The incidence and burden of chronic headaches, including migraines, is a significant public health concern. Chronic pain conditions such as migraines and other recurrent headaches can have a profound impact on our quality of life, causing disability, anxiety, depressive symptoms, and reduced productivity.
Complementary or alternative therapies are increasingly being used to treat headache pain, and spinal manipulation is among the most common of these. Additionally, over the last decade, emerging research is reporting that various types of exercise likely play a role in preventing migraine and other chronic headaches. Doctors of chiropractic are dedicated to helping restore function and quality of life for their patients, and strive to promote exercise which has demonstrated many positive outcomes. Chiropractors are interested in taking care of the whole person with an emphasis on a structure-function relationship, and the downstream effects on other parts of the body.
A report by the Duke University Evidence-Based Practice Center concluded that cervical spine manipulation was associated with significant improvement in headache outcomes in patients with neck pain and/or neck dysfunction and headache. Adverse events are uncommon with spinal manipulation. A number of other studies over the last decade support the use of chiropractic care for a variety of chronic headaches. Chiropractors commonly also recommend a variety of individualized exercises for patients with headache to promote self-care and ongoing reduction of the headache burden.
Dr. Mark Pfefer is a chiropractor, and the director of research at Cleveland University-Kansas City. He believes the pharmaceutical approach for those seeking headache relief is not always the best option.
“Nearly all patients with headaches have used medications at one time or another to alleviate their pain,” Pfefer said. “But even with recent developments of newer drugs for headache prevention and management, pharmacologic treatments are not suitable for all patients, nor are they universally effective. Also, many headache medications are very expensive and out of reach (financially) for some patients. Drug treatments may also produce undesired side effects or become less effective if overused or used chronically.”
Partly for these reasons, there is interest among patients and health care providers in complementary interventions to treat or prevent headaches. Especially with cervicogenic headaches, commonly used manual therapy interventions and spinal manipulation (most commonly performed by chiropractors) are often considered a first-choice therapy for most patients.
“As a stand-alone intervention, sometimes chiropractic spinal manipulation is very effective in treating and preventing headaches, but the addition of exercise has many beneficial effects, not only related to headaches but to the whole person”
Non-pharmacologic headache treatment may be well-suited for many patients who: (a) have poor tolerance of pharmacologic treatments; (b) have medical contraindications for pharmacologic treatments; (c) experience insufficient relief from, or are unresponsive to, pharmacologic treatment; (d) wish to become pregnant (or are nursing); (e) have a history of long-term, frequent, or excessive use of analgesic or abortive medications that can aggravate headache problems (medication overuse or rebound headache): (f) prefer to avoid medication use; or (g) cannot afford pharmacologic interventions.
The last decade has seen the publication of numerous high-quality studies that explore aspects of exercise’s effects on migraine prevention, including as a stand-alone intervention, as non-inferior to some pharmacologic interventions, or as an add-on to other interventions.
Most studies have focused on the use of exercise as a prophylactic for migraine and other headaches that often overlap with chronic migraine in some patients.
Investigators have attempted to characterize the mechanisms that underlie benefits that exercise has on headaches. Mechanisms may overlap but fall into two identified categories: biological and psychological.
Proposed biological mechanisms suggest that exercise appears to play a role in suppression of inflammatory markers that are elevated in patients with migraines, including CRP, cytokines (CGRP, substance P), and adipocytokines (TNF-a, IL-6). Reduction in inflammatory markers associated with exercise may explain improvement in migraine frequency, duration, and intensity over time.
An additional biological pathway has also been proposed to demonstrate how exercise may positively affect migraine by improving endothelial dysfunction centrally and peripherally (cerebral and peripheral vascular function). Various exercise intensities and frequencies have been studied and may have different effects on vascular function.
Psychological and biological effects of exercise on migraine may not be mutually exclusive. In addition to changes in proinflammatory cytochines, exercise may promote production of beneficial neuromodulators such as endorphins, which may explain some of the exercise benefits in a variety of orthopedic and neurologic pain syndromes.
Several studies have demonstrated that moderate to higher intensity aerobic exercise may have the best benefit for migraine prevention in many patients.
Some patients do report that exercise may induce migraine or other types of headache attacks. This may be related to production of lactate during exercise which is consistent with the findings of one study that showed a higher frequency of migraine correlates with increased brain lactate levels. Also, a rise in systolic blood pressure and cardiac output may trigger migraines as it has been suggested that migraineurs may have impairments in vascular reactivity.
For patients with exercise-induced migraine and other headaches, low impact, low-intensity, non-aerobic exercise may afford some benefit. A number of studies have demonstrated some benefits of yoga among patients with headache syndromes and other associated symptoms that are often comorbid with migraine, including fibromyalgia, anxiety, and depression.
Migraine and other headache conditions are often chronic and recurrent, and the interventions should emphasize multimodal and multidisciplinary care, including the addition of individualized exercise recommendations which may provide added benefit for many headache patients. Special headache populations, like those with comorbid neck pain or tension headache, often respond well to a combination of spinal manipulation and exercise. Patients with chronic headache conditions who cannot tolerate high-impact and/or high intensity exercise may even benefit from low-impact exercise like yoga or Pilates.