Abstract
Introduction
Avoidance of physical activity is a common migraine management strategy. Anxiety sensitivity (i.e. fear of anxiety and bodily sensations due to physical, cognitive, or social consequences) is a potential correlate of physical activity avoidance and may strengthen beliefs about physical activity's detrimental effect on migraine.
Method
Women (n = 100) with probable migraine diagnosis completed an online survey about migraine and physical activity, which included the Anxiety Sensitivity Index-3.
Results
Anxiety sensitivity was associated with significantly increased odds of avoiding moderate- and vigorous-intensity physical activity. Anxiety sensitivity, particularly cognitive concerns, was associated with more frequent vigorous and moderate physical activity avoidance. Social concerns about anxiety sensitivity were associated with stronger expected likelihood of vigorous-intensity physical activity as a triggering and worsening factor in migraine.
Discussion
Preliminary findings indicate that anxiety sensitivity may contribute to avoidance of moderate and vigorous physical activity and fear-based cognitions about exercise.
Introduction
Physical activity (PA) is recommended for migraine prevention and management (1–3). However, 80% of individuals with migraine report intentional PA avoidance and, while PA avoidance is intended to mitigate migraine, it is adversely associated with migraine attack frequency and duration (4). PA avoidance is influenced partially by beliefs that PA will trigger or worsen migraine (4). Consistent with the fear-avoidance models (5), fear of pain and biased appraisal of pain and related stimuli contribute to avoidance of situations and behaviors that are perceived as triggering or worsening factors, which in turn, maintain pain and disability.
Anxiety sensitivity (AS) (5) is the fear of anxiety-related arousal (6) due to harmful physical, cognitive and socially-observable consequences (7). AS is associated with fearful pain appraisals, lower pain tolerance, and pain-related avoidance (8). AS has been linked to frequent headache and migraine symptoms, sensitivity to headache triggers, and headache-related disability (9), which may be driven by concerns about cognitive effects of arousal. AS may also be related to PA avoidance in migraine, particularly PA of higher intensities given its stronger perceived triggering or worsening effect on migraine (versus lighter-intensity PA) (4).
The goal of the current pilot study was to advance understanding of PA avoidance in migraine by evaluating AS as a correlate: findings could inform intervention targets to reduce intentional PA avoidance and migraine. We hypothesized that AS (particularly cognitive concerns) would be associated with greater likelihood and frequency of PA avoidance, particularly vigorous-intensity PA. We also hypothesized that AS would be associated with fearful appraisals of PA: namely, higher expected likelihood that PA will trigger and worsen migraine. These associations were expected above and beyond migraine frequency and body mass index (BMI), known correlates of PA (3).
Method
Participants (n = 100 women, aged 37.8 ± 9.6 years) screened positive for a probable migraine per the IDMigraine (10) and completed an anonymous online survey about migraine and PA avoidance (4). The current study involved secondary data analyses. Study procedures were approved by the Institutional Review Board.
Migraine attack frequency was retrospectively self-reported based on the number of attacks experienced in the past 30 days. BMI was calculated using self-reported height and weight (BMI (kg/m2) = weight (kg)/(height [m])2)). The Anxiety Sensitivity Index-3 (ASI-3) (7) includes 18 items that assess fear of anxiety and related sensations that are rated from 0 (“very little”) to 4 (“very much”) and summed to derive a total and three subscale scores reflecting concerns about the physical, cognitive, and social consequences of arousal. Intentional avoidance of PA “to manage migraine headaches” was assessed with four items formatted based on the Global Physical Activity Questionnaire (GPAQ), and evaluated PA avoidance at moderate (i.e. PA that causes slight acceleration in breathing or heart rate) and vigorous intensity (i.e. PA that causes large increases in breathing or heart rate). Items were formatted to assess past 30-day PA avoidance (yes/no) and frequency of PA avoidance in a typical week over the course of the past month (days/week). Perceived likeliness (0–100% scale) was also rated for likelihood that PA will trigger migraine attack and likelihood that PA will worsen migraine symptoms.
Statistical analysis
All statistical tests, conducted using IBM SPSS v25, were two-tailed with significance p < 0.05. Logistic regression models evaluated associations of AS with likelihood of avoidance of moderate- and vigorous-intensity PA. Linear regressions evaluated associations of AS with weekly frequency of avoidance of moderate- and vigorous-intensity PA. Because frequency of PA avoidance followed a zero-inflated distribution, these two variables were square-root transformed. Linear regressions evaluated AS in relation to expected likelihood of PA as a triggering and worsening factor at moderate and vigorous intensities. Migraine frequency and BMI were covariates in all models. For multiple regression, 0.02, 0.25, and 0.40 denoted small, medium, and large effect sizes (Cohen's f2).
Results
Participants reported a mean ASI-3 total score of 24.0 ± 15.2, with subscale scores as Physical concerns (7.2 ± 6.0), Cognitive concerns (6.5 ± 6.2), and Social concerns (10.1 ± 6.3). On average, participants reported 10.3 ± 8.8 attacks/month and had BMI (28.1 ± 8.3 kg/m2) in the overweight range.
Regression results.
ASI-3: Anxiety Sensitivity Index-3; b: beta coefficient; CI (l, u): confidence interval, lower and upper limit; f2: Cohen's f2 (0.02, 0.25, and 0.40 denote small, medium, and large effect sizes); OR: odds ratio; p: p-value (significance: p < .05); PA: physical activity; t: t-value. Note: Letters in italics are statistical values.
ASI-3 total scores were also significantly and incrementally associated with more frequent PA avoidance at vigorous and moderate intensities (small-to-medium effects). ASI-3 Cognitive concerns was uniquely related to frequency of PA avoidance at both intensity levels. Significant positive associations were also documented between ASI-3 scores and stronger expectations of vigorous-intensity PA as a triggering and worsening factor for migraine. ASI-3 scores were generally not associated with expectations of moderate-intensity PA as a triggering and worsening factor.
Discussion
This study presents a preliminary evaluation of the associations of AS with intentional PA avoidance in migraine and related beliefs. As hypothesized, AS was related to both presence and frequency of intentional PA avoidance in migraine. For every one-point increase on the ASI-3, the odds of avoiding PA of moderate and vigorous intensities increased by a magnitude of 4–5%. Concerns about the physical consequences of bodily sensations (e.g. difficulty breathing) were most strongly related to avoidance of vigorous-intensity PA, perhaps due to higher levels of exertion experienced during higher intensity PA. Indeed, elevated ASI-3 Physical concerns were associated with a 7.5-fold increase in the likelihood of avoiding vigorous-intensity PA. In contrast, concerns about the cognitive consequences of bodily sensations (e.g. inability to concentrate) were uniquely related to avoidance of moderate-intensity PA. Elevated ASI-3 Cognitive concerns scores were associated with a 5.2-fold increase in the likelihood of avoiding moderate-intensity PA. Moreover, AS (cognitive concerns) accounted for unique variance in the frequency of weekly PA avoidance at moderate and vigorous intensities. This is the first study to document AS as a correlate of intentional PA avoidance among individuals with migraine. AS Cognitive concerns may reflect a unique risk marker in migraine, especially in light of prior research documenting the link between AS cognitive concerns with headache-related disability (9).
Findings also provide novel evidence for AS as a correlate of beliefs related to PA and migraine. AS was associated with higher expected likelihood that vigorous-intensity PA would trigger and worsen migraine, which appeared to be driven by concerns about the social impact of arousal (e.g. blushing, fainting, embarrassment). Given that AS contributes to fearful appraisal and catastrophic responding to pain (8), individuals with migraine and elevated AS may also hold biased expectancies about the detrimental effect of PA on migraine, particularly PA of higher intensities (due to greater exertion and bodily discomfort and the socially observable effects of such exertion). Although directionality of causality cannot be established, the present cross-sectional findings, when placed in the context of the fear-avoidance pain model, provide preliminary evidence to support the potential role of AS in fear-related beliefs and avoidance of PA in migraine. Prospective studies that utilize behavioral assessment of PA avoidance (e.g. via combining objective movement sensors and ecological momentary assessment) are needed to understand the temporal relations between these features, variability in the course of these associations over the course of migraine (e.g. prodrome vs. during attack), and the degree of reliability and stability of these features within individuals and across contexts.
Avoidance of triggering or worsening factors is an often-recommended migraine prevention strategy, though it can also heighten trigger sensitivity over time and contribute to greater migraine disability (11). While certain triggers that have a true biological mechanism for headache onset/exacerbation (e.g. menses via estrogen withdrawal, chocolate via phenylethanolamine) should be avoided, triggering or worsening factors that operate through anticipatory anxiety or fearful expectancies may be best addressed by gradual exposure to facilitate desensitization to these factors (11). Based on the present findings, PA may be a particularly promising behavior in migraine to target via exposure intervention. Patients with migraine and elevated AS could benefit from tailored, multi-component intervention, ideally including: Psychoeducation about the positive effect of PA on migraine (1,2) and the detrimental effect of avoidance (11), feedback about the perceived versus actual rates of PA in triggering/worsening migraine (4), and use of gradual exposure to facilitate desensitization to avoided of PA and related bodily sensations (12). Short PA bouts could be framed as “behavioral experiments” to test the accuracy of feared beliefs and allow for corrective learning opportunities. Additional research is needed to test whether exposure-based interventions among women with migraine with high AS can help decrease PA avoidance, increase PA engagement, and ultimately prevent migraine attacks.
Footnotes
Article highlights
Elevated AS is associated with increased odds of intentional avoidance of vigorous- and moderate-intensity PA in those with migraine.
AS cognitive concerns are uniquely related to more frequent avoidance of PA in migraine.
AS is positively correlated with higher expected likelihood that vigorous-intensity PA will trigger or worsen migraine.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was not required for this study because of the anonymous nature of the research; however, all participants were provided with a description of the study that was approved by the institutional review board and acknowledged understanding of the study description prior to initiating the survey.
Declaration of conflicting interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The first, third, fifth, and seventh authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The second author serves as a consultant to Slimming World. The fourth author holds stock options in eNeura Therapeutics and Biohaven, and serves as consultant, advisory board member, or has received honoraria from: Allergan, American Headache Society, Autonomic Technologies, Biohaven, Eli Lilly, eNeura Therapeutics, Novartis, and Teva. The sixth author is the president of the Association of Migraine Disorders, and on the speaker’s bureau for Amgen Inc. The eighth author has received consulting honoraria from Allergan Inc, Alder, Biohaven, and Promius Pharma, and has received travel support from the American Headache Society and North American Menopause Society. The last author has received travel support from the American Headache Society.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant from the National Heart, Lung, and Blood Institute [T32-HL076134-11].