Migraine is a debilitating neurological disorder 1, affecting over a billion individuals globally. It is frequently characterized by recurrent and taxing headaches, some of which are accompanied by an aura 2,3. This disorder imposes a significant economic burden worldwide, detrimentally impacting the person with migraine’s quality of life, as well as their family, coworkers, and society at large 2,4,5.
In terms of prevalence, migraines rank as the second leading cause of disability worldwide, and as the foremost cause of disability among young women 6. The profound effect of migraines on quality of life cannot be understated, due to its influence on professional spheres, family, and social relationships, resulting in pronounced emotional decline 7,8.
Migraine pathophysiology is associated with various alterations in the central and peripheral nervous systems 1. Neuroimaging and electrophysiological studies have identified both structural and functional aberrations in the brains of patients with migraine 9–12. Spread depolarization appears to be the root cause of the aura and can also trigger trigeminal sensory activation, which is the underlying mechanism of headache pain 3. Theoretical models applied to patients with migraine suggest that augmented and sustained pain perception induces neuroplastic changes in the central nervous system. These changes potentially impact motor behavior and are influenced by contextual and cognitive-emotional factors (fear avoidance beliefs, feelings of reduced self-efficacy, catastrophic cognition, and increased depressive symptoms). It is suggested that maladaptive changes in motor behavior can heighten disability levels and pain perception and can further reduce quality of life 13.
Understanding migraines from a biobehavioral perspective entails acknowledging their biological foundations and their interplay with psychological elements pertinent to patients’ symptomatology. Those with migraines frequently endure psychological distress, including symptoms of depression and anxiety, and they face societal stigma and misunderstanding 7,8,14. Research has shown that psychological elements, such as anxiety, depression, and pain catastrophizing, are strongly correlated with migraine-related disability 15.
The therapeutic landscape of migraines has been extensively researched and reviewed, covering both pharmacological and non-pharmacological treatments 3,16,17. Although drugs are the typical treatment, they pose challenges, such as drug interactions, patient response variability, and safety concerns, which are intensified when polytherapy is required to address comorbidities or to achieve a sufficient therapeutic effect 17.
Given the heterogeneity in treatment response, it is important to consider the patients’ perspectives. Qualitative studies delving into the views of those with migraine have highlighted challenges in accessing healthcare, establishing relationships with providers, having aversions to prescribed medications, and a preference for non-drug treatments 16. They have also highlighted the importance of understanding the social implications and diagnosis, as well as knowing the potential migraine triggers.
Beyond pharmacological approaches, behavioral interventions have emerged as a promising alternative that is backed by robust scientific evidence. Effective patient–healthcare provider communication is essential, recognizing individual factors influencing migraine onset and management 18. Among behavioral strategies, exercise, notably aerobic, has been pinpointed as a promising preventive treatment, with significant symptomatic improvements having been observed 19. Such is the impact of exercise on these patients that various scientific societies related to headaches have included exercise as part of their non-pharmacological treatment recommendations 20–22. Moreover, multiple authors have highlighted the efficacy of behavioral interventions, such as relaxation and biofeedback, in migraine prevention and management 18,23,24. When combined with pharmacotherapy, these techniques have proven particularly advantageous 18.
This manuscript will describe the potential bio-behavioral factors influencing disability and other alterations affecting patients with migraine. Furthermore, it will detail a multimodal physiotherapy treatment proposal based on a bio-behavioral approach, incorporating therapeutic education and an evidence-based exercise prescription.
Migraine and physical activity
The nexus between physical activity (PA) and migraine has been scrutinized in various scientific contexts. Though findings differ, creating a complex and intricate landscape, PA remains a pivotal topic in therapeutic and diagnostic approaches, particularly from a physiotherapy perspective.
Several researchers have evaluated the PA levels of patients with migraine compared with asymptomatic individuals and those with other headache types. In this context, Rogers et al. (2020) compared PA levels among adolescents with migraine, those with tension-type headache, and headache-free controls. Those with migraine displayed reduced overall PA compared with those without headaches, not only during headache episodes but also on headache-free days, suggesting a general reduction in PA for migraine-afflicted individuals 25. Aligning with these findings, Stronks et al. discerned that patients with migraine, while having heart rates comparable to controls, were notably less physically active in their routine settings. Moreover, their bodily motion during activity was subpar compared with controls. These interictal phenomena of low physical activity reinforce the chronic impact of migraine on patients’ daily lives 26.
Physical inactivity appears to also play a role in migraine onset. As posited by Varkey et al., those with a sedentary lifestyle had a heightened probability of developing non-migraine headaches a decade later. Furthermore, reduced PA was correlated with a surge in both migraine and non-migraine headache prevalence 27. Reinforcing these findings, recent research has illustrated that inactive individuals have a higher migraine prevalence compared with their active or highly active counterparts. Notably, population-based studies showed that PA levels were inversely associated with depression, anxiety, negative self-perceived health, and analgesic use 28, as well as headache disability 29.
Compelling data have also emerged from the ELSA-Brasil cohort studies 30,31, which pointed to an association between physical inactivity and migraine attack frequency. These findings suggest that adhering to World Health Organization (WHO) PA guidelines could mitigate migraine occurrence, with leisure-time PA being especially significant 30. Further findings from the same cohort (2022) highlighted that those meeting the WHO’s PA criteria had a decreased migraine occurrence. Moreover, the type and intensity of PA could have distinct roles concerning migraine subtype 31. In the All of Us study, a prospective study with 6,042 participants using wearable devices and analyzed during a 4-year period, each additional increment of 1,000 daily steps beyond the sample median resulted in an 8% reduction in the incidence of migraine 32. The study by Domingues et al. (2011), noted reduced functional disability in a sample of medical students with migraine who engaged in PA 33.
Conversely, Bond et al. found that women with obesity and migraines spent approximately 1.5 fewer hours per day performing PA compared with controls. Intriguingly, this reduced PA was not linked to the clinical characteristics of their migraines. This study accentuates the imperative to explore barriers to PA in these women 34. The migraine–body composition relationship extends beyond mere PA levels. A systematic review and meta-analysis identified an association between migraine and obesity, possibly mediated by gender and migraine frequency 35. Another meta-analysis highlighted that migraine risk is elevated in both individuals with obesity and in those below the normative weight 36.
Migraine, kinesiophobia, and physical activity avoidance behavior
Kinesiophobia, defined as “an exaggerated, irrational, and debilitating fear of physical movement and activity stemming from a sense of vulnerability to painful or new injuries” 37,38 has been associated with functional disability and pain intensity 39,40. Some authors have speculated that kinesiophobia affects between 51% and 72% of those with chronic pain 41–43.
Regarding prevalence, Benatto et al. (2019) reported kinesiophobia’s presence in approximately half of those with migraine, correlating with cutaneous allodynia severity. In this study, patients with migraine often believed that PA might not alleviate their pain, and those with kinesiophobia assumed exercise might be detrimental 44.
In relation to migraine symptoms, Altay and Celenay (2023) probed the association between cutaneous allodynia and kinesiophobia in patients with migraine. Their findings unveiled a correlation between the severity of cutaneous allodynia and kinesiophobia, gastrointestinal symptoms, and migraine-related disability 45.
Disability remains paramount in diagnostic and therapeutic strategies concerning migraines. Some observations have found that the presence of kinesiophobia is associated with higher levels of migraine-related disability, augmented fear of falls, and dizziness-induced impairment 46.
PA avoidance behaviors are a pronounced trait amongst those with migraine. During migraine episodes, an exacerbation of pain linked to motion and a consequential avoidance of certain movements (such as head motion and forward inclination) have been identified. Notably, these manifestations were distinctively prevalent and specific in individuals with migraine, contrasting with other headache typologies 47. Moreover, Farris et al. (2019) elucidated that anxiety sensitivity, or an apprehension regarding bodily sensations, might be correlated with deliberate PA evasion in women predisposed to migraines 48. Such insights suggest that fear-based cognition could be pivotal in shaping the exercise and movement choices of these patients.
Extending the discourse to a broader paradigm, Ruscheweyh et al. (2019) probed the association between pain avoidance and resilience in migraine contexts. Their study unveiled a positive association between social avoidance behaviors and pain-induced disability 49. Consequently, such behaviors might exacerbate the disability engendered by migraines, curtailing the overall quality of life in affected individuals.
Depression, self-efficacy, catastrophizing, and migraine-related disability
Many studies have delved into the multifaceted characteristics and elements associated with migraine, encompassing psychological facets such as pain catastrophizing, depression, and self-efficacy. Klonowski et al. (2022) highlighted that psychological factors exhibit a stronger association with the subjective degree of headache-related disability than with pain frequency 50. Emotional states undeniably play a pivotal role in these patients. Corroborating this, Kim et al. (2021) showed altered emotional responses to pain perception in patients with migraine, identifying pain-related anxiety as a significant influencer of headache-associated disability 51.
Elsewhere, D’Amico et al. (2015) postulated that the incorporation of psychosocial variables into assessment protocols could enhance our comprehension and management of headache-associated disability and quality of life in patients with migraine 52.
Recent observations indicate that even in individuals without psychiatric comorbidities, specific behavioral and psychological factors correlate with migraines, notably those categorized as chronic 53. This investigation determined that patients with chronic migraines manifest heightened tendencies toward pain catastrophizing, showcasing more pronounced cognition related to helplessness and rumination compared with episodic migraine and asymptomatic controls.
Pain catastrophizing, defined as a negative cognitive and emotional response to pain, emerges as a potent determinant in pain perception and management among those with migraine 54. Studies, including that of Mortazavi Nasiri et al. (2017), have discerned a positive correlation between pain catastrophizing and headache-related disability. Intense pain, as elucidated by their research, mediates this relationship, suggesting that maladaptive coping strategies, such as catastrophizing, might exacerbate pain experiences in these patients 55. Additionally, Bond et al. (2015) reported that one-quarter of participants with migraines and obesity exhibited clinical catastrophization, which correlated with a higher frequency of attacks and greater pain impact 56.
Conversely, the role of self-efficacy—defined as the belief in one’s ability to manage and overcome challenges—is instrumental in the context of migraines. Yousefi Afrashteh et al. (2023) found that pain self-efficacy mediated the perception of life’s meaning, social support, spiritual well-being, and pain catastrophizing with quality of life in patients with migraine 57. In essence, the belief in one’s capability to manage pain could influence how migraine is experienced and its impact on daily life.
From another perspective, Woldeamanuel et al. (2020) offered an intriguing insight by identifying distinct natural clusters in patients with chronic migraine. Patients with higher levels of self-efficacy and physical activity reported less migraine-related disability, depression, and other symptoms 58.
It is vital to note that various psychological variables can impact pain perception and headache-related perception. Self-efficacy emerges as a crucial factor to counter and mitigate the adverse effects of migraines, whereas pain catastrophization acts as a barrier that intensifies some migraine-related symptoms. It is imperative for physiotherapists to recognize the complexity and multidimensionality of migraines to be able to provide more effective active treatment strategies.
Behavioral modifications, lifestyle changes, and physical activity in migraine management
The significance of maintaining a consistent and healthy lifestyle is a recurrent theme in migraine literature. It has been highlighted that significant disruptions in daily routines, such as skipping meals or altering sleep patterns, correlate with the onset of migraine attacks 59. Prior research has evaluated regular lifestyle behaviors, including sleep, exercise, meal patterns, and hydration, and found them to independently influence migraine occurrences. Patients with chronic migraine exhibited fewer consistent lifestyle behaviors compared with those with episodic migraines 60. Along these lines, the literature accentuates the pertinence of addressing health-related behaviors in episodic migraines, given that disruptions in daily routines and fluctuations in stress, sleep, and other factors can modulate both migraine onset and severity 61.
Although pharmacotherapy plays an indispensable role in migraine treatment, various studies have underscored the significance of lifestyle interventions in managing the frequency and severity of migraines, including modifications in stress management, establishing regular sleep patterns, maintaining a balanced diet, and performing physical activity 62. In this context, maintaining consistent health behaviors is vital. Rosenberg et al. (2018) advise that because establishing and maintaining behavioral changes is challenging, they ought to be bolstered by a multidisciplinary team, and they posit that consistent daily routines could be an important tool for enhanced migraine management 61.
Among the recommended lifestyle modifications, exercise is most prominent. Barber and Pace (2020) offered a review on the role of exercise in migraine prevention, elucidating its potential biological and psychological benefits in migraine management. They highlighted how exercise can attenuate inflammatory markers and how an aerobic exercise regimen can markedly diminish migraine frequency and intensity 63. In line with this, Oliveira et al. (2017), in a randomized controlled trial, probed how aerobic exercise might correlate with changes in plasma cytokine concentrations and its association with migraine prevention. Their study found that exercise induced a decline in migraine days, anxiety levels, and plasma cytokine (interleukin-12p70) levels 64. There were significant correlations between the post-intervention levels of interleukin-12p70 levels, migraine days and anxiety scores, with the authors proposing a specific anti-inflammatory mechanism through which regular aerobic exercise could prevent migraine 64.
Addressing exercise as a preventive agent in a cohort study, Hagan et al. (2021) pinpointed how routine moderate-to-vigorous aerobic exercise (3 times weekly) might correlate with a reduction in headache frequency among adults with episodic migraines. This research suggests that exercise could be beneficial, especially for those already on prophylactic medication, emphasizing the merits of a combined approach 65.
Multimodal physiotherapy in patients with migraine, based on a biobehavioral approach
The bio-behavioral paradigm for the diagnosis and treatment of patients with pain disorders accentuates the interplay of psychological factors, including learning history, current emotional and cognitive status, beliefs, learned behaviors, and coping strategies and skills, in conjunction with physiological alterations that shape the pain experience and associated disability 66. From a therapeutic standpoint, this model equips patients with the capability to self-manage pain, thereby enhancing overall functioning 67. Given the bio-behavioral traits associated with patients with migraine, we posit this model as a prime candidate for application within the physiotherapy approach.
Physiotherapy with a bio-behavioral focus is defined as a therapeutic practice that combines evidence-based interventions with a multidimensional viewpoint, embracing both biological and psychosocial factors in patient diagnosis and treatment. This therapeutic modality is anchored within a framework that centralizes the patient within the care paradigm, fostering a holistic understanding of their needs and circumstances. Furthermore, within this approach, therapeutic procedures and decisions are navigated and recalibrated through structured clinical reasoning processes, ensuring a coherent, efficacious, and individually-tailored intervention.
A multimodal physiotherapy approach grounded in a bio-behavioral paradigm integrates treatments such as patient therapeutic education, therapeutic exercise, and orthopedic manual therapy, among others. Evidence for this approach has been documented in patients with chronic neck pain 68, chronic low back pain 69, temporomandibular disorders 70, chronic tension-type headache 71, and radial nerve injuries 72.
Our therapeutic proposition for addressing patients with migraine is rooted in this bio-behavioral paradigm. Although there is abundant evidence on the efficacy of various therapeutic exercise prescription modalities in patients with migraine, there is currently no scientific evidence on the effect of combining patient therapeutic education with exercise. Evidence has showcased the impact of therapeutic education on reducing the frequency, intensity, and disability of patients with migraine 73. Additionally, prior scientific findings delineate how educational strategies influence the outcomes of therapeutic exercise 74–76. Therapeutic patient education is defined as “a therapeutic modality that explicitly entails a dynamic communication and interaction system with the patient, grounded in a bio-behavioral paradigm, incorporating educational or formative activities that promote learning and the acquisition of adaptive skills to bolster self-management and knowledge, facilitating shifts in beliefs, attitudes, and behaviors associated with functional loss” 77.