FAQ Episode 17 Exercise and Migraine: preventive, provocative or both? Part I

FAQs for Natural Migraine Relief

FAQ Episode 17:  Exercise and Migraine  Part I

Hi! Jeff Baker here again as your physician host for Frequently Asked Questions about Natural Migraine Relief for Women.  As I survey the popular and scientific literature, I find few migraine-related factors with as many variable opinions as that of the role of exercise in causing or preventing migraines.  Why is this?  At the risk of sounding repetitious, it traces back to understanding which root cause factors provoke your version of migraine, and how exercise can either calm or aggravate each root cause that may apply to you.

I’d like to review some underlying factors as they affect exercise. No doubt, one could make the list longer, or divide it up differently, but here are six I’d like to cover for you. Given the volume of this information, I am going to address the first three of these factors in this episode and the other three in next week’s FAQ: Episode 18 Part II.   Each of these factors has stand-alone applications that you can apply in discerning what version of an exercise plan may work best for your own migraine story.  I’ll include action plan ideas for each of them and then summarize them at the end of each article.   The root factor interactions with exercise we will address in two parts include:

Episode 17 Part I

1. Exercise, blood flow, and the role of nitric oxide.

2. Exercise and the neurochemistry of migraine

3. Exercise and the role of rest and sleep

Episode 18 Part II

4. Exercise and metabolic factors in migraine

5. Exercise and female hormone balance

6. Exercise and fitness level in migraine expression

Please keep in mind that we could easily fill each section with 15-20 pages of discussion and documentation.  For the sake of brevity, I will stay as focused, brief, and to the point as possible. 

Let’s begin Part I with:

1. Exercise, blood flow, and the role of nitric oxide.

The molecule nitric oxide (NO) production increases in skeletal muscle and endothelial cells in response to physical activity.   It assists in dilating arteries and veins, increases brain blood flow in the brain, and can also sensitize pain receptors.  Through these mechanisms, excessive NO has been known to cause migraines.  Nitric oxide however, is not the sole factor in this migraine connection.  It is as much or more its the oxidation (breakdown damage) of NO to something called peroxynitrite (chemical symbol: ONOO…isn’t that just ironic) that is a major culprit in promoting a migraine.  Migraine patients have a higher peroxynitrite (ONOO) load than other people.   A combination of extra NO and then additional stress factors that oxidize NO to ONOO can push your migraine buttons.

For most people, exercise doesn’t cause headaches.  This can also be true for some with migraines.  But, if you: 1) make extra NO and 2) have enough stressful oxidation to make excess ONOO, you may cross the migraine threshold much more readily during or after exercise.

Excess peroxynitrite can also be associated with symptoms such as:

-chronically cold hands and feet

-inflammation of all kinds

-headaches of all kinds, including migraine headaches

-sore joints and muscles

-bruising more readily

-depression, lack of motivation

-fatigue, as well as an inability to sleep even though chronically tired

-feeling anxious and irritable

-poor memory, lack of focus and attention

-feeling lightheaded when you stand up.

If you have these symptoms, especially migraines, and exercise at times worsens your situation, you should consider the following measures:

   a) Minimize factors boosting your nitric oxide level.   This includes:

    -avoid amino acid supplements containing arginine or citrulline, which promote NO.

   -avoid meds that augment NO, such as nitrates and the Viagra type prescriptions.  This also can include the drug amlodipine, typically used for hypertension.

   -reducing exercise that is excessively intense for your level of fitness.  Consider a gradual warm-up, shorter sessions, lower intensity, and more recovery time between sessions until you find the sweet spot between making fitness progress and avoiding headaches related to excess NO production.

   b) Recognize that times of excess physical, emotional, and situational stress may require reducing your frequency or intensity of exercise to minimize provocations of migraine.  You can then phase back up when those stressors fade back to baseline levels.

   c) Consider taking nutrients that can reduce ONOOs and their downstream effects.  Many contribute in this area, but my favorites include curcumin, optimal levels of Vitamin D3, and the antioxidant astaxanthin.

2. Exercise and the neurochemistry of migraine

Exercise is well known for raising brain chemicals like dopamine, serotonin, endocannabinoids, and endorphins that contribute to reduced stress and anxiety, a sense of joy, improved mood and self-confidence, better sleep quality, and sharper cognitive function. Optimal levels of these neurochemicals can reduce migraine expression and your recovery after an event.  So, on the plus side, multiple studies have shown that regular exercise can reduce migraine frequency. 

I’d also like to mention two more recently described brain/migraine connections and the exercise/cerebral blood flow connection:

 a) It has been found that for some, exercise increases the release of the calcitonin gene-related peptide (CGRP) that is known to provoke migraines.  Around 1/3 of those with migraines find that exercise can be a precipitating factor.   We don’t yet know if the two are related, but it is interesting to note that roughly 1/3 of those with migraine respond well to CGRP-blocking medications.  It would be reasonable to consider that if your exercise leads to a headache, you may be a good candidate to try one of the newer drugs that block the CGRP pathway and allow you to exercise without headache pain.  If this sounds like your story, check out this option with your primary care or neurology physician.

b) hypocretin is a neurohormone produced by the hypothalamus. Right now you can’t check this with routine blood work, but research studies have shown that impaired hypocretin pathways have been found in subjects with migraine.  This has been associated with symptoms preceding a migraine attack such as excessive sleepiness, food cravings, yawning, and fatigue.  Some studies have found that vigorous exercise could influence the hypocretin pathway and theoretically initiate attacks.  If you find that the above symptoms occur before your migraine, limiting the high-intensity aspects of your exercise sessions for the next 1-2 days after experiencing thosr symptoms could be helpful.

c) an intense exercise session can result in an exaggeration of increased cerebral pressure and blood flow.  For some this can be a promoting factor for a migraine, and in general, you should consider:

a) staying within an aerobic threshold (a heart rate no higher than 60-80% of your ‘predicted maximum’*) and

b) for strength training, using less weight but perhaps with a few added reps, with good form and a breathing technique where your long, easy breath out is during the exertion phase of the lift.

* using the formula of maximal heart rate = 220 – your age.   So 60-80% effort for a 40-year-old would be in the (220 – 40) X 0.6 or 0.8 range, or ~110-140 beats per minute.  Maybe split the difference and aim for a training heart rate in the 120s.

3. Exercise and the role of rest and sleep

Healthy exercise challenges the body to expand its limits on fitness, flexibility, strength, and endurance.  But it comes at a price. In the best-case scenario, the metabolic cost to power exercise and then repair and restore depleted resources breaks even and we make gradual progress without paying excessive dues. 

But if we are already marginal in our nutrient resources, or the hormone levels needed for repair, or if we have other underlying inflammatory factors, those shortfalls can both limit response to exercise as well as bring out the expression of underlying problems like migraine headaches.

Attending to the applicable migraine root factors that can be stressed by exercise or exertion should be on our to-do list.  When they are addressed, we promote the ability of sleep to do its optimal repair work.   Some of these include:

a) having sufficient protein, magnesium, or B vitamins in the diet or by supplementation, if required.    

b) supplementing the nutrient CoQ10 if you are taking a statin drug for your cholesterol.                                                                                         

c) supplementing deficiencies in key repair hormones like estrogen, testosterone, progesterone, or adrenal building blocks, especially if you are in the 30-50 age group and may be experiencing peri-menopausal transition.   This is especially important if hormone deficits and associated heat exchange problems are robbing your deep restorative sleep.   To individualize this for you, it can be helpful to locate a physician who understands bio-identical hormone support.

d) considering that pro-inflammatory factors like high levels of histamine or an excess of prostaglandins before your cycle may be worsened with excess exercise.

Still, even if these are optimized, and depending on our level of fitness, we need sufficient time spent in sleep or rest to pay the dues incurred by the exertion of work, chores, and exercise.  Most people, especially those of us with a chronic health problem tend to underestimate the amount of sleep or relative rest needed to pay these dues.

Summary of Part I:  Questions to ask yourself about exercise and migraine.  Look to the text above to review the details.

1. Minimize factors that could excessively boost your nitric oxide level.  

2. Recognize that times of excess physical, emotional, and situational stress may require reducing your frequency or intensity of exercise.

3. Consider taking nutrients that can reduce peroxynitrite (ONOOs) and their downstream effects. These can include:

   -curcumin 500 mg 1-2 caps per day (look for ‘95% curcuminoids’ on the label)

   -optimal Vitamin D3.  Aim for a blood level of 60-80 ng/dl, which usually requires 3000-7000 IU/day.   Take it with a meal to optimize absorption.

    -astaxanthin 4-8 mg/day

4. If your exercise leads to a headache, you may be a good candidate to try one of the newer drugs that block the CGRP pathway.

5. If you have symptoms preceding a migraine attack such as excessive sleepiness, food cravings, yawning, and fatigue you may find that it is helpful to limit the higher-intensity aspects of your exercise session.

6. You may find that moderating either the aerobic workload (~60-80% predicted max HR) or the intensity of weight lifted in strength training can reduce the exercise to migraine link.

7. Attend to any applicable migraine root cause factors that can be stressed by exercise or exertion.  See the four action items in Part 3 which discuss sleep and repair.

8. Although it can be frustrating at times, it is important not to underestimate the amount of sleep needed to pay the dues incurred by the exertion of work, chores, and exercise.  Please, make paying those sleep dues a priority.  No question, that’s hard to do, but if you don’t respect those boundaries, who will?

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Please plan to look for the upcoming Episode 18 Part II, where we will complete our review of root factors that help explain how exercise can affect your migraines.

If you would like to understand the broader range of root cause factors that drive your migraines and then individualize your therapy options, you may want to to survey the Natural Migraine Relief for Women course and its unique Migraine Action Plan system.   See www.naturalmigrainerelief.online for more details.