Abstract
Headaches and migraines are disabling, costly conditions. While physical activity shows benefits, specific exercise patterns’ effects on headaches in the U.S. remain underexplored. This study aims to examine the cross-sectional relationship between different exercise patterns and the occurrence of severe headaches or migraines in adults using data from a nationally representative U.S. sample. Data from the National Health and Nutrition Examination Survey (NHANES) cycles 1999-2004 were analyzed. The study included adults aged 20-65 years who reported their exercise habits and severe headache or migraine status. Logistic regression models were used to assess the predictive relationships between vigorous, moderate, and muscle-strengthening exercise, as well as combinations of these activities, and the occurrence of migraines. The final sample comprised 2011 participants representing a weighted population of about 32 million U.S. adults. Combining vigorous and muscle-strengthening activities showed the most significant reduction in headache/migraine occurrence (OR: .48, 95% CI: 0.26-0.90), indicating a 52% reduction. Other exercise combinations were also associated with lower odds ratios compared to no exercise, but they were not statistically significant in the fully adjusted model. Regular physical activity, especially the combination of vigorous and muscle-strengthening exercise, is linked to a lower risk of severe headaches/migraines.
“Regular exercise generally appears to decrease the incidence of severe headaches/migraines.”
Introduction
Headaches and migraines are among the most prevalent and disabling neurological conditions worldwide, significantly impacting individuals’ quality of life and imposing substantial economic burdens due to healthcare costs and lost productivity. 1 According to the Global Burden of Disease Study, migraines are the second leading cause of years lived with disability globally. 1 In the United States, nearly 12% of the population suffers from migraines, with higher prevalence rates among adults aged 20-65 years.2,3 Despite their widespread occurrence and impact, effective non-pharmacological management strategies remain limited.
Exercise is widely recognized for its health benefits, including improved cardiovascular health, enhanced mental well-being, and reduced risk of chronic diseases. 4 Emerging evidence suggests that physical activity may also reduce the frequency and severity of headaches and migraines. 5 Several international scientific societies, including the American, French, and Danish Headache Societies, recommend incorporating exercise into migraine management. Recently, the Professional College of Physiotherapists of the Community of Madrid published a clinical practice guideline for prescribing exercise in migraine treatment, based on a thorough analysis of previous research. 6
Our understanding of the relationship between exercise and headaches/migraines has significantly improved over the past decades, but several research gaps remain. Most studies have focused on the effects of different exercise types (e.g., high-intensity, moderate-intensity) on migraines/headaches, comparing their efficacy.5-7 Some studies suggest high-intensity exercise is most beneficial, while others highlight muscle-strengthening exercise.5,7 Notably, Woldeamanuel et al found that muscle-strengthening exercise is more beneficial than aerobic exercise for managing migraines and proposed that a combination of these exercise types may be optimal. 7 Despite this, few studies have explored the relationship between different exercise patterns and headaches/migraines. In daily life, many people engage in multiple types of exercise, such as combining vigorous exercise with moderate exercise or muscle-strengthening exercise. The 2018 Physical Activity Guidelines for Americans recommend a mix of aerobic, muscle-strengthening, and bone-strengthening activities for optimal health. The relationship between these combined exercise patterns and headache/migraine outcomes remains underexplored and poorly understood. 8
Several population-based studies have investigated the relationship between exercise and headaches/migraines in various countries and regions.9-13 However, no study has yet been conducted using a nationally representative U.S. population. Furthermore, most prior population-based studies have primarily focused on general exercise or specific exercise intensities, such as vigorous or moderate exercise. These studies have not included muscle-strengthening exercise or examined the relationship between specific exercise patterns and headaches/migraines.
The National Health and Nutrition Examination Survey (NHANES) provides a valuable dataset for addressing these research gaps. 14 NHANES offers comprehensive health and nutritional data from a nationally representative sample of the U.S. population, including data on exercise patterns. Utilizing NHANES data presents an opportunity to explore the relationship between various exercise patterns—including different combinations of vigorous, moderate, and muscle-strengthening exercise—and the occurrence of headaches/migraines. This study aims to leverage NHANES data to provide new insights and potentially inform more effective non-pharmacological management strategies for headaches and migraines in the U.S.
The specific research questions of this study were: (a) What is the predictive relationship between each of the 3 types of exercise—vigorous, moderate, and muscle-strengthening exercise—and the occurrence of severe headaches or migraines? (b) What is the predictive relationship between different exercise patterns, comprising various combinations of vigorous, moderate, and muscle-strengthening exercise, and the occurrence of severe headaches or migraines?
Methods
Study Design
This research utilizes data from the NHANES, an ongoing project managed by the National Center for Health Statistics within the Centers for Disease Control and Prevention. 14 NHANES conducts periodic cross-sectional studies to assess the health and nutritional status of the American populace. Each cycle of the survey randomly selects a representative sample of the U.S. civilian noninstitutionalized population through a sophisticated, stratified, multistage probability sampling method.
The survey includes both a household interview and a subsequent medical examination at a mobile examination center. This study specifically utilizes data gathered from the household interviews of 3 consecutive NHANES cycles: 1999-2000, 2001-2002, and 2003-2004. These cycles were selected because they consistently included queries about headaches or migraines. During these interviews, trained personnel collected detailed demographic data, behavioral risk factors like exercise habits, and various medical conditions, including headaches. The data from these 3 cycles were merged to form a comprehensive dataset covering 1999-2004. The research protocols for NHANES were approved by the NHANES Institutional Review Board from 1999 to 2002 and by the National Center for Health Statistics Research Ethics Review Board from 2003 to 2004
Participants
This study targeted adults between the ages of 20 and 65, a demographic known for the highest incidence and impact of headaches and migraines.
3
The combined dataset from 1999 to 2004 consisted of 31,750 participants. The exclusion criteria were as follows: individuals outside the age range of 20-65, pregnancy, daily use of pain-relieving medications, unclear exercise behavior in the past 3 months, missing responses for headache and PA behaviors, missing data on demographic covariates (as detailed in the Covariates section), missing data on lifestyle covariates, and missing data on health condition covariates. Figure 1 provides a flowchart illustrating the exclusion process and the final sample size. After applying these exclusions, 2011 participants with complete data were included in the analysis, representing a weighted population of about 32 million U.S. adults. Table 1 summarizes the demographic details of the final sample. Flow chart of the study population selection. Characteristics of Study Participants by Severe Headache/Migraine Status (Unweighted). ap values represent results of results of t test for 2 means for continuous variables and Chi-square tests for categorical variables.
Occurrence of Severe Headache/Migraine Assessment
In home interviews conducted in either English or Spanish, trained interviewers assessed the presence of headaches or migraines using the question “During the past 3 months, did you have severe headaches or migraines? (Yes/No)” from the Miscellaneous Pain module (QI: MPQ090). Respondents affirming this were classified as probable migraine sufferers. These self-reported cases lack additional criteria required for the International Headache Society classification of migraine, and misclassification with other types such as tension-type or cluster headaches might occur. However, it is generally accepted that most of these cases are likely migraines, which is the most prevalent diagnosis for such symptoms, a stance supported by other experts in the field. Due to the potential for misclassification with medication-overuse headaches, individuals taking analgesic pain relievers every day were excluded from the study.
Vigorous, Moderate, and Muscle-Strengthening Exercise Assessment
Exercise behavior was assessed during home interviews by trained interviewers who inquired about 3 specific types of activities: vigorous, moderate, and muscle-strengthening. These activities were evaluated using specific questions from the Physical Activity module. For vigorous exercise (QI: PAD200), participants were asked “Over the past 30 days, did you do any vigorous activities for at least 10 min that caused heavy sweating, or large increases in breathing or heart rate?” (Yes/No). For moderate exercise (QI: PAD320), the question was “Over the past 30 days, did you do moderate activities for at least 10 min that cause only light sweating or a slight to moderate increase in breathing or heart rate?” (Yes/No). Muscle-strengthening exercise (QI: PAD440) were identified by asking “Over the past 30 days, did you do any physical activities specifically designed to strengthen your muscles such as lifting weights, push-ups or sit-ups?” (Yes/No). Due to the survey design, where physical activity was reported for the previous 30 days and headache or migraine status for the past 3 months, only participants who indicated that their physical activity level over the last 30 days was consistent with the past 12 months, as recorded in the Physical Activity module (QI: PAQ500), were included in the analysis.
Exercise Pattern
Based on the assessment of the 3 types of exercise mentioned above, a variable representing different exercise patterns was developed, encompassing 8 distinct categories of exercise patterns. These patterns are defined as follows: 1 = did not exercise; 2 = only did muscle-strengthening exercise; 3 = only did moderate exercise; 4 = did moderate + muscle-strengthening exercise; 5 = only did vigorous exercise; 6 = did vigorous + muscle-strengthening exercise; 7 = did vigorous + moderate exercise; 8 = did vigorous + moderate + muscle-strengthening exercise.
Covariates
The selection of covariates for this study was guided by previous research. The chosen demographic covariates included sex, age, race, and the family poverty income ratio (PIR), which is a ratio of family income to poverty threshold. The lifestyle covariates included alcohol consumption and smoking. Alcohol consumption was measured using 2 items from the Alcohol Use module: ALQ120Q, which asks about the frequency of alcoholic beverage consumption over the past 12 months, and ALQ120U, which records the time unit of consumption (week, month, year). These responses were used to calculate an Alcohol Drinking variable reflecting the number of alcoholic drinks consumed per week. Cigarette smoking was evaluated through a question from the Smoking-Adult module, SMQ040, which asks if the respondent currently smokes cigarettes (Every day, some days, not at all). Health condition covariates included overweight status, high blood pressure, diabetes, cardiovascular diseases, stroke, and cancer. These were assessed using relevant questions from the Medical Conditions, Blood Pressure, and Diabetes modules.
Statistical Analyses
To address the first research question, we initially performed 3 sets of logistic regression analyses, with the occurrence of severe headaches or migraines as the dependent variable and vigorous, moderate, and muscle-strengthening exercises as the 3 predictors. Four different models were used to evaluate the sensitivity of the effect estimates: an unadjusted model with only 3 predictors and without any covariates; a minimally adjusted model that included the demographic covariates; a partially adjusted model that further included lifestyle covariates; and a fully adjusted model that additionally accounted for health condition covariates.
To address the second research question, we conducted another series of logistic regression analyses, this time using exercise pattern as the predictor variable for severe headache or migraine occurrence. The sensitivity of these effect estimates was again evaluated using 4 models: an unadjusted model with no covariates, a minimally adjusted model including demographic covariates, a partially adjusted model further including lifestyle covariates, and a fully adjusted model that further incorporated health condition covariates.
For the statistical analysis, IBM SPSS 28.0 was utilized, specifically the Complex Samples module to accommodate NHANES’s stratified, multistage probability cluster sampling design. 15 NHANES provides sampling weights to adjust for oversampling of specific subgroups, nonresponse biases, and population size discrepancies. We combined data from 3 2-year cycles (including the 1999-2002 period) and adjusted the weights accordingly, based on NHANES guidelines: a 6-year weight derived as 2/3 of the 1999-2002 wt for those sampled during that period and 1/3 of the 2003-2004 wt for those sampled in those years, given that the 2-year weights from 2003-2004 are comparable to the 4-year weights from 1999-2002 based on the 2000 Census.
In SPSS, a CSAPLAN file was initially set up using the NHANES stratification variable (SDMVSTRA), Primary Sampling Unit (SDMVPSU), and the 6-year weight. Logistic regression analyses were then performed based on this configuration. All statistical tests were two-sided and used a significance level of .05.
Results
Table 1 shows the unweighted characteristics of study participants by severe headache/migraine status. The group differences between participants with and without severe headache/migraine for each variable were also examined (Chi-square test for categorical variables and t test for continues variables) and shown in Table 1.
Three Types of Exercise and Headache/Migraine
Unadjusted and Adjusted Associations of Different Types of Exercise With Headache/Migraine a Respectively.
aReference group = people without headache/migraine.
bRef. = reference group.
cOnly with 3 type of PA as predictors, no covariates included.
dThree predictors and demographic covariates included.
eThree predictors, demographic and lifestyle covariates included.
fThree predictors, demographic, lifestyle, and health condition covariates included.
Odds ratio (ORs) with 95% confidence intervals (CIs) for severe headache/migraine according to each of the 3 types of exercises.
Exercise Patterns and Headache/Migraine
Unadjusted and Adjusted Associations of Exercise Pattern With Headache/Migraine. a
aReference group = people without headache/migraine.
bRef. = reference group.
cWithout any covariates.
dAdjusted for only demographic covariates: sex, age, race, and family PIR.
eAdjusted for demographic covariates and lifestyle covariates: alcohol consumption and smoking.
fAdjusted for demographic covariates, lifestyle covariates, and health condition covariates: high blood pressure, overweight, diabetes, cardiovascular diseases, stroke, and cancer.
Odds ratio (ORs) with 95% confidence intervals (CIs) for severe headache/migraine according to each of exercise patterns.
The minimally adjusted model, accounting for demographic variables, maintains similar trends. The odds of severe headaches/migraines remain significantly lower for those performing vigorous plus moderate plus muscle-strengthening exercise pattern (pattern 8, OR = .62, 95% CI: 0.44-0.88, P < .01) with a 38% reduction, vigorous plus muscle-strengthening exercise pattern (pattern 6, OR = .68, 95% CI: 0.46-0.99, P = .05) with a 32% reduction, and only vigorous exercise pattern (pattern 5, OR = .73, 95% CI: 0.54-0.99, P = .04) with a 27% reduction. Other combinations continue to show reduced odds, though they lose statistical significance.
In the partially and fully adjusted models, the pattern persists. For instance, in the fully adjusted model, which includes demographic, lifestyle, and health condition variables, the most significant reduction in the odds of severe headaches/migraines is observed for those engaging in vigorous plus muscle-strengthening exercise pattern (pattern 6, OR = .48, 95% CI: 0.26-0.90, P = .02) indicating a 52% reduction in the odds of severe headaches/migraines. Other patterns also indicate reduced odds, though they are not statistically significant.
Overall, vigorous exercise combined with muscle-strengthening activities (pattern 6), consistently associates with a lower likelihood of severe headaches/migraines across all models. These findings suggest that combining vigorous physical activity and muscle-strengthening activities may be most beneficial in reducing the occurrence of severe headaches or migraines.
Discussion
This research aimed to explore how different forms of exercise—vigorous, moderate, and muscle-strengthening—and various combinations thereof relate to the occurrence of severe headaches or migraines. It’s crucial to recognize that in our analysis, exercise types were categorized simply by whether participants engaged in more than 10 min of each type of exercise monthly. Therefore, interpretations of our findings should consider this measurement approach. Key outcomes from our study include: (a) Regular exercise generally appears to decrease the incidence of severe headaches/migraines. (b) Vigorous exercise seems to offer greater benefits compared to moderate or muscle-strengthening exercises. (c) Combining different types of exercise, particularly vigorous and muscle-strengthening exercise, may provide additional or even synergistic benefits.
Efficacy of Different Types of Exercise
Many studies employing diverse methodologies have consistently demonstrated the positive impact of regular physical activity on reducing the occurrence and frequency of headaches/migraines.5,6 Population-based research from various regions, including Europe, Brazil, Spain, Norway, Denmark, Iran, and Hong Kong, China, supports the notion that physical activity can diminish the likelihood of experiencing headaches or migraines.9-13 For instance, findings from the European Health Survey indicated that engaging in physical activity several times a week could reduce the occurrence of migraines by about 20% compared to those who do not exercise. 12 Similarly, a study from Brazil showed that physical inactivity increased the likelihood of having definite or probable migraines by approximately 1.3-1.5 times compared to those actively participating in vigorous physical activities. 10 Our study contributes to this body of research by addressing the absence of such studies within the U.S. population, showing a comparable trend that underscores the benefits of exercise.
Historically, most population-based studies have generalized physical activity without differentiating between types of exercise.9,11 However, a few studies have focused on the impact of exercise intensity on headache and migraine occurrences.10,13 For example, a Brazilian study highlighted that vigorous activities significantly lowered the risk of migraines, whereas moderate activities did not. 10 A Norwegian study differentiated between hard and light physical activities, finding a significant reduction in headache and migraine occurrences with 1-2 h of hard activity per week, but not with light activity. 13 Similarly, a Danish study found significant benefits from heavy exercise compared to light exercise. 16 Our findings align with these studies, distinguishing between vigorous, moderate, and muscle-strengthening exercises and noting a stronger association of vigorous exercise with decreased headache/migraine occurrences.
Moreover, numerous randomized controlled trials have been conducted to evaluate the relative effectiveness of different exercise types on managing headaches and migraines, with mixed results.5-7,17 For instance, Reina-Varona and colleagues conducted a network meta-analysis that showed both high-intensity and moderate-intensity exercises significantly reduced migraine frequency, with high-intensity exercise being more effective. 5 La Touche and colleagues suggested clinical practice guidelines recommending moderate exercise over vigorous and resistance exercises based on the quality and quantity of research. 6 Additionally, Woldeamanuel and Oliveira found that strength training was the most effective at reducing migraine frequency, followed by high-intensity and moderate-intensity aerobic exercises in their systematic review and network meta-analysis. 7
These findings highlight the varied effectiveness of different exercise types on migraine management. Many review studies have highlighted the significant heterogeneity present in current research exploring the relationship between exercise and headaches or migraines. This diversity may stem from differences in how exercises are defined, the designs of the studies, and the characteristics of control groups. To better determine the most effective exercise regimens for headache and migraine management, future research must focus on standardizing these elements.
Synergistic Effects of Combining Different Types of Exercise
The most significant aspect of our study lies in the exploration of various exercise patterns and their impact on severe headache/migraine occurrence. Recognizing the most effective exercise type is useful, but understanding the optimal combination of exercises is even more pertinent, as many individuals tend to incorporate diverse types of activities into their exercise routines rather than sticking to a single exercise type. Specifically, our results highlighted the combination of vigorous and muscle-strengthening exercise pattern as the most effective, with the inclusion of moderate exercise nearing significance. These results underscore the potential additive or synergistic benefits of incorporating varied exercise types into exercise routines to manage migraine occurrences.
Several mechanisms may underlie the beneficial effects of exercise on migraines. 18 Vigorous activities are thought to trigger the release of endorphins and enkephalins, which are natural compounds known for their pain-relief and mood-enhancing properties. 18 These substances may increase pain tolerance and reduce migraine frequency by decreasing the body’s sensitivity to migraine triggers. Additionally, vigorous exercise can elevate Brain-Derived Neurotrophic Factor levels, which improve mood and cognitive function, factors inversely related to migraine frequency. 19 The endocannabinoid system, stimulated by regular vigorous exercise, may also play a role in alleviating migraine severity by providing natural pain-relief. 20
Muscle-strengthening exercises may offer unique advantages, particularly through targeted strengthening of the neck, shoulders, and upper limbs. 7 This focus may lessen nociceptive input from neck structures tied to the trigemino-cervical complex involved in migraine disorders.21,22 Reducing neck pain, often associated with migraines, could lower both the frequency and intensity of migraine episodes.23,24 The local metabolic and neuromuscular changes from strength training might enhance muscle strength and modulate nociceptive inputs to the brain, influencing migraine pathways.25,26 Additionally, the increase in pain threshold through muscle-strengthening might be facilitated by endorphins and the regulation of stress hormones.22,27
Beyond these well-known mechanisms, emerging research also highlights the relevance of broader physiological axes, including the muscle-brain axis, muscle-gut-brain axis, and bone-brain axis.28-31 The muscle-brain axis involves myokines—cytokines secreted by contracting skeletal muscles—that modulate brain function, neuroinflammation, and pain signaling pathways. 31 The muscle-gut-brain axis underscores how exercise influences gut microbiota composition, potentially reducing systemic inflammation and positively impacting neuroimmune responses linked to headaches and migraines.28,29 Similarly, the bone-brain axis highlights osteokines, such as osteocalcin, released during weight-bearing activities, which can influence brain health, stress resilience, neurotransmitter signaling, and inflammation. 30
Together, these interconnected mechanisms suggest that combining vigorous and muscle-strengthening exercises may amplify their beneficial effects, enhancing cardiovascular health, structural integrity, stress resilience, pain modulation, and overall neuroimmune homeostasis. Such a comprehensive approach potentially offers a more effective strategy to mitigate migraine triggers, reduce migraine frequency and severity, and enhance the quality of life for affected individuals.
Strengths, Limitations, and Future Research Directions
This study’s strengths are grounded in its use of the NHANES database, providing a large and nationally representative sample that enhances the external validity of the findings. Furthermore, by examining multiple exercise patterns, this research offers valuable insights into real-world physical activity behaviors. This comprehensive approach allows for a better understanding of how different combinations of exercise types can influence the frequency and severity of headaches and migraines, thus providing a more realistic perspective on the potential benefits of varied exercise routines.
Nonetheless, the study has several limitations that must be acknowledged. It is important to note that our cross-sectional design precludes definitive conclusions about the direction of causality in the relationship between exercise and severe headaches/migraines. Individuals with frequent or intense migraine episodes may be less inclined to engage in physical activity due to pain or fear of triggering an attack, leading to the possibility of reverse causation. Future longitudinal studies or randomized controlled trials will be critical to clarify whether physical activity itself exerts a protective effect against headache/migraine occurrence or if migraine symptoms reduce individuals’ ability or willingness to engage in exercise.
Another set of limitations stems from the design of the original survey. Although these cannot be modified, it is crucial to acknowledge these constraints. The first is the reliance on a single self-reported item from NHANES that combines “severe headaches” and “migraines” into one measure. While this approach does not strictly adhere to the gold-standard International Classification of Headache Disorders (ICHD) diagnostic criteria, NHANES is the only large-scale, nationally representative dataset that includes both exercise pattern data and a measure of severe headaches/migraines. Therefore, despite the lack of diagnostic specificity, these data still provide valuable insights into real-world, population-level relationships between exercise patterns and headache or migraine occurrence. Future research would benefit from employing validated clinical assessments or standardized diagnostic tools to distinguish more clearly between migraine and other headache types. Another limitation is the lack of data on potential confounders such as stress, sleep quality, and medication use. Although NHANES includes a broad array of health information, the specific cycles used did not consistently capture detailed measures of these variables. Consequently, we could not adjust for their potential impact in our analysis. Future research should incorporate these factors to provide a more nuanced understanding of how they may jointly influence exercise behaviors and the occurrence of severe headaches or migraines. It is also important to note that our classification of physical activity as “more than 10 min per month” was determined by the way NHANES measured physical activity behaviors during the 1999-2004 cycles. While this approach allows a broad examination of exercise patterns at a population level, it does not align with standard public health guidelines (e.g., minutes per week). Consequently, our findings may overlook more nuanced patterns of exercise duration and intensity. We recommend that future studies adopt more precise and guideline-consistent measures to better elucidate the relationship between physical activity and severe headaches or migraines.
Conclusions
This study provides compelling evidence that engaging in a combination of vigorous and muscle-strengthening exercises is associated with the reduced occurrence of severe headaches and migraines. The findings extend the current understanding of exercise’s role in headache management, offering new insights into effective non-pharmacological strategies. The implications for clinical practice and public health are significant, advocating for comprehensive exercise routines to mitigate headache and migraine burdens.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
