Perceived headache responses to exercise in patients with migraine: A cross-sectional study

To characterize patient-perceived headache responses to exercise in migraine and to identify associated clinical factors using a large-scale registry.

Regular exercise is often recommended for patients with migraine; however, it can also trigger migraine attacks. This complex effect makes it challenging for both patients and clinicians to determine the appropriate role of exercise in migraine management.

We conducted a cross-sectional survey of patients with migraine who visited the headache clinic of a university hospital in Seoul, South Korea, between October 2022 and December 2024. Based on the responses to a structured questionnaire, patients were classified into four mutually exclusive groups: no-association, provocation, headache-improvement-during-exercise, and headache-worsening-without exercise. Self-reported headache responses to exercise were further analyzed according to monthly headache days (low-frequency episodic migraine [LFEM]: 0-7 days/month, high-frequency episodic migraine [HFEM]: 8-14 days/month, and chronic migraine [CM]: ≥15 days/month).

A total of 1828 patients responded to the survey. Among them, 883 (48.3%) reported no association between exercise and headache, 443 (24.2%) reported provocation, 457 (25.0%) reported headache improvement during exercise, and 45 (2.5%) reported headache worsening without exercise. The perceived likelihood of exercise-related headache provocation was greater among patients with more frequent headaches; compared with LFEM, both HFEM (adjusted odds ratio [aOR] 1.71, 95% confidence interval [CI] 1.19-2.46) and CM (aOR 2.50, 95% CI 1.88-3.31) were associated with greater odds of provocation. Younger age, higher migraine burden (HFEM, CM), the presence of allodynia (Allodynia Symptom Checklist-12 item ≥ 3), and self-reported anxiety were independently associated with exercise-related headache provocation. Headache improvement during exercise was associated with older age, CM (vs. LFEM, aOR 1.42, 95% CI 1.09-1.86), and self-reported anxiety (aOR 1.58, 95% CI 1.12-2.25).

Perceived headache responses to exercise are highly heterogeneous and vary according to migraine burden and clinical characteristics. These findings underscore the importance of individualized clinical counseling over uniform exercise recommendations in migraine management.