and Warner[24] (1984)Migraine (100%)nrMigraine diagnosis4-8 headaches/monthn/a

Two of the studies were RCTs,[16, 17] 2 were non-randomized experimental studies,[18, 19] and 5 studies described results of a single-group intervention.20-22 Both of the non-randomized studies utilized historical control groups, which were drawn from different settings than the intervention group.[18, 19] Studies drew participants from a variety of settings, including pain centers,[18, 19, 22, 23] medical centers,[16, 20] inpatient units,[21] and local physician referrals.[17]

Studies that utilized comparison groups16-19 reported total sample sizes ranging from 30 to 168 (mean = 96.3), while those with a single group20-24 reported larger samples, ranging from 18 to 497 (mean = 246.4). Average ages of participants ranged from 27 to 45.5. In all studies, the majority of the sample comprised females.

In 4 studies, including both RCTs, participants were diagnosed with either migraine with aura or migraine without aura;[16, 17, 20, 24] the other studies included participant samples with a variety of headache diagnosis, including tension-type, post-traumatic, medication overuse, as well as participants with more than 1 headache diagnosis. Both RCTs[16, 17] and 3 single-group studies[20, 22, 23] specified whether diagnostic criteria were used to determine headache diagnoses; 1 non-randomized trial[18] reported diagnostic criteria for the intervention group, but not the control. All but 1 study[16] identified headache-specific inclusion criteria. Both RCTs[16, 17] and 1 non-randomized study[18] identified baseline headache frequency for intervention and control groups; 2 single-group studies reported this information.[23, 24]

Intervention Characteristics

Intervention characteristics are presented in Table 4. In general, interventions lasted from 5 days to 8 weeks, although in 3 studies the intervention took place over variable periods of time based on individual participants' needs.[19, 21, 22] In terms of exercise dose, both RCTs[16, 17] provided information on amount, format, and supervision of exercise sessions; 1 non-randomized trial provided this information. Two single-group studies reported partial information on the exercise prescription utilized,[22, 23] while 3 provided no information.[20, 21, 24] Aspects of the intervention varied between studies, but in general consisted of behavioral skills, education, and medication management. Comparison groups all included medication management.16-19 No study commented on the presence of intervention-related side effects.

Table 4. Summary of Intervention Characteristics
StudyTreatment DurationNumber of Exercise SessionsExercise FrequencyAerobic Exercise DurationExercise FormatExercise SupervisionExercise ComponentsOther Intervention Components
  1. a

    Denotes aerobic exercise components without an operational definition.

  2. b

    Denotes non-aerobic exercise activities.

  3. c

    Denotes optional treatment components.

  4. d

    Denotes services that were available to participants based on individual need.

  5. CBT = cognitive behavioral therapy; nr = information not reported.

Hoodin et al[21] (1999)≈12 daysnrnrnrnrnrModerate aerobic exercisea

CBT

Relaxation training

Biofeedback

Behavioral pain management training

Healthy lifestyle education

Medication management

Wallasch et al[22] (2012)≈5 to 10 days55 times/week60 minutesnrnr

Endurance sports

Nordic walking

Physical therapyb

Headache education

Self-management skills

Cognitive behavioral pain managementd

Progressive muscle relaxationd

Medication managementd

Medication withdrawald

Gaul et al[23] (2011)5 days55 times/week60 minutesnrSupervised

Aerobe ergometer training

Physical therapyb

Headache education

Behavioral recommendations

Progressive muscle relaxation

Medication management

Gallagher and Warner[24] (1984)5 monthsnrDailynrnrnrnr

Biofeedback

Stress reduction counseling

Tyramine- and caffeine-restricted diets

Sleep pattern regimentation

Gunreben-Stempfle et al[18] (2009)16 days162 times/weeknrGroupSupervised

Sub-maximum aerobic exercisea

Stretchingb

Light weight trainingb

CBT/stress management

Biofeedback

Relaxation training

Education

Medication management

Dittrich et al[16] (2009)6 weeks122 times/week25 minutesGroupSupervised

Gymnastics

Coordination training

Strength trainingb

Stretchingb

Progressive muscle relaxation

Standard medical care

Magnusson et al[19] (2003)2-22 months (m = 11 months)nrnrnrGroupSupervised

Aerobic training

Strength trainingb

Pain management training

Relaxation trainingc

Sleep hygienec

Maintenance educationc

Family support workshopc

Relationship skills trainingc

Nutrition educationc

Lemstra et al[17] (2002)6 weeks18nrnrGroupSupervised

Sub-maximum aerobic exercisea

Stretchingb

Light weight trainingb

Physical therapy

Relaxation training

Stress management

Dietary education

Massage therapy

Standard medical care

Blumenfeld and Tischio[20] (2003)8 weeksnrnrnrnrnrRecommended as lifestyle change

Headache education

Lifestyle change education

Stress management training

Biofeedbackc

Mental health servicesd

Physical therapyd

Comorbid pain managementd

Medication servicesd

Treatment Outcomes

Improvements Within Intervention Groups

Table 5 summarizes the results of within-group analyses for the intervention groups in each study on headache symptoms (frequency, intensity, headache days) and secondary variables (headache-related disability, quality of life, medication use, and depression). Neither RCT reported within-group analyses for headache-related variables.[16, 17] Non-randomized trials reported improvements in headache frequency, intensity, headache days, and secondary variables.[18, 19] Two of the 5 single-group studies showed improvements in headache days,[22, 23] and 4 showed improvement in secondary outcome variables.20-23 In general, studies with higher quality ratings reported significant post-intervention improvements in headache-related and secondary outcome variables.

Table 5. Summary of Within-Group Statistical Improvements for Intervention Groups
Study Headache FrequencyHeadache IntensityHeadache DaysDisabilityQuality of Life Medication UseDepression
  1. a

    Denotes statistically significant improvements were found between pretreatment and post-treatment and/or follow-up period.

  2. BDI = Beck Depression Inventory;[33] CES-D = Center for Epidemiological Studies Depression Scale;[34] HAD = Hospital Anxiety and Depression Scale;[38] HDI = Headache Disability Inventory;[35] MIDAS = Migraine Disability Assessment Questionnaire;[36, 37] MOH = medication overuse headache; MSQ = Migraine-Specific Quality of Life Questionnaire;[31] NSAID = non-steroidal anti-inflammatory drug; PLC = profile of quality of life in the chronically ill;[32] SF-36 = Short Form-36 health survey;[30] TTH = tension-type headache.

Gunreben-Stempfle et al[18] (2009)

Migraines/

montha

Migraine

TTH

Migrainea

TTHa

  

NSAIDa

Triptana

Prophylactic

CES-Da
Dittrich et al[16] (2009)PLCBDI
Magnusson et al[19] (2003)

Currenta

Lowest (past week)a

Highest (past week)a

Average (past week)a

HDIaSF-36a
Blumenfeld and Tischio[20] (2003)

SF-36

8-week follow-upa

6-month follow-upa

MSQ

8-week follow-upa

6-month follow-upa

Triptans

Narcoticsa

Hoodin et al[21] (1999)BDIa
Wallasch et al[22] (2012)

Migrainea

TTHa

Migraine and TTHa

MOHa

MIDASa

Abortive

Migrainea

TTH

Migraine and TTHa

MOHa

HADa
Gaul et al[23] (2011)

Migrainea

TTHa

Migraine and TTHa

Acutea
Improvements in Intervention Groups Compared With Comparison Groups

Table 6 summarizes between-group analyses comparing the intervention group to 1 or more comparison groups. The variables tested included headache outcomes (frequency, intensity, number of headache days) and secondary outcome variables (disability, quality of life, and depression). Of the 9 studies reviewed, 3 reported results of such statistical testing.16-18 Both RCTs found statistically significant improvements in headache intensity,[16, 17] and 1 found an additional improvement in headache frequency and other related variables in the intervention group compared with the control group.[17] One non-randomized trial[18] reported statistically significant improvements in headache frequency, intensity, headache days, and secondary variables. Studies with higher quality rankings tended to report a larger number of significant post-intervention improvements than those of moderate or lower quality.

Table 6. Summary of Between-Group Statistical Improvements for Intervention Groups
Study Headache FrequencyHeadache IntensityHeadache DaysDisabilityQuality of Life Medication UseDepression
  1. a

    Denotes statistically significant improvements were found between intervention group and comparison groups at post-treatment and/or follow-up.

  2. BDI = Beck Depression Inventory;[33] CES-D = Center for Epidemiological Studies Depression Scale;[34] PLC = profile of quality of life in the chronically ill;[32] QoL = quality of life; BDI-II = Beck Depression Inventory-II;[40] TTH = tension-type headache; VAS = visual analog scale; PDI = Pain Disability Index.[39]

Gunreben-Stempfle et al[18] (2009)

Migraines/month

v. low intensity management group

v. primary care groupa

Migraine

v. low intensity management group

v. primary care group

TTH

v. low intensity management group

v. primary care group

Migraine

v. low intensity management group

v. primary care group

TTH

v. low intensity management group

v. primary care groupa

CES-D

v. low intensity management groupa

v. primary care group

Dittrich et al[16] (2009)Migraine intensityaPLCBDI
Lemstra et al19 (2002)

Change in pain frequency (VAS)

Post-treatmenta

3-month follow-upa

Change in pain intensity (VAS)

Post-treatmenta

3-month follow-upa

PDI

Post-treatmenta

3-month follow-upa

Change in QoL (VAS)

Post-treatmenta

3-month follow-upa

Prescription

Post-treatment

3-month follow-up

Non-prescription

Post-treatment

3-month follow-up

Change in

BDI-II post-treatmenta

3-month follow-upa

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Statement of Authorship
  7. References

While there recently has been increasing research and discussion regarding the role of aerobic exercise as a behavioral headache management strategy, little attention has been given to its effectiveness within a multicomponent behavioral treatment program. Based on recommendations by Busch and Gaul,[9] this review aimed to summarize the existing treatment outcome literature. The current state of the literature makes it difficult to draw conclusions about the specific role of exercise, as studies have evaluated the effectiveness of the intervention as a whole, rather than conducting component analyses of the exercise portion of treatment. Additionally, of the 9 studies meeting inclusion criteria, only 2 were RCTs,[16, 17] and 2 others used historical control groups drawn from different samples than the intervention group,[18, 19] a strategy that is particularly discouraged in evaluating the effectiveness of behavioral trials.[25] The quality of the studies was mixed, with the majority being of moderate quality. In general, studies that adhered to more rigorous design and reporting standards reported improvements in a greater number of outcome variables than lower quality studies.

Despite these limitations, results of existing studies suggest that the behavioral headache interventions that include aerobic exercise may be associated with positive outcomes for headache variables. Four out of 5 single-group studies reported statistically significant improvements in at least 1 headache variable (frequency, intensity, or headache days) at the end of treatment;20-23 the fifth study did not report statistical analyses.[24] Both RCTs[16, 17] and 1 non-randomized trial[18] reported statistically significant post-treatment improvement in at least 1 headache outcome variable in the intervention group compared with control groups. None of the studies found that the intervention was associated with worse outcomes at post-treatment, or compared with control groups. Given this, it does not appear that the inclusion of exercise in headache treatments is harmful. Rather, its association with improved cardiovascular fitness[11, 26] may represent a reason to include it in behavioral headache treatments, although the relationship between exercise and headache variables is not yet understood. Furthermore, there is some evidence that exercise may have an additive effect on treatment outcome variables, as Lemstra et al found that individuals who reported maintaining their exercise regimen post-treatment had better health outcomes than those who discontinued exercise.[17] Additionally, participants indicated that they found the exercise component to be the most helpful aspect of the treatment program (which included physical therapy, relaxation training, stress management, massage therapy, dietary education, and standard medical care).

In addition to improved headache outcomes, the studies included in this review reported positive outcomes for secondary variables. For example, 3 studies included validated quality of life measures.[16, 19, 20] Blumenfeld and Tischio measured multiple dimensions of this construct (general and migraine-specific).[20] Three studies used validated measures to assess headache-related[19, 22] and pain-related[17] disabilities. Five studies also included validated self-report depression scales.16-18,21,22 Collectively, results suggest that behavioral interventions that include aerobic exercise are helpful at reducing patient disability and depression, and improving quality of life. Again, it is unclear of the specific role that exercise contributes to improvements in these variables, although there does not appear to be evidence to suggest that it is associated with negative outcomes.

Moving forward, there are a number of general recommendations for future research. First, more RCTs are needed, as this design is essential to ultimately establish the effectiveness of a given treatment.[25] Another area for improvement involves the reporting of outcomes for specific headache diagnoses. While 4 studies investigated patients with specific headache diagnoses (eg, migraine with aura),[16, 17, 20, 24] the others included multiple diagnoses. Among the 5 articles included in this review that included multiple diagnoses,[18, 19, 21, 22, 24] only Gunreben-Stempfle et al[18] and Wallasch et al[22] reported separate results for headache type (migraine and tension-type headache). It is important that future research investigating exercise as a component of behavioral headache treatments provide results for individual headache types, as exercise may have differential effects across diagnostic groups.

Per the American Headache Society (AHS) behavioral research guidelines,[25] investigators are strongly encouraged to report outcomes for multiple headache-related variables (eg, intensity, duration), in addition to headache frequency. Ideally, headache frequency should be the principal outcome variable. In this review, only 2 studies present results of headache frequency before and after treatment, as well as pre-and post-treatment results for multiple headache variables (eg, intensity and the number of headache days). Lack of data on multiple domains makes it difficult to interpret the effects of interventions on patients' overall headache experiences. As research continues to investigate the effects of headache interventions that include exercise, it will be especially important to report outcomes in terms of multiple headache dimensions.

Regarding exercise, there are several ways in which trials could be improved to begin to help accumulate information to not only determine the effectiveness of physical activity on headaches, but also to establish exercise guidelines for patients with chronic headache. While authors' descriptions of the interventions used were adequate, they were less specific regarding details of the exercise component of treatment. When prescribing exercise, the following factors should be taken into account: frequency of sessions (eg, number of sessions a week), duration of treatment (number of weeks of exercise), duration of individual exercise session (minutes of exercise during each bout), mode of activity (running, walking, bicycling, weight training), intensity (percent maximum heart rate), and volume (kilocalories expended per week, steps per day). Only 1 RCT[16] provides complete information regarding the number of exercise sessions, exercise frequency, and duration. Such information is crucial in guiding future research, as there are no headache-specific recommendations for the appropriate dose of exercise.[9] Furthermore, studies also should report compliance with the exercise prescription. From these studies, it is unclear what percentage of participants adhered to the given exercise prescription, as only 1 study reported this information.[23] As this line of research moves forward, it is recommended that researchers adhere to CONSORT guidelines[26] for reporting design, methodological, and study outcomes.

Future studies should also evaluate what constitutes a sufficient dose of physical activity when assessing the effects of aerobic activity on chronic headache. According to the U.S. Department of Health and Human Services,[27] adults should accumulate 150 minutes of moderate-intensity aerobic activity, or 75 minutes a week of vigorous intensity aerobic activity. Similar guidelines have been put forth by the American College of Sports Medicine and the American Heart Association[10] on the minimum level of regular aerobic exercise for healthy adults. These guidelines are based on results from numerous studies showing the benefits of this dose of physical activity on multiple outcomes, such as prevention of weight gain, improved cardiorespiratory and muscular fitness, prevention of falls, reduced depression, and improved cognitive functions. Given the lack of knowledge of how exercise prescriptions function as part of a comprehensive behavioral treatment program, these existing public health guidelines may be a reasonable starting point for researchers seeking to develop headache-specific guidelines for exercise.

Conclusions and Recommendations for Future Research

This paper reviewed 9 studies that incorporated exercise into a behavioral treatment protocol for chronic headache. While it seems that headache patients benefit from completing a multicomponent behavioral program that includes aerobic exercise, its specific and unique contributions to behavioral headache interventions are not yet clear. There are several recommendations for future research that may facilitate greater understanding of this factor.

First, researchers are strongly urged to adhere to published guidelines (eg, AHS behavioral research guidelines,[25] CONSORT guidelines[26]) when developing clinical trials and reporting outcome data. One limitation to the existing research on behavioral headache treatments that include exercise is the lack of RCTs investigating this form of treatment. In addition, the majority of studies included in this review either drew comparison groups from different samples than the intervention group, or did not utilize a comparison group at all. Such research designs make it difficult to accurately understand how an intervention compares with existing treatments, and findings must be interpreted cautiously.

Second, it is recommended that researchers adhere to clinical and research guidelines common to headache research. Specifically, in order to understand how these interventions affect different types of headaches, investigators may either limit the scope of their investigation to include participants with a specific headache diagnosis (eg, migraine with aura) or, if multiple diagnoses are included, analyses should be run and reported separately for each diagnosis. Along the same lines, pre- and post-treatment outcome data should be reported for multiple headache variables (eg, frequency, intensity) in order to better understand the effect of treatment on patients' overall headache experiences.

Finally, it is recommended that researchers develop exercise prescriptions for headache populations based on existing public health guidelines in order to evaluate effective dosages of exercise in headache patients. In order to further facilitate this process, researchers should report all aspects of exercise prescriptions (frequency of sessions, duration of treatment, duration of individual exercise sessions, intensity, and volume), as well as adherence measures to indicate whether participants engaged in the exercise prescription.

In conclusion, incorporating exercise into behavioral headache treatments may be a promising approach to managing headache symptoms. Further work is needed to evaluate the individual contribution of exercise in such treatment programs in order to fully understand its clinical significance in headache populations.

Statement of Authorship

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Statement of Authorship
  7. References

Category 1

  • (a)
    Conception and Design
    Lauren E. Baillie; Jeanne M. Gabriele; Donald B. Penzien
  • (b)
    Acquisition of Data
    Lauren E. Baillie
  • (c)
    Analysis and Interpretation of Data
    Lauren E. Baillie; Jeanne M. Gabriele

Category 2

  • (a)
    Drafting the Manuscript
    Lauren E. Baillie
  • (b)
    Revising It for Intellectual Content
    Lauren E. Baillie; Jeanne M. Gabriele; Donald B. Penzien

Category 3

  • (a)
    Final Approval of the Completed Manuscript
    Lauren E. Baillie, Jeanne M. Gabriele; Donald B. Penzien

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Statement of Authorship
  7. References
  • 1
    Bigal ME, Lipton RB. The epidemiology, burden and comorbidities of migraine. Neurol Clin. 2009;27:321-334.
  • 2
    Penzien DB, Rains JC, Lipchik GL, Creer TL. Behavioral interventions for tension-type headache: Overview of current therapies and recommendation for a self-management model for chronic headache. Curr Pain Headache Rep. 2004;8:489-499.
  • 3
    Rains JC, Penzien DB, McCrory DC, Gray RN. Behavioral headache treatment: History, review of the empirical literature, and methodological. Critique. 2005;45:207-234.
  • 4
    Darling M. Exercise and migraine. A critical review. J Sports Med Phys Fitness. 1991;31:294-302.
  • 5
    Simons A, Solbach P, Sargent J, Malone L. A wellness program in the treatment of headache. Headache. 1986;26:343-352.
  • 6
    Varkey E, Hagen K, Zwart JA, Linde M. Physical activity and headache: Results from the Nord-Trondelag Health Study (HUNT). Cephalalgia. 2008;28:1292-1297.
  • 7
    Domingues RB, Teixeira AL, Domingues SA. Physical practice is associated with less functional disability in medical students with migraine. Arq Neuropsiquiatr. 2011;69:39-43.
  • 8
    Seok JI, Hyung I, Chin-Sang C. From transformed migraine to episodic migraine: Reversion factors. Headache. 2006;46:1186-1189.
  • 9
    Busch V, Gaul C. Exercise in migraine therapy: Is there any evidence for efficacy? A critical review. Headache. 2008;48:890-899.
  • 10
    Haskell WL, Lee I, Pate RR, et al. Physical activity and public health: Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1423-1434.
  • 11
    Lockett D, Campbell JF. The effects of aerobic exercise on migraine. Headache. 1992;32:50-54.
  • 12
    Fitterling JM, Martin JE, Gramling S, Cole P, Milan MA. Behavioral management of exercise training in vascular headache patients: An investigation of exercise adherence and headache activity. J Appl Behav Anal. 1988;21:9-19.
  • 13
    Varkey E, Cider A, Carlsson J, Linde M. A study to evaluate the feasibility of an aerobic exercise program in patients with migraine. Headache. 2008;49:563-570.
  • 14
    Varkey E, Cider A, Carlsson J, Linde M. Exercise as migraine prophylaxis: A randomized study using relaxation and topiramate as controls. Cephalalgia. 2011;31:1428-1438.
  • 15
    Darabaneanu S, Overath CH, Rubin D, et al. Aerobic exercise as a therapy option for migraine: A pilot study. Int J Sports Med. 2011;32:455-460.
  • 16
    Dittrich SM, Gunther V, Franz G, et al. Aerobic exercise with relaxation: Influence on pain and psychological well-being in female migraine patients. Clin J Sport Med. 2008;18:363-365.
  • 17
    Lemstra M, Stewart B, Olszynski WP. Effectiveness of multidisciplinary intervention in the treatment of migraine: A randomized clinical trial. Headache. 2002;32:50-54.
  • 18
    Gunreben-Stempfle B, Griebinger N, Lang E, et al. Effectiveness of an intensive multidisciplinary headache treatment program. Headache. 2009;49:900-1000.
  • 19
    Magnusson JE, Riess CM, Becker WJ. Effectiveness of a multidisciplinary treatment program for chronic headache. Can J Neurol Sci. 2004;31:72-79.
  • 20
    Blumenfeld A, Tischio M. Center of excellence for headache care: Group model at Kaiser Permanente. Headache. 2003;43:431-440.
  • 21
    Hoodin F, Brines BJ, Lake AEI, Wilson J, Saper JR. Behavioral self-management in an inpatient headache treatment unit: Increasing adherence and relationship to change in affective distress. Headache. 2000;40:377-383.
  • 22
    Wallasch TM, Angeli A, Kropp P. Outcomes of a headache-specific cross-sectional multidisciplinary treatment program. Headache. 2012;52:1094-1105.
  • 23
    Gaul C, van Doorn C, Webering N, et al. Clinical outcome of a headache specific multidisciplinary treatment program and adherence to treatment recommendations in a tertiary headache center: An observational study. J Headache Pain. 2011;12:475-483.
  • 24
    Gallagher RM, Warner JB. Patient motivation in the treatment of migraine. A non-medicinal study. Headache. 1984;24:269-271.
    Direct Link:
  • 25
    Penzien DB, Andrasik F, Freidenberg BM, et al. Guidelines for trials of behavioral treatments for recurrent headache, first edition: American Headache Society behavioral clinical trials workgroup. Headache. 2005;45(Suppl 2):S110-S132.
  • 26
    Moher D, Hopewell S, Schulz KF. CONSORT 2010 explanation and elaboration: Updated guidelines. J Clin Epidemiol. 2010;63:e1-e37.
  • 27
    Physical activity guidelines for Americans. U.S. Department of Health and Human Services website. Available at: http://www.health.gov/paguidelines/factsheetprof.aspx (accessed December 14, 2011).
  • 28
    Headache Classification Subcommittee of the International Headache Society. Classification and diagnosis criteria for headache disorders, cranial neurologias, and facial pain, 2nd edition. Cephalalgia. 2004;24:1-160.
  • 29
    Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain. Cephalalgia. 1988;8:1-96.
  • 30
    Ware JW. SF-36 Health Survey Manual & Interpretation Guide. Boston, MA: New England Medical Center; 1993.
  • 31
    Martin BC, Pathak DS, Sharfman MI, et al. Validity and reliability of the Migraine-Specific Quality of Life Questionnaire (MSQ version 2.1). Headache. 2000;40:204-215.
  • 32
    Siegrist J, Broer M, Junge A. Profil Der Lebensqualität Chronisch Kranker: Manual. Gottingen: Beltz-Test; 1996.
  • 33
    Beck AT, Steer RA. Manual for the Beck Depression Inventory. San Antonio, TX: The Psychological Corporation; 1987.
  • 34
    Radloff LS. The CES-D Scale: A self-report depressionscale for research in a general population. Appl Psychol Meas. 1977;1:385-401.
  • 35
    Jacobson GP, Rmadan NM, Aggarwal SK, Newman CW. The Henry Ford Hospital Headache Disability Inventory (HDI). Neurology. 1994;44:837-842.
  • 36
    Stewart WF, Lipton RB, Whyte J, et al. An international study to assess reliability of the Migraine Disability Assessment (MIDAS) score. Neurology. 1999;53:988-994.
  • 37
    Stewart WF, Lipton RB, Dowson AJ, Sawyer J. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology. 2001;56:20-28.
  • 38
    Herrmann-Lingen C, Buss USRP. Hospital Anxiety and Depression Scale- Deutsche verson (HADS-D). Bern: Huber; 2005.
  • 39
    Chibnall JT, Tait RC. The Pain Disability Index: Factor structure and normative data. Arch Phys Med Rehabil. 1994;75:1082-1086.
  • 40
    Beck AT, Steer RA, Brown GK. Manual for Beck Depression Inventory II (BDI-II). San Antonio, TX: Psychology Corporation; 1996.