# Exercise as it relates to Disease/Effects of exercise on cerebrovascular health and episodic migraines
## What is the background of this research?

Migraines are severe headaches that can be disruptive to many daily activities. Migraines are generally considered to be one of the most disabling migraines, preventing people from going about the daily live due to immense pain. Studies have shown that around 15-20% of the population suffer from migraines, although the actual prevalence is still debated by neurologists. Migraines can be self-treated however, sometimes requires pharmaceutical support to alleviate the pain and discomfort that occurs during migraines. Migraines have been related to other issues such as increased risk cardiovascular disease (CVD) and reduced arteriolar-venular ratio (AVR). Both of these can be affected positively by physical activity.
The cost of treatment per year for a patient who suffers from migraines can reach an average of 6000aud per year. This costs may check-ups, Diagnosis, Pharmaceuticals, production and other prescribed treatments depending on the client. This is an excellent point for physical activity as it does not require a cost to be conducted and can be a method of self-treatment. Exercise may be great as migraine preventative treatment and will also increase cardiovascular health.

## Where is the Research from?

This randomised control trial was conducted in Europe with a European population. Utilising both females and males in the trial, the majority of the participants were female, this can relate to the real world as females are roughly three times more likely to suffer from migraines compared to males. The article was published in the 'Scandinavian Journal of Medicine and Science in Sports'.
Henner Hanssen was the corresponding author for this article. He has assisted in the publication of many articles with a focus on exercise in relation to vascular related conditions. Hanssen is currently a professor at University of Basel in the sports medicine department. The rest of the authors have also worked on multiple other journal articles, these articles mainly related to physical activity and health conditions as well.

## What type of research is this?

The research conducted was a randomly controlled clinical trial. In the studies the researchers assigned the patients into 3 separate groups undergoing different forms of exercise interventions and a control group. This allows for the observers to assess the effectiveness of different exercise interventions by comparing them together and with the control group.
Randomized control trials are some of the most effective tests when assessing the reliability of interventions. This test outlines the effectiveness of an intervention by often utilising a group without the interventions for comparison. In addition, after compiling a pool of participants researchers randomly assign them into groups to decrease reliability errors. This research article is a 3 armed randomly controlled clinical trial. This type of research sits at the top of unfiltered research reliability, above this in reliability is filtered articles, these utilise third party research to assess and compare validity of multiple articles and collate results to provide a more reliable observation.

## What did the research involve?
#### Inclusion Criteria

Participants diagnosed by an experienced neurologist with episodic migraines without aura in accordance with the International Clarification of Headache Disorders.

#### Exclusion Criteria

* Participants currently undergoing a medical preventative (Participants were permitted if preventative medication had been ceased 8 weeks prior to study).
* Participants who suffer from additional internal or neurological disease (especially CVD or Chronic Inflammatory Disease).
* Regular exercise experience or currently undergoing exercise preventative.
Participants ability to exercise were assessed using the Physical Activity Readiness Questionnaire (PAR-Q) and exercise testing.

#### Participant Pool

Originally 45 participants were selected. 9 dropouts were recorded due to non-compliance, pregnancy or non-intervention related injuries.
Final pool assessed were 36 participants, 29 Females and 7 Males

#### Exercise Programming

Warmup: 400m of easy running, 2 skipping exercises
Cooldown: 400m of easy running
MCT: Maintain a calculated HR of 70% +/- 5 bpm of HRmax for 45 minutes.
HIIT: 90-95% +/- 5 bpm of HRmax for 4 minutes followed by 3 minutes of 70% HRmax active recovery, intervals repeated 4 times.
CON: Minimal Physical activity outside of the participants usual daily activity prior to commencing the Research.
20-24 exercise sessions in the 12-week period were necessary to complete to meet compliance for assessment.

#### Assessment of exercise intervention

Prior to conducting the intervention participants underwent Anaerobic Lactate Threshold, HRmax and VO2 max testing, utilising a treadmill.
Heart Rate Monitors were utilised during exercise to determine HR throughout the course of the exercise programs. Distance was also recorded for each session of each exercise program.
Participants were asked to maintain a diary record of the number of migraines experienced throughout the course of the research.
Migraine attack frequency, Maximal and sub maximal Parameters and Retinal Vessel Diameters were recorded as means with standard deviations.
The pre- and post- exercise results for MCT, HIT and CON Groups were calculated together with 90 percent confidence intervals.

#### Strengths

* The study conducted is relatively cheap to conduct.
* The programs are not lengthy in terms of time period required to participate.
* Utilises specific HR% as to keep participants exercising at the same intensities.

#### Weaknesses

* Relies on participant compliance to record the number of migraine days.
* Lacks program specificity reducing repeatability as the program will need to talk of be restructured.
* Migraines have many triggers and may be triggered by other stimuli other than physical health.

## What are the basic results?

Hanssen et al summarise their results and make the following findings
* Both MCT and HIT group displayed beneficial reduction in migraine days when undergoing an exercise program, with results being in the favour of HIIT programming.
* Migraines are related to Cardiovascular risk profiles and MCT and HIT improved migraine frequency and Cardiovascular health.
* MCT and CON Migraine days had similar decreases this may be due to the participant exercise profiling and physical activity recommendations provided for CON.

## What conclusions can we take from this research?

The study concludes with the summary that HIIT has a greater impact on migraine days as opposed to MCT. This leads to the idea that Higher Exercise Intensity Intervals may be required to improve on a patients migraine symptoms, however data is suggestive and does not prove the suggestive data. Both MCT and HIIT have positive impacts on cerebrovascular health and improve on migraine days.
Hanssen et al talk of similarities between their study and other studies conducted where exercise was studied as a way to improve cerebral vessel health and preventing migraine triggers. Hanssen et al outline how their study is primarily to look at physical activity modality and how improving cardiovascular health, fitness levels and retinal vessel diameters can decrease the pain and frequency of migraines. The other articles produce positive results in exercise decreasing migraine triggers.

## Practical Advice
###### Clinical Recommendations

* Assess your client's fitness levels and draw out a program for the patient. It is important to recognise that high intensity exercise is also a migraine trigger so if the client isn't usually physically active start with moderate continuous training and work up to HIIT.
* Assess client exertion levels during a workout exercise intensity may need to be lowered to ensure compliance remains, the aim is to get them more active and improve on their cardiovascular health.
* Stay hydrated during exercise, it is easy to undergo physical activity without drinking enough, it is important to utilise each period provided for drink is utilised for hydration. ensure the client is hydrated before commencing the session, ensure they rehydrate before they leave, this will help to prevent migraines during exercise.
* Keep up motivation, work ethic is important to maintain during these programs so ensure to motivate clients through encouragement or music this will help them to maintain intensity.

## Further Information/Resources
#### Migraine classification and assistance.

-International Clarification of Headache Disorders - Migraine or Simplified Clarification of Migraine
- What is a migraine? When to see a doctor
- Migraine Australia Support Group

## References

* 1 2 3 4 5 6 7 8 9 Hanssen H, Minghetti A, Magon S, et al. Effects of different endurance exercise modalities on migraine days and cerebrovascular health in episodic migraineurs: A randomized controlled trial. Scand J Med Sci Sports. 2018;28: 1103–1112. https://doi.org/10.1111/sms.13023
* ↑ Peterlin, B. L., Gupta, S., Ward, T. N., & Macgregor, A. (2011). Sex matters: evaluating sex and gender in migraine and headache research. Headache, 51(6), 839–842. https://doi.org/10.1111/j.1526-4610.2011.01900.x
* ↑ Cheng, T. (2021). "Migraine – a Common and Distressing Disorder." 2021, from https://headacheaustralia.org.au/migraine/migraine-a-common-and-distressing-disorder/.
* ↑ Alexander, L. (2018). "Prevalence and Cost Of Headache." 2021, from https://headacheaustralia.org.au/what-is-headache/prevalence-and-cost-of-headache/.
* ↑ (2021). "Raising Money for MIGRAINE RESEARCH." 2021, from https://migraineresearchfoundation.org/about-migraine/migraine-facts/.
* ↑ Peterlin, B. L., Gupta, S., Ward, T. N., & Macgregor, A. (2011). Sex matters: evaluating sex and gender in migraine and headache research. Headache, 51(6), 839–842. https://doi.org/10.1111/j.1526-4610.2011.01900.x
* 1 2 InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. What types of studies are there? 2016 Jun 15 [Updated 2016 Sep 8]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK390304/
* ↑ Minkow, D. (2014). "The Evidence-Based Medicine Pyramid." https://s4be.cochrane.org/blog/2014/04/29/the-evidence-based-medicine-pyramid/ 2021.
* ↑ Schmidt W, Endres M, Dimeo F, Jungehulsing G, J: Train the Vessel, Gain the Brain: Physical Activity and Vessel Function and the Impact on Stroke Prevention and Outcome in Cerebrovascular Disease. Cerebrovasc Dis 2013;35:303-312. doi: 10.1159/000347061
* ↑ Lippi, G., Mattiuzzi, C., & Sanchis-Gomar, F. (2018). Physical exercise and migraine: for or against?. Annals of translational medicine, 6(10), 181. https://doi.org/10.21037/atm.2018.04.15
* ↑ Koppen, H., van Veldhoven, P.L. Migraineurs with exercise-triggered attacks have a distinct migraine. J Headache Pain 14, 99 (2013). https://doi.org/10.1186/1129-2377-14-99
* ↑ Wöber, C., & Wöber-Bingöl, Ç. (2010). Chapter 12 - Triggers of migraine and tension-type headache. In M. J. Aminoff, F. Boller, & D. F. Swaab (Eds.), Handbook of Clinical Neurology (Vol. 97, pp. 161-172). Elsevier. https://doi.org/https://doi.org/10.1016/S0072-9752(10)97012-7
* ↑ Donna J. Plonczynski, Measurement of motivation for exercise, Health Education Research, Volume 15, Issue 6, December 2000, Pages 695–705, https://doi.org/10.1093/her/15.6.695