Table 8 Summary table with each exercise modality and its respective studies

AEROBIC EXERCISE

GRADE OF RECOMMENDATION: B in favour of intervention

 Herranz-Gómez et al., 2021 [35]

MMA, umbrella and mapping review

ICHD

Experimental group: Aerobic exercise, manual therapy and manual therapy with therapeutic exercise

Control group:

Any type of intervention it was possible to isolate

Frequency (days/month or days/week)

Pain intensity (VAS, NPRS, numeric pain index, MVK pain scale)

Disability (HDI)

Quality of life (HIT-6, SF-36, SF-12)

There is moderate evidence that aerobic exercise reduces pain intensity in migraine patients. The applied interventions showed a positive effect in terms of pain intensity, quality of life and frequency

1-

No adverse effects were reported

 La Touche et al.,2020 [40]

SR of RCTs and q-RCTs

MA of RCTs

Migraine with or without aura diagnosed with ICHD

Experimental group: aerobic exercise

Control group: Other forms of exercise, minimal education, information, maintenance of daily living activity or drugs

Frequency (days/month or days/week)

Pain intensity (VAS)

Duration (hours of migraine)

Quality of life (HIT-6, PLC, WHO-5, MSQoL, grading the severity of chronic pain)

It was found statistically significant differences in the decrease in pain intensity, frequency and duration of migraine in the short term, and an increase in quality of life. Aerobic exercise has low to moderate evidence in migraine patients

1-

No adverse effects were reported

 Lemmens et al., 2019 [36]

SR of RCTs and q-RCT s

MA of RCTs and Q-RCT s

Migraine diagnosed with the ICHD-II

Experimental group: Physical endurance, physical fitness, aerobic exercise and exercise therapy performed during at least 6 weeks

Control group: no intervention, education, treatment based on medication, relaxation therapy and advice to maintain habitual daily activity

Frequency (days/month)

Pain intensity (NPRS, VAS)

Duration (hours/attack and hours/month)

Significant reductions in the number of migraine days after aerobic exercise treatment were found, and small to moderate reductions in attack duration and pain intensity after aerobic exercise intervention

1-

No adverse effects were reported

 Luedtke et al., 2016 [38]

SR of RCTs and q-RCT s

MA of RCTs

Migraine diagnosed with IHS criteria

Experimental group: standard physiotherapy (exercise, manual therapy, soft-tissue techniques, or strength and endurance training)

Control group: placebo, standard care, waiting list or other active intervention

Frequency (number of episodes or number of headache days

within a defined period of time)

Pain intensity (VAS)

Duration (hours or

days without relief)

Aerobic exercise results suggest a statistically significant reduction in the intensity, frequency and duration of migraine

1-

No adverse effects were reported

 Varangot et al., 2021 [13]

SR and MA of RCTs

ICHD and medical diagnosis

Experimental group: exercise training (aerobic training, strength training, yoga or aerobic and strength training)

Control group: non-active interventions, education, relaxation, breathing or no interventions

Frequency (painful days/month)

Pain intensity (VAS, NRS)

Duration (hours)

Disability (HDI, HIT-6, HIT, PDI)

Quality of life (SF-36)

Aerobic training has a small to moderate clinical effect on pain intensity and frequency of headache episodes in migraine patients, with very low to low certainty of evidence

1-

The study of Lemstra et al. 2002 reported minor musculoskeletal pain in 20% of patients in the intervention group, which include exercise as part of the therapy

 Ahn et al., 2013 [75]

Narrative review

There are several lines of evidence supporting the role of exercise in migraine management. Though individually these studies have some limitations, they are still altogether compelling because this view still emerges clearly from several independent lines of investigation

-

4

No adverse effects were reported

 Amin et al., 2018 [76]

Narrative review

-

-

-

It seems that although exercise can trigger migraine attacks, regular exercise may have a prophylactic effect on migraine frequency. This is most likely due to an altered migraine-triggering threshold in people who exercise regularly. Frequency and intensity of exercise that is required is unclear

-

4

Exercise can minimally trigger migraine

 Barber et al., 2020 [77]

Narrative review

-

-

An aerobic exercise routine alone is sufficient to reduce migraine frequency, intensity, and duration. Higher-intensity training appears to confer more benefits. The addition of exercise to a traditional preventive regimen may provide added benefits. Patients who cannot tolerate high-impact exercise may even benefit from low-impact exercises like yoga

-

4

Exercise may induce migraine

 Busch V, Gaul C, Headache, 2008 [80]

Narrative review

-

-

-

Most of the reviewed studies did not find a significant reduction of headache attacks or headache duration and only indicate a reduction of pain intensity in migraine patients due to regular exercise

-

4

It should not be forgotten that exercise can induce sport-related headaches

 Busch V, Gaul C, Schmerz, 2008 [79]

Narrative review

-

-

-

Regular endurance sports are found in many general recommendations for the treatment of migraine patients. However, the evidence on which these recommendations are based is weak

-

4

No adverse effects were reported

 Daenen et al., 2015 [81]

Narrative review

-

-

-

Aerobic exercise on a submaximal level is the best option in migraine prophylaxis

-

4

Exercise could be a migraine-triggering factor

 Guarín-Duque et al., 2021 [87]

Narrative review

-

-

-

Adults who don't tolerate migraine drugs very well may find relief in preventive therapies such as exercise

-

4

Some authors show that exercise, especially if it is at high intensity, can trigger a migraine attack

 Hindiyeh et al., 2013 [82]

Narrative review

-

-

-

There are demonstrable

differences in the way migraineurs respond to aerobic exercise during their headaches and there is more than a suggestion that

migraineurs do, in fact, process the changes brought on by aerobic activity differently than non-migraineurs or

migraineurs when they are inter-ictal

-

4

22% of migraineurs list exercise as a trigger

 Irby et al., 2016 [83]

Narrative review

-

-

-

Regular aerobic exercise routine is recommended as a means of managing and preventing migraine. Anyway, the optimal parameters of exercise regimens for migraine are still unclear

-

4

Physical activity may not play an important role in triggering or exacerbating migraine

 Lippi et al., 2018 [84]

Narrative review

-

-

-

High-intensity exercise should be avoided in patients with a history of exercise-provoked migraine

Regular moderate aerobic physical exercise (> 40 min, 3 times per week) seems effective to reduce both the severity and frequency of migraine attacks

-

4

Since exercising may sometimes worsen migraine, being engaged in physical exercise during a migraine attack must be established on an individual basis, according to the personal history of exercise-provoked migraine

 Mauskop et al., 2012 [85]

Narrative review

-

-

-

Aerobic exercise is proven to be effective

in the prevention of migraine

headaches

-

4

No adverse effects were reported

 Patel et al., 2019 [88]

Narrative review

-

-

-

The overall data are

still insufficient to recommend aerobic exercise as a single

therapy for migraine prevention because of methodological limitations

-

4

No adverse effects were reported

 Robblee et al., 2019 [89]

Narrative review

-

-

The best current recommendation for patients with migraine is to engage in graded moderate cardiorespiratory exercise, although any exercise is better than none

-

4

No adverse effects were reported

 Song et al., 2021 [90]

Narrative review

-

-

-

Regarding efficacy, side effects, and health benefits, aerobic exercise promises to be a good strategy in the preventive treatment of migraine

-

4

Exercise can trigger a migraine attack. Pain aggravation by routine physical activity has been reported by approximately 2/3 of individuals with migraine. High-intensity exercise and an insufficient warm-up period can trigger a migraine attack

 Tepper et al., 2015 [91]

Narrative review

-

-

-

Aerobic exercise combined with behavioural therapy may be useful as a complementary migraine management

-

4

No adverse effects were reported

 Wells et al., 2019 [92]

Narrative review

Aerobic exercise

-

Aerobic exercise reduces migraine frequency, pain intensity, duration of migraine, and migraine disability. Also, yoga and tai-chi may be beneficial for migraine patients

-

4

Physical exertion can trigger migraines in some patients

MODERATE-INTENSITY CONTINUOUS AEROBIC EXERCISE

GRADE OF RECOMMENDATION: B in favour of intervention

 Ahmadi et al., 2015 [41]

RCT

ICHD-II

Episodic migraine

Experimental group: Aerobic exercise (n = 15)

Control group: Were told not to exercise (n = 14)

Frequency (attacks/month)

Pain intensity (VAS)

Duration (average minutes/attack)

Post-immediate

Significant improvement in all outcomes in the experimental group. No significant change in any variable in the control group

No significant difference between groups in any outcome

1-

No adverse effects were reported

 Oliveira et al., 2017 [62]

RCT

ICHD II

Episodic migraine

Experimental Group: Aerobic exercise (n = 10)

Control Group: Waiting list (n = 10)

Frequency (days with migraine /month)

Significant improvement in the experimental group. No significant change in the control group

Analysis not performed

1-

No adverse effects were reported

Oliveira et al., 2019 [63]

RCT

Migraine ICHD-II

Episodic migraine

Migraine aerobic exercise group (n = 13)

Migraine waitlist group (n = 12)

Control aerobic exercise group (n = 12)

Control waiting list group (n = 13)

Frequency (attacks/month and days with migraine /month)

Pain intensity (0 = no pain; 1 = mild; 2 = moderate; 3 = severe)

Post-immediate

Migraine exercise: Significant improvement in attacks/month, days/month. No significant change in pain intensity

Migraine waitlist: No significant change in any outcome

Favours significantly migraine exercise over migraine waitlist in days with migraine

No significant change in pain intensity

1-

No adverse effects were reported

 Hanssen et al., 2017 [50]

RCT

ICHD III-B

Episodic migraine

Experimental group: HIIT group (n = 16)

Experimental group: MCT group (n = 16)

Control Group: Maintain habitual daily physical activity profile and received additional standard physical activity recommendations (n = 16)

Frequency (days/month)

Post-immediate

No significant improvement in any group

Significant difference that favours HIIT versus MCT

No significant difference between HIIT-Control and MCT-Control

1-

No adverse effects were reported

 Hanssen et al., 2018 [49]

RCT

Episodic migraine without aura ICHD-IIIb

Experimental group 1: HIIT group (n = 15)

Experimental group 2: MCT group (n = 15)

Control Group: maintain habitual physical activity profile (n = 15)

Frequency (days/month)

Post-immediate

No significant improvement in any group

Significant difference that favours HIIT versus MCT

No significant difference between HIIT-Control and MCT-Control

1-

No adverse effects were reported

 Varkey et al., 2011 [67]

RCT

ICHD-II

Episodic migraine

Group 1: Relaxation group. (n = 30)

Group 2: Aerobic exercise group. (n = 30)

Group 3: Topiramate group

(n = 31)

Frequency (attacks/month and days with migraine / month)

Pain intensity (VAS)

Quality of life (MSQoL)

Post during treatment period

Post during last month of treatment

Post 3 months

Post 6 months

Post during the treatment period:

Significant reduction in attacks/month in all groups

No significant changes in other outcomes in any group

Post during the treatment period:

Significant difference between groups in pain intensity favours the topiramate group

No significant difference between groups in attacks/month, days with migraine/month

1-

No adverse effects were reported

Post during the last month of treatment:

Significant reduction in attacks/month in all groups

No significant change in other outcomes in any group

Post during the last month of treatment:

No significant difference between groups in any outcome

Post 3 months:

Significant reduction in attacks/month in all groups

No significant change in other outcomes in any group

Post 3 months:

No significant difference between groups in any outcome

Post 6 months:

Significant reduction in attacks/month in all groups

No significant change in other outcomes in any group

Post 6 months:

No significant difference between groups in any outcome

 Darabaneanu et al., 2011 [47]

Q-RCT

IHS

Episodic migraine with or without aura

Experimental group: Aerobic exercise (n = 8)

Control group: No exercise (n = 8)

Frequency (days with migraine /month)

Pain intensity (NPRS)

Duration (h/month)

Post-immediate

Follow-up 8 weeks

Significant improvement in all outcomes in the experimental group in post-immediate. No significant change in any outcome in the control group in post-immediate

Significant interaction between exercise group and frequency and an interaction effect between exercise group and intensity of migraine attacks

No significant difference in duration

1-

1 person was excluded because of pain during exercise and 4 persons because of a lack of motivation to perform the training

 Luedtke et al., 2020 [56]

Q-RCT

ICHD-III

Chronic or frequent episodic migraine

Group 1: Standard physiotherapy (manual therapy mobilization, myofascial treatment, exercise and education) (n = 79)

Group 2: Aerobic exercise (n = 24)

Frequency (days/month)

Disability (MIDAS)

Post-immediate:

No significant change in any outcome measure

Post-immediate:

No significant differences in any outcome measure

1-

2 patients discontinued the aerobic group because they reported an increase in headache intensity

Post 4 weeks:

No significant change in any outcome measure

Post 4 weeks:

No significant differences in any outcome measure

Post 3 months:

No significant change in any outcome measure

Post 3 months:

No significant differences in any outcome measure

 Narin et al., 2003 [61]

Q-RCT

Episodic migraine without aura. IHS

Experimental group: Moderate aerobic training and medical treatment. (n = 20)

Control group: Medical treatment (n = 20)

Pain frequency (attack/month)

Pain intensity (VAS)

Duration (hours)

Disability (PDI)

Post-immediate

Significant improvements in both groups in frequency and disability

Significant differences in pain relief favour the experimental group

1-

No adverse effects were reported

 Overath et al., 2014 [64]

Q-RCT IHS

Episodic migraine with or without aura

Exercise cohort (n = 28)

Frequency (attacks/month)

Frequency (days/month)

Post-immediate

Significant improvements in all outcomes in favour of intervention

-

1-

No adverse effects were reported

 Varkey et al., 2009 [66]

Q-RCT

ICHD-II

Episodic migraine with or without aura

Aerobic exercise (n = 26)

Frequency of days (days/month)

Frequency of attacks (attacks/month)

Intensity (VAS)

Quality of life (MSQol)

Post-immediate

Significant improvements in all outcomes in favour of intervention

-

1-

One patient reported a migraine attack immediately after training

3 dropouts because of noncompliance with the treatment, and 3 dropouts because of lack of time

 Hagan et al., 2021 [71]

Cohort Episodic migraine. ICHD-III

Exercise cohort (n = 98)

Headache frequency (headache/month)

Intensity (VAS)

Duration (hours)

Post-immediate

Moderate-vigorous exercise at least three times per week had fewer headache frequency, though not statistically significant. This association was significantly stronger in those who used prophylactic medication for migraines

-

2 + 

No adverse effects were reported

YOGA

GRADE OF RECOMMENDATION: B in favour of intervention

 Long et al., 2022 [37]

SR of MA of RCT

ICHD-IIIb

Experimental group: Yoga

Control group:

Standard treatment

Frequency (Attacks/month)

Pain intensity (10-point scale)

Duration (hours)

Disability (MIDAS and HIT-6)

-

Compared with the control group, yoga therapy could decrease pain intensity, frequency, duration and disability

1-

No adverse effects were reported

 Wu et al., 2022 [39]

SR and MA of RCT

ICHD III

Experimental group: Yoga therapy

Control group: Standard medical treatment and self-care

Frequency (headaches days/month, headaches/week)

Intensity (VAS or NRS)

Duration (hours)

Disability (HIT-6 and MIDAS)

-

Compared with the control group, yoga therapy was associated with substantially reduced headache frequency and HIT-6 score, but revealed no obvious influence on pain intensity

1-

No adverse effects were reported

 Boroujeni et al., 2015 [45]

RCT

Episodic migraine IHS

Experimental Group: Yoga and pharmacological intervention (n = 18)

Control group: Pharmacological intervention (n = 14)

Frequency (Headaches/month)

Intensity (VAS)

Duration (days)

Disability (HIT-6)

Post-immediate

Experimental group:

Significant improvements in frequency, intensity and disability, but not in duration

Control group:

No significant improvements

Significant improvements in intensity, frequency and disability favour the experimental group. No significant differences in duration

1-

No adverse effects were reported related to yoga

 John et al., 2007 [51]

RCT

Episodic migraine without aura. IHS 2004

Experimental group: yoga (n = 36)

Control group: self-care (n = 36)

Frequency (headache days/week)

Intensity (NRS and VAS)

Duration (hours)

Post-immediate

Experimental group:

Significant improvements in frequency, intensity, and duration of attack

Control group: Significant increase of symptoms in all outcomes except duration

Significant improvements in frequency, intensity and duration of pain favours the experimental group

1-

No adverse effects were reported

 Kisan et al., 2014 [52]

RCT

Episodic migraine ICHD-II

Experimental group: Yoga and conventional care (n = 30)

Control group: Conventional care (n = 30)

Frequency (Number of headaches/month)

Intensity (VAS)

Disability (HIT-6)

Post-immediate

Significant improvements in all outcomes in both groups

Significant improvements in all outcomes favour the experimental group in post-immediate follow-up

1-

No adverse effects were reported

 Kumar et al., 2020 [54]

RCT

Episodic migraine ICHD-III-beta

Experimental group: Yoga and medical therapy (n = 80)

Control group: Medical therapy (n = 80)

Frequency (headaches days/month)

Intensity (VAS)

Disability (HIT-6 and MIDAS)

Post-immediate (3 months)

Significant improvement in all outcomes in both groups

Significant improvements in all outcomes favour experimental group in post-immediate follow-up

1-

1 patient reported weight gain in the intervention group, due to medication

 Mehta et al., 2021 [58]

RCT

ICHD III

Episodic migraine, with or without aura

Group 1: Physical therapy: PMR exercise, stretching, isometric exercise of neck muscles, and cardiorespiratory endurance training. (n = 20)

Group 2: Yoga. (n = 20)

Group 3: Standard treatment. (n = 21)

Frequency (headaches/month)

Intensity (VAS)

Disability (HIT-6)

1 month since the initiation of the intervention

2 months since the initiation of the intervention

3 months since the initiation of the intervention (post-immediate)

Frequency:

Significant reduction in all groups at 1 month, 2 month and 3 months

Intensity:

Significant reduction in all groups at 1 month, 2 month and 3 months

Disability:

Significant reduction in all groups at 2 and 3 months

Frequency reduced significantly in group 1, compared to yoga and standard treatment. No significant differences in other outcomes were observed

1-

No adverse effects were reported

 Wells et al., 2021 [68]

RCT

ICHD-II

Episodic migraine

Experimental group: Standardized training in mindfulness/yoga (n = 45)

Control group: Headache education group (n = 44)

Frequency (migraine days/month)

Intensity (VAS)

Duration (no data)

Disability (MIDAS and HIT-6)

Quality of life (MSQv 2.1)

4 weeks post-treatment

16 weeks post-treatment

28 weeks post-treatment

At 4 weeks post-treatment, both groups showed a reduction in frequency

At 4, 16 and 28 weeks post-treatment a reduction in disability and an increase in quality of life was observed in the experimental group compared with the baseline

No significant changes over time in intensity and duration

Significant differences favour the experimental group in disability and quality of life at 4, 16 and 28 weeks post-treatment

1-

No adverse effects were reported due to the intervention

 Barber et al., 2020 [77]

Narrative review

-

-

The addition of exercise to a traditional preventive regimen may provide added benefits. Patients who cannot tolerate high-impact exercise may even benefit from low-impact exercise like yoga

-

4

Exercise may induce migraine

 Wells et al., 2019 [92]

Narrative review

-

-

Aerobic exercise reduces migraine frequency, pain intensity, duration of migraine, and migraine disability. Also, yoga and tai-chi may be beneficial for migraine patients

-

4

Physical exertion can trigger migraines in some patients

EXERCISE AND LIFESTYLE RECOMMENDATIONS

GRADE OF RECOMMENDATION: B in favour of intervention

 Lemstra et al., 2002 [55]

RCT

Chronic migraine with or without aura diagnosed with IHS criteria

Experimental group: exercise therapy, relaxation, stress management, massage therapy and dietary lecture. (n = 44)

Control group: waiting list with standard care with patient´s family physician (n = 36)

Frequency (days/month)

Pain intensity (VAS)

Duration (hours/month)

Quality of life (PDI)

Post-immediate

3 months follow up

The intervention group experienced statistically significant changes in frequency, pain intensity, duration, disability and quality of life at 3 months follow-up, but not in the control group

Significant differences in frequency, intensity, duration and quality of life favour the experimental group

1-

Eight subjects in the intervention group reported minor musculoskeletal pain

 Bond et al., 2018 [44]

RCT

ICHD-III

Episodic and chronic migraine with or without aura

Experimental group: fat-restricted diet, 250 min/week of home-based exercise and behavioural modification strategies. (n = 54)

Control group: Migraine education. (n = 56)

Frequency (days/month)

Pain intensity (NPRS)

Duration (hours/attack)

Disability (HIT-6)

Post-immediate

4 months follow-up

Significant reduction in all outcomes in the control group, significant reduction in attack duration and disability but no significant change in frequency and pain intensity in the experimental group in post-immediate

Significant reduction in all outcomes in the experimental and control groups except for pain intensity in the control group at follow-up

No significant difference between groups in any outcome at any endpoint assessment

1-

No adverse effects were reported

 Seok et al., 2006 [72]

Cohort

ICHD II

Chronic migraine

Lifestyle recommendations with exercise cohort (n = 136)

Frequency (headaches/month)

1-year follow-up

Regular exercise was significant positive contributor to the reversion of transformed migraine into episodic migraine

-

2 + 

No adverse effects were reported

 Woldeamanuel et al., 2016 [73]

Cohort

ICHD-IIb

Chronic and episodic migraine

Group 1: Episodic migraine. (n = 175)

Group 2: Chronic migraine (n = 175)

Regular lifestyle behaviours of sleep, exercise, mealtime patterns and hydration status

The chronic migraine cohort showed less regular lifestyle behaviours, including exercise habit, than the episodic migraine cohort

-

2 + 

No adverse effects were reported

 Gaul et al., 2011 [70]

Cohort

ICHD-II

Episodic and chronic migraine with or without aura

Muscular progressive relaxation, headache education, aerobic exercise, individual psychology therapy, group behavioural treatment with lifestyle recommendations cohort (n = 210)

Frequency (attacks/month and days with migraine/month)

There was a reduction of 45% in the number of attacks per month, and a mean reduction of 4 days with migraine per month

Significant amount difference in adherence to lifestyle modification recommendations between the patients who showed a reduction of ≥ 50% in headache days per month and the ones who did not fulfil this outcome at the primary endpoint

-

2-

No adverse effects were reported

 Agbetou et al., 2022 [93]

Narrative review

Chronic and episodic migraine

-

-

Lifestyle modifications are essential in reducing the frequency and severity of migraine attacks. Managing obesity, alcohol, and tobacco consumption discontinuation, regular physical activity, sufficient hydration, and a healthy lifestyle are highly accessible and cost-efficient interventions for any patient with migraine

-

4

RELAXATION TECHNIQUES

GRADE OF RECOMMENDATION: C in favour of intervention

 Meyer et al., 2016 [59]

RCT

Episodic migraine with and without aura. IHS criteria

Group 1: PMR training in migraine patients (n = 16)

Group 2: waiting list for migraine patients (n = 19)

Group 3: PMR training in healthy subjects (n = 21)

Group 4: Waiting list for healthy subjects (n = 25)

Frequency (days/month and attacks/month)

Post-immediate and follow-up of 3 months

Significant improvements in frequency in favour of PMR training in migraine group in post-immediate and follow-up

Post-immediate and follow–up: Significant differences in frequency favour the PMR training in migraine group versus the waiting list for migraine patients’ group

1-

No adverse effects were reported

 Minen et al., 2020 [60]

RCT

Episodic and chronic migraine

ICHD-IIIb

Experimental group: PMR with a smartphone. (n = 77)

Control group: only download the smartphone app. (n = 62)

Frequency (Days/month)

Disability (MIDAS)

Post-immediate

Follow-up 3 months

There were no significant differences in all outcomes post-immediate and in follow-up

There was a greater no significant decline in disability in favour of the experimental group at post-immediate and follow-up

1-

No adverse effects were reported

 Varkey et al., 2011 [67]

RCT

ICHD-II

Episodic migraine

Group 1: Relaxation group. (n = 30)

Group 2: Aerobic exercise group. (n = 30)

Group 3: Topiramate group

(n = 31)

Frequency (attacks/month and days with migraine / month)

Pain intensity (VAS)

Quality of life (MSQoL)

Post during treatment period

Post during last month of treatment

Post 3 months

Post 6 months

Post during the treatment period:

Significant reduction in attacks/month in all groups

No significant changes in other outcomes in any group

Post during the treatment period:

Significant difference between groups in pain intensity favours the topiramate group

No significant difference between groups in attacks/month, days with migraine/month

1-

No adverse effects were reported

Post during the last month of treatment:

Significant reduction in attacks/month in all groups

No significant change in other outcomes in any group

Post during the last month of treatment:

No significant difference between groups in any outcome

Post 3 months:

Significant reduction in attacks/month in all groups

No significant change in other outcomes in any group

Post 3 months:

No significant difference between groups in any outcome

Post 6 months:

Significant reduction in attacks/month in all groups

No significant change in other outcomes in any group

Post 6 months:

No significant difference between groups in any outcome

 Meyer et al., 2018 [86]

Narrative review

-

-

-

PMR is useful in prophylactic migraine therapy and provides indications of a cortical mechanism of action

-

4

No adverse effects were reported

HIGH-INTENSITY AEROBIC INTERVAL TRAINING

GRADE OF RECOMMENDATION: C in favour of intervention

 Hanssen et al., 2017 [50]

RCT

ICHD III-B

Episodic migraine

Experimental group: HIIT group (n = 16)

Experimental group: MCT group (n = 16)

Control Group: Maintain habitual daily physical activity profile and received additional standard physical activity recommendations (n = 16)

Frequency (days/month)

Post-immediate

No significant improvement in any group

Significant difference that favours HIIT versus MCT

No significant difference between HIIT-Control and MCT-Control

1-

No adverse effects were reported

 Hanssen et al., 2018 [49]

RCT

Episodic migraine without aura ICHD-IIIb

Experimental group 1: HIIT group (n = 15)

Experimental group 2: MCT group (n = 15)

Control Group: maintain habitual physical activity profile (n = 15)

Frequency (days/month)

Post-immediate

No significant improvement in all groups

Significant difference that favours HIIT versus MCT

No significant difference between HIIT-Control and MCT-Control

1-

No adverse effects were reported

 Matin et al., 2022 [57]

RCT

ICHD II

Episodic migraine

Group 1: HIIT (n = 15)

Group 2: Supplementation (Magnesium + B12) (n = 15)

Group 3: HIIT + Supplementation

(n = 15)

Group 4: Control group: Migraine cases

(n = 15)

Frequency (days/month)

Intensity (10/15 disabling, 5/9 moderate, ¼ mild)

Duration of attacks (minutes)

Disability (MIDAS)

Post-immediate

Significant improvement in all outcomes in all groups

Significant improvement in all outcomes in favour of HIIT vs control

1-

No adverse effects were reported

LOW-INTENSITY AEROBIC EXERCISE

GRADE OF RECOMMENDATION: C in favour of intervention

 Santiago et al., 2014 [65]

RCT

ICHD-II

Chronic migraine

Experimental group: Amitriptyline and aerobic exercise. (n = 30)

Control group: Amitriptyline alone. (n = 30)

Frequency (days/month)

Intensity: 1 (mild), 2 (moderate) and 3 (disabling)

Duration of headache (hours/day)

Post-immediate

-

Significant improvements-favour the experimental group in frequency, moderate pain intensity and duration

1-

6 persons withdrew for non-adherence to the proposed physical treatment

 Köseoglu et al., 2003 [53]

q-RCT

IHS

Episodic migraine without aura

Aerobic exercise (n = 40)

Frequency (attacks/month)

Intensity (a four-degree scale)

Duration (hours of attack/month)

Post-immediate

Significant improvements in all outcomes

-

1-

No adverse effects were reported

EXERCISE AND RELAXATION TECHNIQUES

GRADE OF RECOMMENDATION: C in favour of intervention

 Dittrich et al., 2008 [48]

RCT

Episodic migraine with and without aura

ICHD-I

Experimental group: Aerobic exercise group and relaxation (n = 15)

Control group: information about

Physical activity (n = 15)

Frequency (attacks/month)

Pain intensity (slight, moderate, intense, very intense, intolerable)

Quality of life (PLC)

There were no significant differences in any outcome except in pain intensity in favour of the exercise group at post-immediate

There were no significant differences in any outcome at post-immediate

1-

No adverse effects were reported

 Mehta et al., 2021 [58]

RCT

ICHD III

Episodic migraine, with or without aura

Group 1: Physical therapy: PMR exercise, stretching, isometric exercise of neck muscles, and cardiorespiratory endurance training. (n = 20)

Group 2: Yoga. (n = 20)

Group 3: Standard treatment. (n = 21)

Frequency (headaches/month)

Intensity (VAS)

Disability (HIT-6)

1 month since the initiation of the intervention

2 months since the initiation of the intervention

3 months since the initiation of the intervention (post-immediate)

Frequency:

Significant reduction in all groups at 1 month, 2 month and 3 months

Intensity:

Significant reduction in all groups at 1 month, 2 month and 3 months

Disability:

Significant reduction in all groups at 2 and 3 months

Frequency reduced significantly in group 1, compared to yoga and standard treatment. No significant differences in other outcomes were observed

1-

No adverse effects were reported

 Butt et al., 2022 [46]

Q-RCT

Episodic and chronic migraine

Experimental group: supervised exercises protocol, including aerobic exercise and PMR (n = 14)

Control group: prophylactic medicines (n = 14)

Pain Intensity (NPRS)

Disability (MIDAS, HIT-6, HDI)

Post-immediate

There were significant differences in all outcomes in both groups at post-immediate

There were significant differences in all outcomes between groups at post-immediate that favour the experimental group

1-

No adverse effects were reported

 Becker et al., 2009 [78]

Narrative review

-

Multidisciplinary treatment, not only medication management is needed in migraine patients. Exercise and relaxation techniques are important components of stress and symptomatic management. For migraine, a more substantial relaxation training program might be necessary

-

-

-

4

No adverse effects were reported

NECK STRENGTH EXERCISE

GRADE OF RECOMMENDATION: C against the intervention

 Benatto et al., 2022 [43]

RCT

Episodic migraine

ICHD-III

Experimental group:

craniocervical muscle-strengthening exercise (n = 21)

Control group: sham ultrasound group (n = 21)

Frequency (days with headache/month)

Intensity (NRS)

Disability (MIDAS)

Post-immediate

1-month post-intervention

2-month post-intervention

3-month post-intervention

Only significant difference in the intensity of headache for both groups

No significant differences in any outcome

1-

No adverse effects were reported

TAI-CHI

GRADE OF RECOMMENDATION: C in favour of intervention

 Xie et al., 2022 [69]

RCT

ICHD-III

Episodic migraine

Experimental group: Tai Chi (n = 40)

Control group: Waiting list (n = 33)

Frequency (attacks/month and days with migraine/month)

Intensity (VAS)

Duration (hours/attack)

Significant reduction in migraine in frequency (both attacks and days with migraine per month) intensity and duration in Tai Chi group at the end of treatment and follow-up

Participants in waiting list only found significant reduction in days with migraine at follow-up

Significant reduction in Tai Chi group compared to control group only in frequency (both attacks and days with migraine per month) at the end of treatment and follow-up

No significant differences in intensity or duration

1-

Joint pain (33.8%), muscle pain (33.3%), slight sprain (10.2%) and dizziness (5.1%)

All participants indicated tolerability of these symptoms. No serious cases appeared

 Wells et al., 2019 [92]

Narrative review

-

-

Aerobic exercise reduces migraine frequency, pain intensity, duration of migraine, and migraine disability. Also, yoga and tai-chi may be beneficial for migraine patients

-

4

Physical exertion can trigger migraines in some patients

RESISTANCE EXERCISE

GRADE OF RECOMMENDATION: C in favour of intervention

 Aslani et al., 2021 [42]

RCT

Episodic migraine

ICHD

Experimental group: Resistance training. (n = 10)

Control group: No exercise. (n = 10)

Frequency (attacks/month)

Intensity (VAS)

Duration (Days)

Quality of life (HIT-6)

Post-immediate

All outcomes improved significantly in the exercise group in the pre-post measures

There were significant differences that favour resistance training in all outcomes

1-

No adverse effects were reported

QI-GONG

GRADE OF RECOMMENDATION: D in favour of intervention

 Elinoff et al., 2019 [74]

Case series

ICHD-II

Episodic migraine

Kiko Exercise and its background

(n = 13)

Frequency (attack/month)

Intensity (1 to 5 scale)

Disability (MIDAS)

Post-immediate

Disability score reduced by 50% in 4/6 patients

Intensity did not show improvement

Frequency was improved in more than 1 attack in 3/6 patients

-

3

No adverse effects were reported