Lifestyle Change for Migraine Management: Practical Tips for the Neurologist and PCP, Part 2

Stephen Silberstein, MD

For Part 1 of this series, click here.

Lifestyle is crucial to migraine management. Significant research^1-10 demonstrates that engaging in certain consistent, healthy behaviors reduces migraine severity and attack frequency. In November 2020, the American Academy of Neurology updated its Headache Quality Measurement Set to reflect those findings,¹¹ with a directive that providers should now counsel migraine patients on behavior modification at each visit.

However, less well known among neurologists and primary care providers is how to counsel migraine patients on behavior modification. Not long ago, belief was that lifestyle changes for migraine revolved around negative strategies such as avoiding triggers and lowering activity levels. It has since emerged that taking a proactive, multimodal approach to positive lifestyle changes is more effective.

As headache specialists for over 30 years, we have seen that proactive lifestyle changes are a powerful complement to pharmaceutical approaches. But initiating and implementing lifestyle changes is also challenging for patients with migraine, who need education, guidance, and support. Here, we present Part 2 of our overview of the lifestyle interventions shown most helpful for migraine, as well as specific strategies to recommend to patients with both episodic and chronic migraine.

The first part of this series discussed the 3 most fundamental lifestyle changes for migraine: sleep, hydration, and nutrition. In this installment, we will address the 3 “higher order” interventions crucial for migraine management. They include the following categories:

• Exercise/Movement
• Mindfulness/Stress Management
• Psychological Health

Exercise/Movement

Research shows that moderate, aerobic exercise 3 times per week at 30 minutes per session reduces the pain, intensity, frequency, and duration of future migraine attacks.^12,13 Exercise may be as effective for migraine as the medications amitriptyline and topiramate.¹⁴

However, movement can be a frightening topic for patients with migraine. Up to 78% of people with migraine avoid exercise,^15,16 either because they feel it has triggered an attack or due to limited energy; but lack of movement actually results in worsening migraine.

Pacing and consistency are essential components for exercise with migraine. We emphasize that each person has their own exercise “FITT”: frequency, intensity, time, and type. For some, that may be the ideal of 3 30-minute aerobic sessions per week. For others, it may be a twice-weekly stretching session of 5 minutes. Truly, the best exercise routine for each patient is whatever they can sustain on a consistent basis.

Patient Counseling Tips:

• Start by anchoring a movement routine to everyday activities, such as taking a walk after dinner, doing yoga upon waking, or adding a little more movement into their everyday household chores like vacuuming.
• We advise a 10-minute rest period for every 5- to 10-minute exercise period until the patient learns to gauge their own overexertion signals.
• A patient handout on movement for migraine is available here from Ctrl M Health.

Mindfulness/Stress Management

Eighty percent of people with migraine report stress as a migraine trigger;¹⁷ stress can also make attacks worse and harder to treat. Migraine itself can be a powerful stressor: As a painful condition, it inevitably influences processes of the mind, usually in negative ways, which exacerbates pain. However, the mind can also learn to positively modulate the experience of pain to reduce suffering.

Self-awareness practices like mindfulness, meditation, relaxation, and emotion regulation help train the brain to be less reactive to stressful thoughts, feelings, and situations in ways that positively modulate the experience of pain and reduce suffering.^18-30 By strengthening vagal tone, patients can train their bodies to more flexibly shift between the stress response and the parasympathetic response as needed. It is also anti-inflammatory.

Regular meditation reduces the intensity and frequency of headache, as well as the psychological distress that inevitably comes with headache and migraine.^26,31-38 Twenty minutes per day are recommended, but even 2 minutes of mindfulness practice per day are beneficial.

Patient Counseling Tips:

• Encourage 1 minute of focused breathing.
• Ask the patient to set a timer for 1 minute, then breathe a little more slowly and deeply, paying full attention to the flow of breath.
• When thoughts appear in the mind, they should notice the thought, then turn the attention back to the breath.
• Repeat until the timer sounds.
• A patient handout on stress management for migraine is available here from Ctrl M Health.

Psychological Health

Migraine is highly comorbid with mental health disorders and the relationship is bidirectional.^{18,19,21,27,30,39,40} More than 50% of migraine patients have anxiety, depression, or both, the presence of which make migraine worse and harder to treat.^41-43 In addition, migraine is a stressful, lonely, and isolating condition. Patients require good emotional coping skills and self-awareness to manage difficult feelings and improve their quality of life. Such skills also markedly reduce headache frequency and intensity: Studies show that talk therapy can reduce headaches by 20%to 67%.⁴⁴

The psychological components that help improve migraine include:

Acceptance. The ability to accept migraine pain, and not fight or deny it, enables a patient to reduce their level of suffering. It frees them to focus their energies on the things they can control, thus emphasizing their wellness and reinforcing their identities as much more than a person with a neurological disorder.^24,45

Connectedness. Connecting to the people, work, or activities that bring joy, support, and meaning leads to neurochemical shifts that mimic medications for mood and migraine, including training the vagus nerve to initiate the relaxation response and the release of oxytocin, which is an inhibitor of calcitonin gene-related peptide (CGRP).^46-52

Self-efficacy. By building confidence in their ability to achieve specific goals, patients can overcome the learned helplessness that can result from living with migraine, which may otherwise inhibit them from making the changes necessary for their health goals.^20,53-66

Growth mindset. Decades of research have shown that a fixed pain mindset—rumination about pain, helplessness, and an expectation that pain will only get worse—is associated with higher pain intensity and disability from pain, and reduced success of multimodal treatment approaches. Developing a growth mindset by reframing unhelpful thoughts and celebrating successes can reduce suffering as a consequence of migraine, and sometimes even downregulate the pain response itself.^67-75

Patient Counseling Tips:

• Ask them to incorporate 1 form of connectedness per day, ie, engaging with friends, family, work, an interest, a hobby, a pet. Inquire about the things that would bring them a sense of satisfaction.
• A patient handout on connectedness for migraine is available here from Ctrl M Health.

Lifestyle changes are a valuable complement to medical approaches to managing migraine. The sheer number and variety of options for behavioral changes and psychological wellness assures an entry point for every patient.

However, current evidence-based, expert-reviewed programs are rare. That is a guiding reason why we at the Jefferson Headache Center and Thomas Jefferson University have partnered with Ctrl M Health, whose app-delivered program makes this information widely accessible. We have created a world-respected advisory panel to help in this important endeavor.

Spreading the word about the essential role of lifestyle change is a significant step toward helping the estimated 40 million Americans with migraine. Importantly, behavioral modifications are factors within a patient’s control, giving them tools they can use every day to help them improve.

For part 1 of the “Lifestyle Changes for Migraine” series, addressing sleep, nutrition, and hydration, click here.

The Jefferson Headache Center and Thomas Jefferson University have partnered with Ctrl M Health to create comprehensive, evidence-based programming and support for people with migraine. For free provider resources, best practice tips, and patient handouts, visit their For Providers page.

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