2023 循证临床实践指南：偏头痛治疗性运动处方

指南神经内科· 头痛与疼痛 · 2023

Authors

Keywords

Migraine disorders, Exercise therapy, Clinical practice guideline, Migraine symptoms, Disability, Quality of life

Abstract

The main objective of this clinical practice guideline is to provide a series of recommendations for healthcare and exercise professionals, such as neurologists, physical therapists, and exercise physiologists, regarding exercise prescription for patients with migraine. This guideline was developed following the methodology and procedures recommended in the Appraisal of Guidelines for Research and Evaluation (AGREE). The quality of evidence and strength of recommendations were evaluated with the Scottish Intercollegiate Guidelines Network (SIGN). A systematic literature review was performed and an established appraisal process was employed to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology).

The evaluation of the current evidence, the elaboration of the grades of recommendation, and their validation show a B grade of recommendation for aerobic exercise, moderate-continuous aerobic exercise, yoga, and exercise and lifestyle recommendations for the improvement of symptoms, disability, and quality of life in patients with migraine. Relaxation techniques, high-intensity interval training, low-intensity continuous aerobic exercise, exercise and relaxation techniques, Tai Chi, and resistance exercise obtained a C grade of recommendation for the improvement of migraine symptoms and disability.

Introduction

Migraine is the second leading cause of disability in the world after low back pain [1] . It is a neurological condition with a global prevalence of 14.4%, with the peak prevalence and years of life lived with disability occurring between ages 35 and 39 years [2] . The impact generated on the patient's various social and family dimensions induces a decline in quality of life and a high economic cost due to work absenteeism, a decrease in work efficiency, and increased healthcare costs [1, 3, 4] .

Pharmacological interventions are the most common approaches, typically consisting of the use of non-steroidal anti-inflammatory drugs and triptans for acute management [5, 6] . Prophylactic drugs, such as topiramate or valproic acid, are recommended for chronic migraine [5, 6] . Other pharmacological approaches have been developed in recent years, including the human monoclonal antibody erenumab, botulinum toxin, ditans, and gepants, with good results in the reduction of the frequency of migraine and evolution of migraine attacks [7] [8] [9] . However, the main problem with these interventions is their concomitant adverse effects, such as the increase in blood pressure with triptans use, the risk of allergic reaction with monoclonal antibodies, the transient development of blepharoptosis and muscle weakness produced by the injection of botulinum toxin, and interaction with other drugs [6] [7] [8] [9] [10] .

In addition to pharmacological treatment, behavioral change interventions are fundamental in the clinical management of migraine. These treatments include management of stress, sleep, diet, and exercise [11, 12] , of which aerobic exercise and yoga modalities are proposed as preventive alternatives for migraine [12] . Exercise prescription for migraine improvement appears to be a safe and effective intervention that could decrease migraine symptoms and disability and increase quality of life. Aerobic exercise has been the most studied modality [13, 14] .

Migraine and exercise information disseminated on social networks has increased exponentially in recent years; however, the quality of that information is questionable [15] . Several international scientific societies recommend the practice of exercise as part of the therapeutic approach to migraine. The French Headache Society includes physical exercise as part of the nonpharmacological treatment of migraine headaches [16] ; the Danish Headache Society agrees with a similar recommendation and also includes relaxation and postural exercises [17] ; and the American Headache Society recommends regular exercise as part of the biobehavioral treatment of migraine management and prevention [18] .

The recommendations of the various headache societies for treatments involving exercise for migraine have one characteristic in common: exercise is mentioned in a very general way, and the various exercise modalities that can be used for migraine treatment are not mentioned in depth. Current scientific evidence has not yet determined the adequate exercise prescription parameters for patients with migraine. Also, there are still no clinical practice guidelines on exercise prescription for migraine. Therefore, we consider it necessary to develop a guide to help clinicians who treat headaches so they can make better recommendations or provide a more specific exercise prescription.

The main objective of this clinical practice guideline is to provide a series of recommendations regarding different exercise modalities that could be effective in the treatment of migraine, and other lifestyle recommendations that could increase the efficacy of exercise interventions, for healthcare and exercise professionals, such as neurologists, physical therapists, and exercise physiologists, so as to better treat patients with migraine. For this proposal, we reviewed the current evidence that shows which exercise interventions improve migraine symptoms (intensity, frequency, and duration), disability, and quality of life. Moreover, the intention of this guideline is to provide parameters of exercise prescription for each exercise modality that could be adapted depending on the patient's characteristics (e.g. migraine frequency, physical condition, and patient's preferences). It is not a standard of medical care that determines the exercise intervention approach for migraine treatment. Patients' clinical presentation, experiences, and expectations, as well as clinicians' experiences and expertise should guide the exercise prescription based on the best recommendations of the current evidence.

Methods

# Overall design and organization

Overall design and organization

Content experts were appointed by the Institute of Neuroscience and Sciences of Movement (INCIMOV) from the La Salle University Center for Advanced Studies (CSEULS) to conduct a systematic review for the development of clinical practice guidelines regarding exercise prescription for patients with migraine. The guideline was reported in accordance with the Reporting Items for Practice Guidelines in Healthcare (RIGHT) statement [19] , and the Appraisal of Guidelines, Research and Evaluation (AGREE) checklist [20] was consulted to ensure the quality of the guideline.

Funding and support

The Professional College of Physiotherapists of the Community of Madrid provided funding and support for this clinical practice guideline. This institution did not take part in the development of the recommendations.

Guideline working group

The task force for the Evidence-Based Practice Guidelines for Exercise Prescription in Migraine Patients consisted of 3 groups: an advisory committee and panel, an expert consensus group, and a scientific evidence evaluation group. Task force members came from a wide range of disciplines, including medicine, physiotherapy, physical activity and sport sciences, and psychology. The scientific-technical knowledge and skills of the task force were related to exercise prescription, migraine diagnosis and treatment, evidence-based medicine, and research methodology.

Registration and protocol

The present clinical practice guideline was registered in the Practice guideline REgistration for trans-PAREncy (PREPARE) with the registration number PREPARE-2023CN046.

Literature search

A systematic review of the evidence regarding exercise efficacy for improving the symptoms, disability, and quality of life in patients with migraine was performed. This review was elaborated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist [21] . Moreover, this study was previously registered in PROS-PERO, an international register for systematic reviews (CRD42022316319).

Search strategy

The search strategy combined medical subject headings (MeSH) and non-MeSH terms and was applied to the following databases without language or time restrictions: MEDLINE (PubMed), Cochrane, EBSCO, Web of Science, and Google Scholar. The most important terms were "Migraine" and "Exercise, " and the last search was conducted in December 2022. Various sub-searches were developed due to the variety of exercise modalities available for the treatment of migraine. The search strategy information is available in the Supporting Information Appendix S1.

Two independent reviewers conducted the search using the same methodology. If any difference emerged during this phase, it was resolved by consensus. Moreover, original articles were manually screened, and the authors were contacted for further information if necessary.

Selection criteria and data extraction

Systematic reviews, randomized controlled trials, quasi-experimental trials, cohort and case-control designs, case series, case reports, and narrative reviews were screened and included in this review. Any form of study that evaluated the effects of exercise on the symptoms, disability, and quality of life of patients with migraine was of relevance for the development of the present clinical practice guidelines.

A specified list of inclusion and exclusion criteria was elaborated for the screening of articles based on the Population, Intervention, Comparator and Outcome (PICO) measure model [22] . The inclusion criteria for the participants in the articles included were patients with episodic or chronic migraine, diagnosed by a physician based on any of the International Classification of Headache Disorders (ICHD) editions [23] , and age 18 years or older. The intervention must be or include exercise in any modality (e.g., aerobic, yoga, resistance training), and the comparator could be any other form of evidence-based exercise intervention that has been shown to be effective for migraine, placebo, or waiting list. Finally, the outcome measures included were pain intensity; migraine attack frequency, defined mainly as days with migraine per month; and duration of migraine attacks, evaluated primarily as the number of hours per migraine attack. Disability and quality of life measures were also analyzed.

For the selection criteria and data extraction, 2 independent reviewers examined the title, abstract, and keywords of each article using the inclusion and exclusion criteria. A full-text article review was similarly conducted for the final elaboration of the set of articles included for the clinical practice guideline recommendations. If any difference emerged during this phase, it was resolved by discussion, mediated by a third reviewer [24] .

Methodological quality and risk of bias assessment

Two independent reviewers assessed the methodological quality of the studies included in the review. Systematic reviews were evaluated with the Modified Quality Assessment Scales for Systematic Reviews (AMSTAR), developed by Barton et al. [25] . The Physiotherapy Evidence Database (PEDro) scale was used for the assessment of the randomized controlled trials and the quasi-experimental trials [26] . Cohort studies were evaluated with the Newcastle-Ottawa Quality Assessment Scale (NOS) [27] . For the evaluation of the case series studies, we employed the National Institutes of Health (NIH) Study Quality Assessment Tool for Case Series Studies [28] . Finally, we assessed the methodological quality of the narrative reviews with the Scale for the Assessment of Narrative Review Articles (SANRA) [29] . We also assessed the risk of bias in the systematic reviews and randomized controlled trials. The Risk of Bias in Systematic Reviews (ROBIS) tool was used for the evaluation of the systematic reviews, and the Cochrane revised Risk of Bias 2.0 scale (RoB 2.0) was used for the evaluation of the randomized controlled trials and the quasi-experimental studies [30, 31] .

The inter-rater reliability between the 2 reviewers was evaluated with κ. This statistic shows a low level of agreement if κ < 0.5; κ of 0.5-0.7 shows a moderate level of agreement; and κ > 0.7 shows a high level of agreement [32] . If any disagreement appeared in the quality assessment score, it was resolved by consensus, mediated by a third independent reviewer.

Level of evidence and grades of recommendation

Once the methodological quality and risk of bias assessments were performed, the Scottish Intercollegiate Guidelines Network (SIGN) was used to evaluate each study's level of evidence and to determine the recommendation grade for each exercise intervention. This tool was designed for the development of evidence-based clinical guidelines, and it has a series of advantages: the methodological quality of each study determines the level of evidence; guideline developers must consider the generalizability, applicability, and consistency of each intervention; the clinical impact of the evidence creates a clear link between the evidence and the recommendation; and grades of recommendation are based on the strength of the supporting evidence, taking into account its overall level and the considered judgment of the guideline developers [33] . Table 1 shows the criteria for the levels of evidence and grades of recommendation.

For the development of each intervention summary, we introduced "improve" or "decrease" (grade A), "likely to" (grade B), "might" (grade C), or "remotely" (grade D) depending on the grade of recommendation and the sum of studies that support or negate each intervention efficacy based on the various migraine variables (symptoms, disability, and quality of life). For example, if an intervention achieved a B grade of recommendation and 3 or more studies found a positive effect on pain intensity, it "is likely to decrease pain intensity". However, if this same intervention had only 1 study that found a positive effect on quality of life, it "remotely improve quality of life".

Patient diagnosis

Subgroups of patients with migraine were established in the present clinical practice guideline to distinguish between episodic and chronic migraine. The ICHD defines chronic migraine as a headache occurring on 15 or more days per month for more than 3 months, which, on at least 8 days per month, has the features of migraine headache [23] . If the headache and migraine features are of lower frequency, it is considered an episodic migraine. This distinction is important, given that studies regarding exercise interventions on patients with migraine could include one or both diagnostics and influence the results obtained.

Exercise modalities

We provided operational definitions for the various exercise modalities and multimodal interventions of this clinical practice guideline. These operational definitions summarize the main characteristics of the various interventions.

For the general exercise recommendations, we focused on the data from the systematic reviews published, and for the specific exercise modalities recommendations we focused on the available RCTs.

Guideline review process and validation

For the evaluation and validation of the guidelines' content, a panel of experts was organized. This panel, as mentioned in the guideline working group section, consisted of 8 physical therapists, 4 of whom were also physical activity and sports professionals, a physician, and a psychologist, all with extensive clinician and research experience in the treatment of patients with migraine and exercise prescription. Operational definitions of each intervention, methodological quality, risk of bias, level of evidence, recommendation grade, prescription parameters, and intervention summary were shown to the panel of experts in a presentation during a meeting in June 2022. The experts had to validate these various intervention categories. For this validation process, the experts used a 5-point Likert scale: (1) strongly disagree, (2) somewhat disagree, (3) neither agree nor disagree, (4) somewhat agreement, (5) strongly agree. Moreover, they could add any correction or suggestion to the various categories. After some rounds of deliberation, the experts reached a consensus and determined the validity of each modality and category.

Updates

The procedure for updating the clinical practice guidelines will be structured according to the Checklist for the Reporting of Updated Guidelines [34] and by analyzing the amount and relevance of emerging evidence for exercise prescription in patients with migraine.

Results

Study selection

A total of 60 studies were included in the clinical practice guidelines. Our article search strategy and selection process are shown in the flow diagram (Fig. 1 ). The included studies were 1 umbrella review and meta-meta-analysis [35] , 6 systematic reviews and meta-analyses [13, [36] [37] [38] [39] [40] , 29 randomized controlled trials , 4 cohorts [70-73], 1 case series [74] , and 19 narrative reviews [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] . The methodological quality and risk of bias assessment for each study are shown in Tables 2, 3, 4, 5, 6, and 7, and in Figs. 2, 3 , and 4. The agreement between the evaluators in the quality assessment of the studies was high in the PEDro (κ = 0.857), RoB 2.0 (κ = 0.708), and NIH (κ = 1.000) scales, and moderate for the NOS (κ = 0.692) and SANRA scales (κ = 0.681).

Sample characteristics

A total of 2493 patients with migraine were included in the articles that compose this clinical practice guideline, 1692 in the intervention groups and 801 in the control group. From this total sample, 1699 patients presented an episodic migraine diagnosis in 28 studies [41-45, 47-54, 57-59, 61-64, 66-71, 73, 74] , and 524 had a chronic migraine diagnosis in 6 studies [44, 55, 65, 70, 72, 73] . However, 270 individuals were included in studies that did not specify the number of episodic and chronic migraine diagnoses [46, 56, 60] . The mean age range of the patients included in the studies was 29 to 51 years, and the mean body mass index range was 22.04 to 35.8 kg/m 2 . Of the total sample, 2133 were women and 360 were men.

Outcome measures

Migraine frequency was measured by attacks per month or days with migraine per month; pain intensity was evaluated with the Visual Analog Scale (VAS), the Numeric Pain Rating Scale (NPRS), the Numeric Rating Scale (NRS), or other ordinal scales (e.g., 0 = no pain; 1 = mild; 2 = moderate; 3 = severe). Pain duration was registered as average minutes per attack, the average duration of headaches in hours, hours per day, hours per month, duration of headache episodes in days or days with a migraine episode. Disability was evaluated with the Migraine Disability Assessment questionnaire (MIDAS), the Headache Impact Test-6 (HIT-6), and the Headache Disability Index (HDI), and quality of life was measured with the Migraine Specific Quality of Life Questionnaire (MSQoL), the Migraine-Specific Quality of Life Questionnaire version 2.1 (MSQv 2.1), and the Quality of Life Profile for the Chronically Ill (PLC).

Evidence statements and recommendations

Grade B of recommendation

Aerobic exercise

This modality contains general advice for aerobic exercise without a specific definition or accurate exercise prescription parameters. It obtained a B grade of recommendation based on the results of 1 umbrella review with meta-meta-analysis [35] , and 4 systematic reviews with meta-analysis [13, 36, 38, 40] (Table 8 ). Professionals should consider that prescription of aerobic exercise for patients with migraine is Table 3 PEDro scale for randomized controlled trials with the information regarding each item score and the total score for each randomized controlled trial Item 1: Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated in the order in which treatments were received); Item 2: Allocation was concealed; Item 3: The groups were similar at baseline regarding the most important prognostic indicators; Item 4: There was blinding of all subjects; There was blinding of all therapists who administered the therapy; Item 6: There was blinding of all assessors who measured at least one key outcome; Item 7: Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups; Item 8: All subjects for whom outcome measures were available received the treatment or control condition as allocated, or, where this was not the case, data for at least one key outcome were analyzed by "intention to treat"; Item 9: The results of betweengroup statistical comparisons are reported for at least one key outcome; Item 10: The study provides both point measures and measures of variability for at least one key outcome; Score: No likely to decrease pain frequency, intensity, and duration, and to improve quality of life.

Moderate-intensity continuous aerobic exercise

This modality is defined as an exercise intervention that uses large muscle groups, with increased breathing and continuously maintaining a heart rate at an intensity from 12-16 on the Borg perceived exertion scale, a 64%-76% estimated maximum heart rate (HRmax), a 40%-59% heart rate reserve (HRR), or a 40%-59% oxygen uptake reserve (VO 2 R) [95] . It reached a B grade of recommendation based on the results of 6 randomized controlled trials [41, 49, 50, 62, 63, 67] , 5 quasi-randomized controlled trials [47, 56, 61, 64, 66] , and 1 cohort study [71] (Table 8 ). A total of 564 participants were included in these studies, of whom 436 were diagnosed with episodic migraine, 103 were not clearly differentiated between episodic or chronic migraine diagnoses, and 25 were healthy controls.

Professionals should consider that moderate-intensity continuous aerobic exercise, from an 8-week onward intervention applied 3 times per week, is likely to improve headache frequency, might improve pain intensity, and remotely improves attack duration, disability and quality of life in patients with episodic migraine (Table 9 ).

Yoga

Yoga is defined as a mind-body intervention that includes 3 components: physical alignment poses (asanas), breathing techniques, and mindfulness exercises (meditations). Its intensity varies from light to vigorous and includes strength, balance, coordination, and flexibility components [96] [97] [98] .

It obtained a B grade of recommendation based on the results of 2 systematic reviews with meta-analysis [37, 39] , and 6 randomized controlled trials [45, 51, 52, 54, 58, 68] (Table 8 ). A total of 467 patients with episodic migraine were included in these studies.

Professionals should consider that yoga, including asanas, breathing and relaxation techniques, and meditation is likely to improve headache frequency and disability and remotely improves pain intensity and attack duration, from a 6-week onward intervention applied 3 times per week for episodic migraine (Table 9 ).

Exercise and lifestyle recommendations

This recommendation is defined as the conjunction of interventions directed to implement habits regarding physical activity, mealtimes, sleep, medication consumption and stress management. Some specific recommendations included here are focused to achieve regular exercise, regular sleep hours along the week, keeping consistent meal hours, adequate hydration, relaxation for stress management and avoiding excessive medication intake.

This modality achieved a B grade of recommendation based on the results of 2 randomized controlled trials [44, 55] , and 3 cohorts [70, 72, 73] (Table 8 ). A total of 954 individuals participated in these studies, divided in 490 episodic and 464 chronic migraine patients.

Professionals should consider that exercise prescription and physical activity in conjunction with other lifestyle recommendations is likely to decrease pain frequency, might improve pain intensity and attack duration, and remotely decrease the disability of both episodic and chronic migraine patients after 6 weeks of intervention with 3-5 sessions per week. Moreover, it remotely improves the function and quality of life of patients with chronic migraine (Table 9 ).

Grade C of Recommendation Relaxation techniques

These are defined as techniques commonly employed for headache treatment that include progressive muscle relaxation to help patients identify and discriminate between tense and relaxed muscle groups, autogenic training or cued relaxation, visualization and guided imagery, diaphragmatic breathing, and mini-relaxation, which focuses on a limited number of muscles in the head, neck, and shoulders [99] .

This modality reached a C grade of recommendation based on the results of 3 randomized controlled trials [59, 60, 67] (Table 8 ). A total of 311 individuals participated in these studies, of whom 126 had episodic migraine, 139 had no clear differential diagnosis between episodic or chronic migraine, and 46 were healthy controls.

Professionals should consider that relaxation techniques remotely improve headache frequency after at least 6 weeks, from 1 session per week to daily sessions, in patients with episodic migraine. It remotely improves pain intensity after 12 weeks of intervention with 3 sessions per week in patients with episodic migraine (Table 9 ).

High-intensity interval training

This modality is defined as exercise that involves alternating periods of high-intensity aerobic exercise at or below maximal oxygen uptake with light recovery exercise or no exercise between intervals [100] .

It obtained a C grade of recommendation based on the results of 3 randomized controlled trials [49, 50, 57] (Table 8 ). A total of 133 patients with episodic migraine were included in these studies.

Professionals should consider that high-intensity aerobic interval training might improve the frequency of pain and remotely improve the intensity of pain, attack duration, and disability after 8 weeks of intervention with 3 sessions per week in patients with episodic migraine (Table 9 ).

Low-intensity continuous aerobic exercise

The definition of this modality is any activity that uses large muscle groups, increases breathing and heart rate, and can be maintained continuously and rhythmically, using aerobic metabolism to extract energy, at an intensity from 8-11 on the Borg perceived exertion scale, 50%-63% HRmax, 20%-39% HRR, or 20%-39% VO 2 R [95] .

This modality achieved a C grade of recommendation based on the results of 1 randomized controlled trial [65] , and 1 quasi-randomized trial [53] (Table 8 ). A total of 40 episodic and 60 chronic migraine patients participated in these studies.

Professionals should consider that low-intensity aerobic exercise remotely improves headache frequency, pain intensity, and total duration per month of migraine after 6 weeks of intervention with 3 sessions per week in patients with episodic migraine (Table 9 ).

Exercise and relaxation techniques

This modality consists of the combination of exercise and relaxation techniques, previously defined.

This combination of techniques reached a C grade of recommendation based on the results of 2 randomized controlled trials [48, 58] , and 1 quasi-randomized trial [46] (Table 8 ). A total of 119 patients with migraine were included in these studies, of whom 91 were patients with episodic migraine and 28 had no clear differential diagnosis between episodic or chronic migraine. Positive effect (n = 1)

Intervention

Migraine diagnosis

Effect

Grade of recommendation

Studies

Outcomes

Matin 2022 [57] Table 9 (continued)

Low

Resistance exercise

Episodic migraine

Resistance exercise remotely improves pain frequency, intensity, and quality of life of patients with episodic migraine after 8 weeks of intervention with at least 3 sessions per week C in favor of intervention N = 1 RCT: Aslani 2021 [42] Frequency, intensity, and disability (n = 1):

Aslani [42] Positive effect in all outcomes (n = 1): Aslani [42] Qi-Gong

Qi-Gong remotely improves pain frequency and disability of patients with episodic migraine after 3 months of intervention with daily sessions. It might not improve pain intensity of patients with episodic migraine D in favor of intervention N = 1

Case series: Elinoff 2019 [74] Frequency and disability

(n = 1): Elinoff 2009 [74]

Positive effects (n = 1):

Elinoff 2009 [74] Pain intensity (n = 1):

Elinoff 2019 [74] Without effect (n = 1):

Elinoff 2019 [74] RCT Randomized controlled trial, q-RCT Quasi-randomized controlled trial Professionals should consider that exercise and relaxation techniques might improve pain intensity and remotely improve the frequency and disability of episodic and chronic migraine patients after 6 weeks of intervention with at least 2 days per week of sessions (Table 9 ).

Neck strength exercise

This exercise modality consists of motor control and resistance exercise directed to the deep and superficial muscles of the neck and craniocervical regions with the aim of gaining strength.

This modality achieved a C grade of recommendation against this intervention based on the results of 1 randomized controlled trial [43] (Table 8 ). This study included a total of 42 patients with episodic migraine.

Professionals should consider that neck resistance exercise might not improve migraine frequency, pain intensity, or disability of patients with episodic migraine after 8 weeks of intervention with at least 1 supervised session per week and daily home exercises performed twice a day (Table 9 ).

Tai chi

Tai Chi is considered a balance training program that contains slow movements that stress postural control, can be performed in groups and requires the person to move body parts gently and slowly while breathing deeply [101] .

This modality obtained a C grade of recommendation based on the results of 1 randomized controlled trial [69] , and 1 narrative review [92] (Table 8 ). The randomized controlled trial included a total of 73 patients with episodic migraine.

Professionals should consider that Tai Chi remotely improves migraine frequency in episodic migraine patients after 12 weeks of intervention with 5 sessions per week. It might not improve pain intensity or attack duration (Table 9 ).

Resistance exercise is defined as an exercise modality that provokes an improvement in functional performance by increasing muscular strength, power, speed, hypertrophy, local muscular resistance, motor performance, balance, and coordination [102] .

It obtained a C grade of recommendation based on the results of 1 randomized controlled trial [42] (Table 8 ). A total of 20 patients with episodic migraine participated in this study.

Professionals should consider that resistance exercise remotely improves pain frequency and intensity and disability of patients with episodic migraine after 8 weeks of intervention with at least 3 sessions per week (Table 9 ).

Grade D of recommendation

Qi-Gong

Qi-Gong is a series of exercises that incorporates elements of slow, gentle movement, and awareness and regulation of breathing, as well as the intentional direction of thoughts, attention, imagery, and sensation [103] .

This modality achieved a D grade of recommendation based on the results of a case series study [74] (Table 8 ). Only 6 patients with episodic migraine were analyzed in this study.

Professionals should consider that Qi-Gong remotely improves pain frequency and disability of patients with episodic migraine after 3 months of intervention with daily sessions. It might not improve the pain intensity of patients with episodic migraine (Table 9 ).

Prescription exercise parameters

The prescription parameters used in each study are included in Table 10 . The summary of the prescription parameters recommended for prescribing each exercise modality in patients with migraine is shown in Table 11 .

Limitations and future directions

The purpose of this clinical practice guideline is to describe in depth the scientific evidence on exercise prescription for patients with migraine in order to facilitate decision making by physical therapists and other health and exercise professionals. Analysis of the information incorporated herein shows that in the last decade there has been an increase in the number of studies on the effectiveness of exercise in patients with migraine. Most of the research we included presented positive effects; however, there are several limitations in these studies that should be considered when interpreting the results and considering the future direction of studies in this area.

One of the most important limitations of the analyzed and included evidence is related to the comparisons used in the studies: the control groups employed a wide variety of interventions, including waiting lists, placebo, and pharmacological treatments. This limitation is fundamentally derived from ethical requirements, given that pharmacotherapy is established as the first line of treatment, and this situation substantially complicates determining the real magnitude of the effect of the various exercise modalities on migraine.

In relation to the above, it should also be considered that it is not possible to establish a real placebo comparison for treatments in which behavior modification is promoted, as in the case of exercise.

Another limitation is that most of the studies based on exercise and migraine evaluated immediate response, in short and intermediate terms, and only a few studies measured long-term effects. We believe that it is necessary to design studies that assess long-term effects to identify whether the effect is dependent on the duration of the exercise intervention or whether the effect is maintained for a long time after the intervention. At least a one year follow up would be recommended [24] . It would also be necessary to perform analyses that identify the level of adherence to the interventions related to exercise. When using exercise with migraine patients the question arises as to whether it is appropriate to exercise with very intense pain. There is no evidence about the effects of the exercise while the patient is under severe pain, however we consider we must be cautious when prescribing exercise. If the patient has very intense pain, very frequently and/or the exercise is a clear trigger factor, the most appropriate recommendation would be to prescribe a gradual and individualized exposure to exercise.

There remain some unknowns about the effect of exercise on the patient with migraine that need to be addressed in future research. Studies do not currently compare which exercise modality is most effective in reducing the frequency, duration, and intensity of migraine pain, and it would be interesting to identify whether integrating various exercise modalities (e.g., aerobic exercise and strength training) is more effective than using each modality individually.

The evidence currently available does not clarify whether the improvement of physical variables through exercise has an impact on the frequency, duration, and intensity of migraine. It would be necessary to perform studies that introduce as covariates the level of physical activity, strength, or the improvement of range of motion or cardiovascular capacity and determine whether these variables are associated with the improvement of clinical variables.

Finally, we consider it opportune that subsequent studies take into account the psychological status of the patients to better select the most appropriate exercise modality, due to the growing number of studies that point out the impact that kinesiophobia has on patients with migraine [94, 104, 105] . Considering this factor, prescribing an exercise modality, such as gradual exposure to exercise, may be the most appropriate selection for this patient profile.

Conclusions

This clinical practice guideline has followed a rigorous process of quality assessment of the scientific evidence related to the effectiveness of exercise on migraine. Our analysis indicates that aerobic exercise, moderate intensity aerobic exercise, yoga, and lifestyle recommendations that include exercise present a grade B of recommendation for reducing the frequency, duration, and intensity of pain and improving the quality of life in patients with migraine.

The exercise modalities that are effective and have a grade C of recommendation are relaxation techniques, interval training at high intensity, continuous low-intensity aerobic exercise, Tai Chi, and resistance training (strength training). Finally, grade D of recommendation was given to Qi-Gong.

ing). Finally, grade D of recommendation was given to Qi-Gong.

|Levels of evidence| |---|

|Item 1: Explicitly described to allow replication (ie, 100% confident that you could replicate it). If explained but you can't be 100% confident of replication = in part; Item 2: Adequate number and range of databases (3 = in|part, > 3 = yes); Item 3: Alternative searches such as manual searches, Web of Science, reference lists, contact of prominent authors or other sources of information (1 of these = in part, 2 or more = yes); Item 4: Adequate|range of keywords (search likely to be sensitive); Item 5: Non-English language papers included in the search. Must explicitly state that no language restrictions were applied, or something of similar meaning to score|yes; Item 6: Explicitly described to allow replication (unambiguous). If described but not 100% clear = in part; Item 7: Excludes reviews that do not adequately address inclusion and exclusion criteria. One of inclusion or|exclusion = in part, both = yes;Item 8: Two independent reviewers; Item 9: Explicitly described to allow replication. If the described scale is not valid, and/or reliability is not reported, score = in part; Item 10: Meta-analysis|conducted on only homogenous data or limitations to homogeneity discussed; Item 11: Confidence intervals/effect sizes reported where possible; Item 12: Supported by the meta-analysis or other data analysis findings|(effect sizes, confidence intervals, etc.) in the review. If only significance levels relied upon = in part; Item 13: Conclusions address levels of evidence for each intervention/comparison (eg, level A-D evidence, strong-weak|evidence, etc.). Score: No = 0; In part = 1; Yes = 2. Score < 20 = low quality; Score ≥ 20 = high quality| |---|---|---|---|---|---|---|---|

|Yes| |---|

|In Part|

|Yes|

|Explicitly described to allow replication|

|Yes|Yes|No|No| |---|---|---|---|

|Yes|Yes|Yes|Yes|

|Yes|Yes|Yes|In Part|

|Yes|No|No|Yes|

|In Part|Yes|Yes|In Part|

|Yes|In Part|| |---|---|---|

|Yes|Yes||

|In Part|No||

|Explicitly described to allow replication|Excludes reviews that do not adequately address|inclusion and exclusion criteria|

|No| |---|

|Two independent reviewers|

|Yes||Yes|| |---|---|---|---|

|Yes||Yes||

|In Part||Yes||

|No||No||

|= 76-100%| |---|

|= 51-75%; Excellent|

|= 26-50%; Good|

|= 0-25%; Fair|

|= 1. Poor|

|= 0; Yes|

|Scores: No|

|8 (Excellent)|| |---|---|

|1||

|0||

|Elinoff et al.,|2019 [74]|

|Score: No = 0; In part = 1; Yes = 2. There are no established cut-offs for different grades of quality| |---|

no established cut-offs for different grades of quality| |---|

|Agbetoy et al., 2022 [93] 0|0|1|2|0|0|| |---|---|---|---|---|---|---|

|Ahn et al., 2013 [75]|0|1|0|2|1|1|

|Amin et al., 2018 [76]|2|2|1|2|2|2|

|Barber et al., 2020 [77]|2|2|0|2|2|2|

|Becker et al., 2009 [78]|0|0|0|0|2|1|

|Busch V, Gaul C, Head-|1|2|1|2|2|2|

|ache, 2008 [80]|||||||

|Busch V, Gaul C,|2|2|2|2|2|2|

|Schmerz, 2008 [79]|||||||

|Daenen et al., 2015 [81] 1|2|0|2|1|0||

|Hindiyeh et al., 2013|1|1|0|1|1|1|

|[82]|||||||

|Irby et al., 2016 [83]|2|1|0|2|2|1|

|Lippi et al., 2018 [84]|2|2|1|1|0|2|

|Mauskop et al., 2012|1|1|0|2|1|1|

|[85]|||||||

|Meyer et al., 2018 [86]|1|1|0|2|2|2|

|Guarín-Duque et al.,|1|2|1|2|1|0|

|2021 [87]|||||||

|Patel et al., 2019 [88]|2|2|0|2|2|1|

|Robblee et al., 2019 [89] 1|2|0|2|2|1||

|Song et al., 2021 [90]|1|2|1|2|2|2|

|Tepper et al., 2015 [91] 1|2|0|1|2|2||

|Wells et al., 2019 [92]|0|2|1|2|2|2|

|= low risk;|= high risk; = unclear risk| |---|---|

|La Touche et al., 2020 [40]| |---|

|Lemmens et al., 2019 [36]|

|Long et al., 2022 [37]|

|Luedtke et al., 2016 [38]|

|Varangot-Reille et al., 2021 [13]|

|Wu et al., 2022 [39]|

|Adverse effects|||No adverse effects were|reported||||||||No adverse effects were|reported|||||||||No adverse effects were|reported|||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence||1-|||||||||1-||||||||||1-|||||||||||||

|Results Between|Group||||||||||||||||||||||||||||||||||

|Results Within Group|||There is moderate|evidence that aerobic|exercise reduces pain|intensity in migraine|patients. The applied|interventions showed a|positive effect in terms|of pain intensity, quality|of life and frequency|It was found statistically|significant differences|in the decrease in pain|intensity, frequency and|duration of migraine in|the short term, and an|increase in quality of life.|Aerobic exercise has low|to moderate evidence in|migraine patients|Significant reductions in|the number of migraine|days after aerobic|exercise treatment were|found, and small to|moderate reductions in|attack duration and pain|intensity after aerobic|exercise intervention|||||

|Key Outcomes and|Follow-up||Frequency (days/month|or days/week)|Pain intensity (VAS,|NPRS, numeric pain|index, MVK pain scale)|Disability (HDI)|Quality of life (HIT-6,|SF-36, SF-12)||Frequency (days/month|or days/week)|Pain intensity (VAS)|Duration (hours of|migraine)|Quality of life (HIT-6, PLC,|WHO-5, MSQoL, grading|the severity of chronic|pain)||Frequency (days/month)|Pain intensity (NPRS,|VAS)|Duration (hours/attack|and hours/month)|||||||||

|Study Design and Diagnosis Intervention|AEROBIC EXERCISE|GRADE OF RECOMMENDATION: B in favour of intervention|Herranz-Gómez MMA, umbrella and Experimental group:|et al., 2021 [35] mapping review Aerobic exercise, manual|ICHD therapy and manual|therapy with therapeutic|exercise|Control group:|Any type of intervention|it was possible to isolate||La Touche et al.,2020 SR of RCTs and q-RCTs Experimental group:|[40] MA of RCTs aerobic exercise|Migraine with or without Control group: Other|aura diagnosed with forms of exercise, mini-|ICHD mal education, informa-|tion, maintenance of|daily living activity or|drugs|||Lemmens et al., SR of RCTs and q-RCT s Experimental group:|2019 [36] MA of RCTs and Q-RCT s Physical endurance,|Migraine diagnosed with physical fitness, aerobic|the ICHD-II exercise and exercise|therapy performed dur-|ing at least 6 weeks|Control group: no|intervention, education,|treatment based on|medication, relaxation|therapy and advice to|maintain habitual daily|activity|

|No adverse effects were|reported|||||||||The study of Lemstra|et al. 2002 reported minor|musculoskeletal pain in|20% of patients in the|intervention group, which|include exercise as part of|the therapy|||No adverse effects were|reported||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|1-||||||||||1-|||||||||4||||||||||||

||||||||||||||||||||-||||||||||||

|Aerobic exercise results|suggest a statistically|significant reduction in|the intensity, frequency|and duration of migraine||||||Aerobic training has|a small to moderate|clinical effect on pain|intensity and frequency|of headache episodes in|migraine patients, with|very low to low certainty|of evidence||There are several lines|of evidence supporting|the role of exercise in|migraine management.|Though individually|these studies have some|limitations, they are still|altogether compelling|because this view still|emerges clearly from|several independent|lines of investigation|

|Frequency (number of|episodes or number of|headache days|within a defined period|of time)|Pain intensity (VAS)|Duration (hours or|days without relief )|||Frequency (painful days/|month)|Pain intensity (VAS, NRS)|Duration (hours)|Disability (HDI, HIT-6,|HIT, PDI)|Quality of life (SF-36)|||||||||||||||

|Experimental group:|standard physiotherapy|(exercise, manual|therapy, soft-tissue tech-|niques, or strength and|endurance training)|Control group: placebo,|standard care, waiting|list or other active inter-|vention|Experimental group:|exercise training (aerobic|training, strength train-|ing, yoga or aerobic and|strength training)|Control group: non-|active interventions,|education, relaxation,|breathing or no inter-|ventions||||||||||||

|SR of RCTs and q-RCT s|[38] MA of RCTs|Migraine diagnosed with|IHS criteria|||||||Varangot et al., 2021 SR and MA of RCTs|[13] ICHD and medical|diagnosis|||||||Ahn et al., 2013 [75] Narrative review||||||||||||

|Adverse effects||Exercise can minimally|trigger migraine||||||||||||Exercise may induce|migraine|||||||||||||||It should not be forgotten|that exercise can induce|sport-related headaches||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|4|||||||||||||4||||||||||||||||4|||||||||

|Results Between|Group|-|||||||||||||-||||||||||||||||-|||||||||

|Results Within Group||It seems that although|exercise can trigger|migraine attacks, regular|exercise may have a|prophylactic effect on|migraine frequency.|This is most likely due|to an altered migraine-|triggering threshold in|people who exercise|regularly. Frequency and|intensity of exercise that|is required is unclear|An aerobic exercise|routine alone is|sufficient to reduce|migraine frequency,|intensity, and duration.|Higher-intensity training|appears to confer more|benefits. The addition of|exercise to a traditional|preventive regimen may|provide added benefits.|Patients who cannot|tolerate high-impact|exercise may even|benefit from low-impact|exercises like yoga|Most of the reviewed|studies did not find a|significant reduction|of headache attacks or|headache duration and|only indicate a reduc-|tion of pain intensity in|migraine patients due to|regular exercise|

|Key Outcomes and|Follow-up|-|||||||||||||-||||||||||||||||-|||||||||

|Study Design and Diagnosis Intervention||Amin et al., 2018 [76] Narrative review -|-||||||||||||Barber et al., 2020 Narrative review -|[77]|||||||||||||||Busch V, Gaul C, Narrative review -|Headache, 2008 [80] -||||||||

|Adverse effects||No adverse effects were|reported||||||||Exercise could be a|migraine-triggering factor|||Some authors show that|exercise, especially if it is at|high intensity, can trigger|a migraine attack||22% of migraineurs list|exercise as a trigger|||||||||||||Physical activity may not|play an important role in|triggering or exacerbating|migraine||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|4|||||||||4||||4|||||4||||||||||||||4||||||||

|Results Between|Group|-|||||||||-||||-|||||-||||||||||||||-||||||||

|Results Within Group||Regular endurance|sports are found in many|general recommenda-|tions for the treatment|of migraine patients.|However, the evidence|on which these recom-|mendations are based|is weak|Aerobic exercise on a|submaximal level is the|best option in migraine|prophylaxis|Adults who don't toler-|ate migraine drugs very|well may find relief in|preventive therapies|such as exercise|There are demonstrable|differences in the way|migraineurs respond to|aerobic exercise during|their headaches and|there is more than a|suggestion that|migraineurs do, in fact,|process the changes|brought on by aerobic|activity differently than|non-migraineurs or|migraineurs when they|are inter-ictal|Regular aerobic exercise|routine is recommended|as a means of manag-|ing and preventing|migraine. Anyway, the|optimal parameters of|exercise regimens for|migraine are still unclear|

|Key Outcomes and|Follow-up|-|||||||||-||||-|||||-||||||||||||||-||||||||

|Study Design and Diagnosis Intervention||Busch V, Gaul C, Narrative review -|Schmerz, 2008 [79] -||||||||Daenen et al., 2015 Narrative review -|[81] -|||Guarín-Duque et al., Narrative review -|2021 [87] -||||Hindiyeh et al., 2013 Narrative review -|[82] -|||||||||||||Irby et al., 2016 [83] Narrative review -|-|||||||

|Adverse effects||Since exercising may|sometimes worsen|migraine, being engaged|in physical exercise during|a migraine attack must|be established on an|individual basis, according|to the personal history|of exercise-provoked|migraine|||No adverse effects were|reported||||No adverse effects were|reported|||||||No adverse effects were|reported|||||||Exercise can trigger a|migraine attack. Pain|aggravation by routine|physical activity has been|reported by approximately|2/3 of individuals with|migraine. High-intensity|exercise and an insuffi-|cient warm-up period can|trigger a migraine attack| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|4||||||||||||4|||||4||||||||4||||||||4||||||||||

|Results Between|Group|-||||||||||||-|||||-||||||||-||||||||-||||||||||

|Results Within Group||High-intensity exercise|should be avoided in|patients with a history|of exercise-provoked|migraine|Regular moderate|aerobic physical exercise|( > 40 min, 3 times per|week) seems effective|to reduce both the|severity and frequency|of migraine attacks|Aerobic exercise is|proven to be effective|in the prevention of|migraine|headaches|The overall data are|still insufficient to|recommend aerobic|exercise as a single|therapy for migraine|prevention because of|methodological limita-|tions|The best current|recommendation for|patients with migraine|is to engage in graded|moderate cardiorespira-|tory exercise, although|any exercise is better|than none|Regarding efficacy,|side effects, and health|benefits, aerobic|exercise promises to be|a good strategy in the|preventive treatment of|migraine||||

|Key Outcomes and|Follow-up|-||||||||||||-|||||-||||||||-||||||||-||||||||||

|Study Design and Diagnosis Intervention||Lippi et al., 2018 [84] Narrative review -|-|||||||||||Mauskop et al., 2012 Narrative review -|[85] -||||Patel et al., 2019 [88] Narrative review -|-|||||||Robblee et al., 2019 Narrative review|[89] -|||||||Song et al., 2021 [90] Narrative review -|-|||||||||

|Adverse effects||No adverse effects were|reported||||Physical exertion can|trigger migraines in some|patients||||||No adverse effects were|reported|||||No adverse effects were|reported||||No adverse effects were|reported||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Results Between Level of|Group Evidence|-4|||||-4||||||||No significant difference 1-|between groups in any|outcome||||Analysis not performed 1-|||||Favours significantly 1-|migraine exercise over|migraine waitlist in days|with migraine|No significant change in|pain intensity|||

|Results Within Group||Aerobic exercise com-|bined with behavioural|therapy may be useful|as a complementary|migraine management|Aerobic exercise reduces|migraine frequency, pain|intensity, duration of|migraine, and migraine|disability. Also, yoga and|tai-chi may be beneficial|for migraine patients||Significant improvement|in all outcomes in the|experimental group. No|significant change in any|variable in the control|group|Significant improvement|in the experimental|group. No significant|change in the control|group|Migraine exercise:|Significant improvement|in attacks/month, days/|month. No significant|change in pain intensity|Migraine waitlist: No|significant change in any|outcome|

|Key Outcomes and|Follow-up|-|||||-||||||||Frequency (attacks/|month)|Pain intensity (VAS)|Duration (average min-|utes/attack)|Post-immediate|Frequency (days with|migraine /month)||||Frequency (attacks/|month and days with|migraine /month)|Pain intensity (0 = no pain; 1 = mild; 2 = mod-erate; 3 = severe) Post-immediate|||||

|Study Design and Diagnosis Intervention||Tepper et al., 2015 Narrative review -|[91] -||||Wells et al., 2019 [92] Narrative review Aerobic exercise||||||MODERATE-INTENSITY CONTINUOUS AEROBIC EXERCISE|GRADE OF RECOMMENDATION: B in favour of intervention|Ahmadi et al., 2015 RCT Experimental group:|[41] ICHD-II Aerobic exercise (n = 15) Episodic migraine Control group: Were|told not to exercise|(n = 14)|Oliveira et al., 2017 RCT Experimental Group:|[62] ICHD II Aerobic exercise (n = 10) Episodic migraine Control Group: Waiting|list (n = 10)|Oliveira et al., 2019 [63] RCT Migraine aerobic exer-|Migraine ICHD-II cise group (n = 13) Episodic migraine Migraine waitlist group|(n = 12) Control aerobic exer-|cise group (n = 12) Control waiting list|group (n = 13)||||||||

|Adverse effects||No adverse effects were|reported||||||||||No adverse effects were|reported||||||No adverse effects were|reported|||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|1-|||||||||||1-|||||||1-|||||||||||||||||

|Results Between|Group|Significant difference|that favours HIIT versus|MCT|No significant difference|between HIIT-Control|and MCT-Control||||||Significant difference|that favours HIIT versus|MCT|No significant difference|between HIIT-Control|and MCT-Control||Post during the treat-|ment period:|Significant difference|between groups in pain|intensity favours the|topiramate group|No significant difference|between groups in|attacks/month, days|with migraine/month|Post during the last|month of treatment:|No significant difference|between groups in any|outcome|||

|Results Within Group||No significant improve-|ment in any group||||||||||No significant improve-|ment in any group||||||Post during the treat-|ment period:|Significant reduction|in attacks/month in all|groups|No significant changes|in other outcomes in|any group||Post during the last|month of treatment:|Significant reduction|in attacks/month in all|groups|No significant change in|other outcomes in any|group|

|Key Outcomes and|Follow-up|Frequency (days/month)|Post-immediate||||||||||Frequency (days/month)|Post-immediate||||||Frequency (attacks/|month and days with|migraine / month)|Pain intensity (VAS)|Quality of life (MSQoL)|Post during treatment|period|Post during last month|of treatment|Post 3 months|Post 6 months|||||||

|Design and Diagnosis Intervention||RCT Experimental group:|ICHD III-B HIIT group (n = 16) Episodic migraine Experimental group:|MCT group (n = 16) Control Group:|Maintain habitual daily|physical activity profile|and received additional|standard physical activ-|ity recommendations|(n = 16)|RCT Experimental group 1:|Episodic migraine with-HIIT group (n = 15) out aura ICHD-IIIb Experimental group 2:|MCT group (n = 15) Control Group: main-|tain habitual physical|activity profile (n = 15)|RCT Group 1: Relaxation|ICHD-II group. (n = 30) Episodic migraine Group 2: Aerobic exer-|cise group. (n = 30) Group 3: Topiramate|group|(n = 31)|||||||||||||||||

|Study||Hanssen et al., 2017|[50]||||||||||Hanssen et al., 2018|[49]||||||Varkey et al., 2011|[67]||||||||||||||||

|Adverse effects||||||||||||||||1 person was excluded|because of pain during|exercise and 4 persons|because of a lack of|motivation to perform the|training||||2 patients discontin-|ued the aerobic group|because they reported|an increase in headache|intensity|||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|||||||||||||||1-|||||||||1-||||||||||||||

|Results Between|Group|Post 3 months:|No significant difference|between groups in any|outcome||||Post 6 months:|No significant difference|between groups in any|outcome||||Significant interac-|tion between exercise|group and frequency|and an interaction|effect between exercise|group and intensity of|migraine attacks|No significant difference|in duration|Post-immediate:|No significant differ-|ences in any outcome|measure|||Post 4 weeks:|No significant differ-|ences in any outcome|measure|Post 3 months:|No significant differ-|ences in any outcome|measure|

|Results Within Group||Post 3 months:|Significant reduction|in attacks/month in all|groups|No significant change in|other outcomes in any|group|Post 6 months:|Significant reduction|in attacks/month in all|groups|No significant change in|other outcomes in any|group|Significant improvement|in all outcomes in the|experimental group in|post-immediate. No|significant change in|any outcome in the|control group in post-|immediate||Post-immediate:|No significant change in|any outcome measure||||Post 4 weeks:|No significant change in|any outcome measure|Post 3 months:|No significant change in|any outcome measure|||

|Key Outcomes and|Follow-up|||||||||||||||Frequency (days with|migraine /month)|Pain intensity (NPRS)|Duration (h/month)|Post-immediate|Follow-up 8 weeks||||Frequency (days/month)|Disability (MIDAS)|||||||||||||

|Design and Diagnosis Intervention||||||||||||||||Q-RCT Experimental group:|IHS Aerobic exercise (n = 8) Episodic migraine with Control group: No|or without aura exercise (n = 8)|||||Q-RCT Group 1: Standard|ICHD-III physiotherapy (manual|Chronic or frequent therapy mobilization,|episodic migraine myofascial treatment,|exercise and education)|(n = 79) Group 2: Aerobic exer-|cise (n = 24)||||||||||

|Study||||||||||||||||Darabaneanu et al.,|2011 [47]||||||||Luedtke et al., 2020|[56]|||||||||||||

|Adverse effects||No adverse effects were|reported||||No adverse effects were|reported|||One patient reported a|migraine attack immedi-|ately after training|3 dropouts because of|noncompliance with the|treatment, and 3 dropouts|because of lack of time|No adverse effects were|reported||||||||||No adverse effects were|reported|||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|1-|||||1-||||1-|||||||2 +||||||||||1-||||||

|Results Between|Group|Significant differences|in pain relief favour the|experimental group|||-||||-|||||||-|||||||||||Compared with the con-|trol group, yoga therapy|could decrease pain|intensity, frequency,|duration and disability|

|Results Within Group||Significant improve-|ments in both groups in|frequency and disability|||Significant improve-|ments in all outcomes in|favour of intervention||Significant improve-|ments in all outcomes in|favour of intervention|||||Moderate-vigorous exer-|cise at least three times|per week had fewer|headache frequency,|though not statistically|significant. This asso-|ciation was significantly|stronger in those who|used prophylactic medi-|cation for migraines||-|||||

|Study Design and Diagnosis Intervention Key Outcomes and|Follow-up|Narin et al., 2003 [61] Q-RCT Experimental group: Pain frequency (attack/|Episodic migraine with-Moderate aerobic month)|out aura. IHS training and medical Pain intensity (VAS)|treatment. (n = 20) Control group: Medical Duration (hours) Disability (PDI)|treatment (n = 20) Post-immediate|Overath et al., 2014 Q-RCT IHS Exercise cohort (n = 28) [64] Episodic migraine with Frequency (attacks/ month)|or without aura Frequency (days/month)|Post-immediate|Varkey et al., 2009 Q-RCT Aerobic exercise (n = 26) Frequency of days (days/ [66] ICHD-II month)|Episodic migraine with Frequency of attacks|or without aura (attacks/month)|Intensity (VAS)|Quality of life (MSQol)|Post-immediate|Hagan et al., 2021 Cohort Episodic Exercise cohort (n = 98) [71] migraine. ICHD-III Headache frequency (headache/month)|Intensity (VAS)|Duration (hours)|Post-immediate|||||YOGA|GRADE OF RECOMMENDATION: B in favour of intervention|Long et al., 2022 [37] SR of MA of RCT Experimental group: Frequency (Attacks/|ICHD-IIIb Yoga month)|Control group: Pain intensity (10-point|Standard treatment scale)|Duration (hours)|Disability (MIDAS and|HIT-6)||

|Adverse effects||No adverse effects were|reported||||||||No adverse effects were|reported related to yoga|||||||No adverse effects were|reported||||||||No adverse effects were|reported|||1 patient reported weight|gain in the intervention|group, due to medication|||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|1-|||||||||1-||||||||1-|||||||||1-||||1-||||||||

|Results Between|Group|Compared with the|control group, yoga|therapy was associ-|ated with substantially|reduced headache|frequency and HIT-6|score, but revealed no|obvious influence on|pain intensity|Significant improve-|ments in intensity,|frequency and disability|favour the experimental|group. No significant dif-|ferences in duration|||Significant improve-|ments in frequency,|intensity and duration of|pain favours the experi-|mental group|||||Significant improve-|ments in all outcomes|favour the experimental|group in post-immedi-|ate follow-up|Significant improve-|ments in all outcomes|favour experimental|group in post-immedi-|ate follow-up|||

|Results Within Group||-|||||||||Experimental group:|Significant improve-|ments in frequency,|intensity and disability,|but not in duration|Control group:|No significant improve-|ments|Experimental group:|Significant improve-|ments in frequency,|intensity, and duration|of attack|Control group: Signifi-|cant increase of symp-|toms in all outcomes|except duration|Significant improve-|ments in all outcomes in|both groups||Significant improvement|in all outcomes in both|groups||||||

|Key Outcomes and|Follow-up|Frequency (headaches|days/month, head-|aches/week)|Intensity (VAS or NRS)|Duration (hours)|Disability (HIT-6 and|MIDAS)|||Frequency (Headaches/|month)|Intensity (VAS)|Duration (days)|Disability (HIT-6)|Post-immediate|||Frequency (headache|days/week)|Intensity (NRS and VAS)|Duration (hours)|Post-immediate|||||Frequency (Number of|headaches/month)|Intensity (VAS)|Disability (HIT-6)|Post-immediate|Frequency (headaches|days/month)|Intensity (VAS)|Disability (HIT-6 and|MIDAS)|Post-immediate|(3 months)|

|Study Design and Diagnosis Intervention||Wu et al., 2022 [39] SR and MA of RCT Experimental group:|ICHD III Yoga therapy|Control group: Stand-|ard medical treatment|and self-care|||||Boroujeni et al., RCT Experimental Group:|2015 [45] Episodic migraine IHS Yoga and pharmacologi-|cal intervention (n = 18) Control group: Pharma-|cological intervention|(n = 14)||John et al., 2007 [51] RCT Experimental group:|Episodic migraine with-yoga (n = 36) out aura. IHS 2004 Control group: self-care|(n = 36)|||||Kisan et al., 2014 [52] RCT Experimental group:|Episodic migraine Yoga and conventional|ICHD-II care (n = 30) Control group: Conven-|tional care (n = 30)|Kumar et al., 2020 RCT Experimental group:|[54] Episodic migraine ICHD-Yoga and medical|III-beta therapy (n = 80) Control group: Medical|therapy (n = 80)|||||||||

|Adverse effects||No adverse effects were|reported|||||||||||No adverse effects were|reported due to the|intervention|||||||||||||Exercise may induce|migraine||||||||Physical exertion can|trigger migraines in some|patients||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|1-||||||||||||1-|||||||||||||||4|||||||||4|||||||

|Results Between|Group|Frequency reduced|significantly in group 1,|compared to yoga and|standard treatment. No|significant differences|in other outcomes were|observed||||||Significant differences|favour the experimental|group in disability and|quality of life at 4, 16|and 28 weeks post-|treatment||||||||||-|||||||||-|||||||

|Results Within Group||Frequency:|Significant reduction in|all groups at 1 month,|2 month and 3 months|Intensity:|Significant reduction in|all groups at 1 month,|2 month and 3 months|Disability:|Significant reduction|in all groups at 2 and|3 months|At 4 weeks post-|treatment, both groups|showed a reduction in|frequency|At 4, 16 and 28 weeks|post-treatment a reduc-|tion in disability and|an increase in quality|of life was observed in|the experimental group|compared with the|baseline|No significant changes|over time in intensity|and duration|The addition of exercise|to a traditional preven-|tive regimen may|provide added benefits.|Patients who cannot|tolerate high-impact|exercise may even|benefit from low-impact|exercise like yoga|Aerobic exercise reduces|migraine frequency, pain|intensity, duration of|migraine, and migraine|disability. Also, yoga and|tai-chi may be beneficial|for migraine patients|

|Key Outcomes and|Follow-up|Frequency (headaches/|month)|Intensity (VAS)|Disability (HIT-6)|1 month since the initia-|tion of the intervention|2 months since the|initiation of the inter-|vention|3 months since the ini-|tiation of the interven-|tion (post-immediate)|Frequency (migraine|days/month)|Intensity (VAS)|Duration (no data)|Disability (MIDAS and|HIT-6)|Quality of life (MSQv 2.1)|4 weeks post-treatment|16 weeks post-treat-|ment|28 weeks post-treat-|ment||||-|||||||||-|||||||

|Study Design and Diagnosis Intervention||Mehta et al., 2021 RCT Group 1: Physical|[58] ICHD III therapy: PMR exercise,|Episodic migraine, with stretching, isometric|or without aura exercise of neck muscles,|and cardiorespiratory|endurance training.|(n = 20) Group 2: Yoga. (n = 20) Group 3: Standard treat-|ment. (n = 21)||Wells et al., 2021 [68] RCT Experimental group:|ICHD-II Standardized training|Episodic migraine in mindfulness/yoga|(n = 45) Control group: Head-|ache education group|= 44) (n||||||||Barber et al., 2020 Narrative review -|[77]||||||||Wells et al., 2019 [92] Narrative review -||||||||||||

|Eight subjects in the inter-|vention group reported|minor musculoskeletal|pain||||||No adverse effects were|reported||||||||||||||||No adverse effects were|reported||||No adverse effects were|reported||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|1-|||||||||1-|||||||||||||||||2 +||||2 +|||||||

|Significant differences|in frequency, intensity,|duration and quality of|life favour the experi-|mental group|||||No significant difference|between groups in any|outcome at any end-|point assessment||||||||||||||-|||||-||||||

|The intervention group|experienced statistically|significant changes in|frequency, pain intensity,|duration, disability|and quality of life at|3 months follow-up, but|not in the control group||Significant reduc-|tion in all outcomes|in the control group,|significant reduction in|attack duration and dis-|ability but no significant|change in frequency|and pain intensity in the|experimental group in|post-immediate|Significant reduction|in all outcomes in|the experimental and|control groups except|for pain intensity in|the control group at|follow-up|Regular exercise was|significant positive con-|tributor to the reversion|of transformed migraine|into episodic migraine|The chronic migraine|cohort showed less|regular lifestyle behav-|iours, including exercise|habit, than the episodic|migraine cohort|

|Frequency (days/month)|Pain intensity (VAS)|Duration (hours/month)|Quality of life (PDI)|Post-immediate|3 months follow up||||Frequency (days/month)|Pain intensity (NPRS)|Duration (hours/attack)|Disability (HIT-6)|Post-immediate|4 months follow-up||||||||||||Frequency (headaches/|month)|1-year follow-up|||Regular lifestyle behav-|iours of sleep, exercise,|mealtime patterns and|hydration status|||

|Experimental group:|exercise therapy, relaxa-|tion, stress management,|massage therapy and|dietary lecture. (n = 44) Control group: waiting|list with standard care|with patient´s family|physician (n = 36)|Experimental group:|fat-restricted diet,|250 min/week of home-|based exercise and|behavioural modification|strategies. (n = 54) Control group: Migraine|education. (n = 56)|||||||||Lifestyle recommen-|dations with exercise|cohort (n = 136)||Group 1: Episodic|migraine. (n = 175) Group 2: Chronic|migraine (n = 175)||||||||

|RCT|[55] Chronic migraine with or|without aura diagnosed|with IHS criteria||||||Bond et al., 2018 [44] RCT|ICHD-III|Episodic and chronic|migraine with or without|aura|||||||||||||Seok et al., 2006 [72] Cohort|ICHD II|Chronic migraine|||Woldeamanuel Cohort|et al., 2016 [73] ICHD-IIb|Chronic and episodic|migraine|||

|Adverse effects||No adverse effects were|reported|||||||||||||||||||||||||||||||No adverse effects were|reported||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|2-||||||||||||||||4||||||||||||||||1-||||||||

|Results Between|Group|-||||||||||||||||-||||||||||||||||Post-immediate and|follow-up: Significant|differences in frequency|favour the PMR train-|ing in migraine group|versus the waiting list|for migraine patients'|group|

|Results Within Group||There was a reduction|of 45% in the number|of attacks per month,|and a mean reduction of|4 days with migraine per|month|Significant amount|difference in adherence|to lifestyle modifica-|tion recommendations|between the patients|who showed a reduc-|tion of ≥ 50% in head-ache days per month|and the ones who did|not fulfil this outcome at|the primary endpoint|Lifestyle modifications|are essential in reduc-|ing the frequency and|severity of migraine|attacks. Managing|obesity, alcohol, and|tobacco consumption|discontinuation, regular|physical activity, suf-|ficient hydration, and|a healthy lifestyle are|highly accessible and|cost-efficient interven-|tions for any patient|with migraine||Significant improve-|ments in frequency in|favour of PMR training|in migraine group in|post-immediate and|follow-up|||

|Key Outcomes and|Follow-up|Frequency (attacks/|month and days with|migraine/month)||||||||||||||-||||||||||||||||Frequency (days/month|and attacks/month)|Post-immediate and|follow-up of 3 months|||||

|Study Design and Diagnosis Intervention||Gaul et al., 2011 [70] Cohort Muscular progressive|ICHD-II relaxation, headache|Episodic and chronic education, aerobic|migraine with or without exercise, individual psy-|aura chology therapy, group|behavioural treatment|with lifestyle recommen-|dations cohort (n = 210)||||||||Agbetou et al., 2022 Narrative review -|[93] Chronic and episodic|migraine||||||||||||RELAXATION TECHNIQUES|GRADE OF RECOMMENDATION: C in favour of intervention|Meyer et al., 2016 RCT Group 1: PMR training|[59] Episodic migraine with in migraine patients|and without aura. IHS (n = 16) criteria Group 2: waiting list|for migraine patients|(n = 19) Group 3: PMR training in|healthy subjects (n = 21) Group 4: Waiting list for|healthy subjects (n = 25)|||

|Adverse effects||No adverse effects were|reported|||||No adverse effects were|reported|||||||||||||||||||||||||||||||No adverse effects were|reported|||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|1-||||||1-||||||||||||||||||||||||||||||||4|||||

|Results Between|Group|There was a greater no|significant decline in|disability in favour of|the experimental group|at post-immediate and|follow-up|Post during the treat-|ment period:|Significant difference|between groups in pain|intensity favours the|topiramate group|No significant difference|between groups in|attacks/month, days|with migraine/month|Post during the last|month of treatment:|No significant difference|between groups in any|outcome||||Post 3 months:|No significant difference|between groups in any|outcome||||Post 6 months:|No significant difference|between groups in any|outcome||||-|||||

|Results Within Group||There were no sig-|nificant differences in all|outcomes post-immedi-|ate and in follow-up|||Post during the treat-|ment period:|Significant reduction|in attacks/month in all|groups|No significant changes|in other outcomes in|any group|||Post during the last|month of treatment:|Significant reduction|in attacks/month in all|groups|No significant change in|other outcomes in any|group|Post 3 months:|Significant reduction|in attacks/month in all|groups|No significant change in|other outcomes in any|group|Post 6 months:|Significant reduction|in attacks/month in all|groups|No significant change in|other outcomes in any|group|PMR is useful in prophy-|lactic migraine therapy|and provides indications|of a cortical mechanism|of action|

|Key Outcomes and|Follow-up|Frequency (Days/|month)|Disability (MIDAS)|Post-immediate|Follow-up 3 months||Frequency (attacks/|month and days with|migraine / month)|Pain intensity (VAS)|Quality of life (MSQoL)|Post during treatment|period|Post during last month|of treatment|Post 3 months|Post 6 months||||||||||||||||||||||-|||||

|Design and Diagnosis Intervention||RCT Experimental group:|Episodic and chronic PMR with a smartphone.|migraine (n = 77) ICHD-IIIb Control group: only|download the smart-|phone app. (n = 62)|RCT Group 1: Relaxation|ICHD-II group. (n = 30) Episodic migraine Group 2: Aerobic exer-|cise group. (n = 30) Group 3: Topiramate|group|= 31) (n|||||||||||||||||||||||||Narrative review -|-||||||||

|Study||Minen et al., 2020|[60]|||||Varkey et al., 2011|[67]|||||||||||||||||||||||||||||||Meyer et al., 2018|[86]||||

|Adverse effects|| |---|---|

|Level of|Evidence|

|Results Between|Group|

|Results Within Group||

|Key Outcomes and|Follow-up|

|Design and Diagnosis Intervention||

|Study|HIGH-INTENSITY|

|No adverse effects were|reported||||||||||No adverse effects were|reported||||||No adverse effects were|reported||||||6 persons withdrew for|non-adherence to the pro-|posed physical treatment|||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|1-|||||||||||1-|||||||1-|||||||1-||||||||

|Significant difference|that favours HIIT versus|MCT|No significant difference|between HIIT-Control|and MCT-Control||||||Significant difference|that favours HIIT versus|MCT|No significant difference|between HIIT-Control|and MCT-Control||Significant improve-|ment in all outcomes in|favour of HIIT vs control|||||Significant improve-|ments-favour the|experimental group|in frequency, moder-|ate pain intensity and|duration|||

|No significant improve-|ment in any group||||||||||No significant improve-|ment in all groups||||||Significant improvement|in all outcomes in all|groups|||||-||||||||

|Frequency (days/month)|Post-immediate||||||||||Frequency (days/month)|Post-immediate||||||Frequency (days/month)|Intensity (10/15 disa-|bling, 5/9 moderate, ¼|mild)|Duration of attacks|(minutes)|Disability (MIDAS)|Post-immediate|Frequency (days/month)|Intensity: 1 (mild),|2 (moderate) and 3|(disabling)|Duration of headache|(hours/day)|Post-immediate|

|RCT Experimental group:|[50] ICHD III-B HIIT group (n = 16) Episodic migraine Experimental group:|MCT group (n = 16) Control Group:|Maintain habitual daily|physical activity profile|and received additional|standard physical activ-|ity recommendations|(n = 16)|Hanssen et al., 2018 RCT Experimental group 1:|[49] Episodic migraine with-HIIT group (n = 15) out aura ICHD-IIIb Experimental group 2:|MCT group (n = 15) Control Group: main-|tain habitual physical|activity profile (n = 15)|Matin et al., 2022 RCT Group 1: HIIT (n = 15) [57] ICHD II Group 2: Supplementa-|Episodic migraine tion (Magnesium + B12) (n = 15) Group 3: HIIT + Supple-mentation|(n = 15) Group 4: Control group:|Migraine cases|(n = 15)|LOW-INTENSITY AEROBIC EXERCISE|GRADE OF RECOMMENDATION: C in favour of intervention|Santiago et al., 2014 RCT Experimental group:|[65] ICHD-II Amitriptyline and aero-|Chronic migraine bic exercise. (n = 30) Control group: Amitrip-|tyline alone. (n = 30)|||||||||

|Adverse effects||No adverse effects were|reported||||||||No adverse effects were|reported|||||No adverse effects were|reported|||||||||||No adverse effects were|reported||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|1-|||||||||1-||||||1-||||||||||||1-||||||

|Results Between|Group|-|||||||||There were no signifi-|cant differences in any|outcome at post-|immediate|||Frequency reduced|significantly in group 1,|compared to yoga and|standard treatment. No|significant differences|in other outcomes were|observed||||||There were significant|differences in all out-|comes between groups|at post-immediate that|favour the experimental|group|

|Results Within Group||Significant improve-|ments in all outcomes||||||||There were no signifi-|cant differences in any|outcome except in pain|intensity in favour of the|exercise group at post-|immediate|Frequency:|Significant reduction in|all groups at 1 month,|2 month and 3 months|Intensity:|Significant reduction in|all groups at 1 month,|2 month and 3 months|Disability:|Significant reduction|in all groups at 2 and|3 months|There were significant|differences in all out-|comes in both groups at|post-immediate|||

|Study Design and Diagnosis Intervention Key Outcomes and|Follow-up|Köseoglu et al., 2003 q-RCT Aerobic exercise (n = 40) Frequency (attacks/ [53] IHS month)|Episodic migraine with-Intensity (a four-degree|out aura scale)|Duration (hours of|attack/month)|Post-immediate|EXERCISE AND RELAXATION TECHNIQUES|GRADE OF RECOMMENDATION: C in favour of intervention|Dittrich et al., 2008 RCT Experimental group: Frequency (attacks/|[48] Episodic migraine with Aerobic exercise group month)|and without aura and relaxation (n = 15) ICHD-I Control group: informa-Pain intensity (slight, moderate, intense, very|tion about intense, intolerable)|Physical activity (n = 15) Quality of life (PLC)|Mehta et al., RCT Group 1: Physical Frequency (headaches/|2021 [58] ICHD III therapy: PMR exercise, month)|Episodic migraine, with stretching, isometric Intensity (VAS)|or without aura exercise of neck muscles, Disability (HIT-6)|and cardiorespiratory 1 month since the initia-|endurance training. tion of the intervention|(n = 20) Group 2: Yoga. (n = 20) Group 3: Standard treat-2 months since the initiation of the inter-vention|ment. (n = 21) 3 months since the ini-tiation of the interven-|tion (post-immediate)|Butt et al., 2022 [46] Q-RCT Experimental group: Pain Intensity (NPRS)|Episodic and chronic supervised exercises Disability (MIDAS, HIT-6,|migraine protocol, including HDI)|aerobic exercise and Post-immediate|PMR (n = 14) Control group: prophy-|lactic medicines (n = 14)||||||

|Adverse effects||No adverse effects were|reported||||||||||||||No adverse effects were|reported|||||||||Joint pain (33.8%), muscle|pain (33.3%), slight sprain|(10.2%) and dizziness|(5.1%)|All participants indicated|tolerability of these symp-|toms. No serious cases|appeared|||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|4|||||||||||||||1-||||||||||1-|||||||||||||

|Results Between|Group|-|||||||||||||||No significant differ-|ences in any outcome|||||||||Significant reduction in|Tai Chi group compared|to control group only in|frequency (both attacks|and days with migraine|per month) at the|end of treatment and|follow-up|No significant differ-|ences in intensity or|duration|||

|Results Within Group||-|||||||||||||||Only significant differ-|ence in the intensity|of headache for both|groups|||||||Significant reduction in|migraine in frequency|(both attacks and days|with migraine per|month) intensity and|duration in Tai Chi group|at the end of treatment|and follow-up|Participants in wait-|ing list only found|significant reduction in|days with migraine at|follow-up|

|Key Outcomes and|Follow-up|-|||||||||||||||Frequency (days with|headache/month)|Intensity (NRS)|Disability (MIDAS)|Post-immediate|1-month post-inter-|vention|2-month post-inter-|vention|3-month post-inter-|vention|Frequency (attacks/|month and days with|migraine/month)|Intensity (VAS)|Duration (hours/attack)||||||||

|Study Design and Diagnosis Intervention||Becker et al., 2009 Narrative review Multidisciplinary treat-|[78] -ment, not only medica-|tion management is|needed in migraine|patients. Exercise and|relaxation techniques are|important components|of stress and sympto-|matic management.|For migraine, a more|substantial relaxation|training program might|be necessary|NECK STRENGTH EXERCISE|GRADE OF RECOMMENDATION: C against the intervention|Benatto et al., 2022 RCT Experimental group:|[43] Episodic migraine craniocervical muscle-|ICHD-III strengthening exercise|(n = 21) Control group: sham|ultrasound group|(n = 21)|||TAI-CHI|GRADE OF RECOMMENDATION: C in favour of intervention|Xie et al., 2022 [69] RCT Experimental group: Tai|ICHD-III Chi (n = 40) Episodic migraine Control group: Waiting|list (n = 33)|||||||||||

|Adverse effects||Physical exertion can|trigger migraines in some|patients||||||No adverse effects were|reported|||||||No adverse effects were|reported|||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Level of|Evidence|4||||||||1-||||||||3|||||||

|Results Between|Group|-||||||||There were significant|differences that favour|resistance training in all|outcomes|||||-|||||||

|Results Within Group||Aerobic exercise reduces|migraine frequency, pain|intensity, duration of|migraine, and migraine|disability. Also, yoga and|tai-chi may be beneficial|for migraine patients||All outcomes improved|significantly in the|exercise group in the|pre-post measures|||||Disability score reduced|by 50% in 4/6 patients|Intensity did not show|improvement|Frequency was|improved in more than|1 attack in 3/6 patients|

|Key Outcomes and|Follow-up|-||||||||Frequency (attacks/|month)|Intensity (VAS)|Duration (Days)|Quality of life (HIT-6)|Post-immediate|||Frequency (attack/|month)|Intensity (1 to 5 scale)|Disability (MIDAS)|Post-immediate|||

|Study Design and Diagnosis Intervention||Wells et al., 2019 [92] Narrative review -||||||RESISTANCE EXERCISE|GRADE OF RECOMMENDATION: C in favour of intervention|Aslani et al., RCT Experimental group:|2021 [42] Episodic migraine Resistance training.|ICHD (n = 10) Control group: No|exercise. (n = 10)|QI-GONG|GRADE OF RECOMMENDATION: D in favour of intervention|Elinoff et al., 2019 Case series Kiko Exercise and its|[74] ICHD-II background|Episodic migraine (n = 13)|||||||

|Results|||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Outcomes||||||||||||||

|Grade of Studies|recommendation|B in favor of intervention N||||||||||||

|Effect||Moderate-intensity con-|tinuous aerobic exercise,|from an 8-week onward|intervention applied 3|times per week is likely|to improve headache|frequency, might improve|pain intensity, and|remotely improve attack|duration, disability, and|quality of life in patients|with episodic migraine|

|Migraine diagnosis||Episodic migraine||||||||||||

|Intervention||Moderate-intensity con-|tinuous aerobic exercise|||||||||||

|Grade of Studies|recommendation|B in favor of intervention N = 8 SR and MA in RCT (n = 2): Wu 2022 [39], Long 2022|[37]|RCT (n = 6): Kumar 2020||||||||||

|Effect||Yoga, including asanas,|breathing and relaxation|techniques, and medita-|tion is likely to improve|headache frequency and|disability and remotely|improves pain intensity|and attack duration,|from a 6-week onward|intervention applied 3|times per week in episodic|migraine|

|Intervention||Yoga||||||||||||

|Exercise testing|-Individual|anaerobic|lactate-threshold|-HRmax|-VO 2 max|(supervised)|||||||||||||-|||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity|Main training = 70% HRmax (± 5 bpm)|||||||||Exercise group|intensity based on a|Borg's scale of Rated|Perceived Exertion|(6-20)|-Warm up: 11-13|-Exercise: 14-16|-Cool-down: 11-13|-|||||||||||

|Duration|Main train-|ing = 45 min||||||||Total dura-|tion = 40 min||||||Main training jog-|ging duration of|14 th -30 th session:|30 min continuously|Main training|jogging-walking|intervals duration|from 1 st to 13 th ses-|sion (min): 1-2, 2-2,|2-1, 3-1, 3-1, 4-1,|4-1, 5-1, 7-1, 7-1,|10-1, 10-1, 10-1|

|Frequency|2 times/week for|12 weeks|||||||||3 times/week for|12 weeks|||||||3 times/week for|10 weeks|||||||||

|Distribution|Supervised exercise|Warm-up = 400 m easy running on a|treadmill and 2 skip-|ping exercises|Main training = Con-tinuous running on a|treadmill|Cool down = 400 m easy running on a|treadmill and stretch-|ing exercises|Supervised exercise|Exercise (15 min|warm-up,|20 min exercise and|5 min cool-down)||||Supervised exercise|Warm-up = 10 min on a treadmill|Main training = Jog-ging on a treadmill|Cool down = 10 min on a treadmill||||||||

|Group|MCT||||||||||Exercise group||||||||Exercise group||||||||||

|Design|RCT||||||||||RCT||||||||q-RCT||||||||||

|Trial|Hanssen et al. 2018|[49]|||||||||Varkey et al. 2011|[67]|||||||Darabaneanu et al.|2011 [47]|||||||||

|Type of|intervention||||||||||||||||||||||||||||

|Exercise testing|-|||||||||||||||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity|Main training|for non-trained|patients:11-13 Borg|Main train-|ing for trained|patients:14-15 Borg|||||||||||||||||||||||

|Duration|Total dura-|tion = 40-50 min||||||||||||||Total dura-|tion = 60 min||||||||||||

|Frequency|2 times/week for|5 weeks|1st session/week|supervised|2 nd session/week|unsupervised|||||||||||3 times/week for|8 weeks|||||||||||

|Group|Supervised Aerobic|Exercise Group|||||||||||||||Exercise group||||||||||||

|Design|q-RCT||||||||||||||||q-RCT||||||||||||

|Trial|Luedtke et al. 2020|[56]|||||||||||||||Narin et al. 2003|[61]|||||||||||

|Exercise testing|-|||||||||||||-|||-||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity|-|||||||||||||Warm up = 11-13 Borg|Main train-|ing = 14-16 Borg Cool-down = 11-13 Borg|Light: normal|walking, walking|downstairs, yoga,|gardening, etc|Moderate: brisk walk-|ing, lawn mowing,|shoveling, dancing,|etc|Vigorous: jogging,|running, cycling fast,|kickboxing, etc|

|Duration|Main training|jogging duration|of 6 th -10 th session:|30 min continuously|Main training|jogging-walking|intervals duration|from 1 st to 5 th ses-|sion (min): Steady|increase in running|time compared|to walking time|through weeks|Total dura-|= 40 min tion|-||||||||||||

|Frequency|3 times/week for|10 weeks||||||||||||3 times/week for|12 weeks||0, 1-2, 3-4 or 5|times/week||||||||||

|Distribution|Supervised exercise|Warm up = 5-10 min walking|Main train-|ing = 30 min walking or jogging|Cool-|down = 5-10 min walking and stretch-|ing||||Supervised exercise|Warm up = 15 min indoor cycling|Main train-|ing = 20 min indoor cycling|Cool-down = 5 min indoor cycling|Unsupervised|exercise|||||||||||

|Group|Exercise group (no|control group)||||||||||||Exercise group (no|control group||Exercise|||||||||||

|Design|q-RCT|||||||||||||q-RCT|||Cohort|||||||||||

|Trial|Overath et al. 2014|[64]||||||||||||Varkey et al. 2009|[66]||Hagan et al. 2021|[71]||||||||||

|Type of|intervention|||||||||||||||||||||||||||

|Exercise testing|-|||||||||||-||||||||-||||||-|||||-|||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity|-|||||||||||-||||||||-||||||Exercise that raises|heart rate||||-||||||

|Duration|-|||||||||||Total duration of|programme = 5 h and 30 min||||||Total dura-|tion = 30 min mini-mum per session||||Total dura-|tion = 20 min minimum|||-|||||||||

|Frequency|6 weeks with|3 months follow-up||||||||||Sessions applied|5 days/week mini-|mum||||||Session applied at|least 3 times/week|minimum||||Session applied at|least 6 months|Minimum|||1 time per week for|6 weeks|||||

|Group|Exercise group|||||||||||Muscular progressive|relaxation, aerobic|exercise and lifestyle|recommendation|||||Lifestyle behaviour|modifications, exer-|cise and medication|use|||Regular Lifestyle|Behaviours cohort||||Progressive Muscle|Relaxation|||||

|Trial Design|Lemstra et al. 2002 RCT|[55]||||||||||Gaul et al. 2011 [70] Cohort||||||||Seok et al. 2006 [72] Cohort||||||Woldeamanuel Cohort|et al. 2016 [73]||||Meyer et al. 2016 RCT|[59]|||||

|Type of|intervention||||||||||||||||||||||||||||||Relaxation tech-|niques|||||

|Exercise testing|-||||||||-|||||-Individual|anaerobic|lactate-threshold|-HRmax|-VO 2 max|(supervised)||||||-Individual|anaerobic|lactate-threshold|-HRmax|-VO 2 max|(supervised)|| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity|-||||||||-|||||High-intensity|intervals = 90-95% HRmax (± 5 bpm)|reached after 1 min|from the beginning|of the high-intensity|interval|Active rest inter-|vals = 70% HRmax|||High-intensity|intervals = 90-95% HRmax (± 5 bpm)|reached after 1 min|from the beginning|of the high-intensity|interval|Active rest inter-|vals = 70% HRmax|

|Duration|Total dura-|tion = 15 min||||||Total duration:|30-120 min||||High-intensity inter-|vals vs active rest|period (min) = 4-3 High-intensity inter-|vals were repeated|4 times, with a total|duration of 16 min of|high-intensity||||High-intensity inter-|vals vs active rest|period (min) = 4-3 High-intensity inter-|vals were repeated|4 times, with a total|duration of 16 min of|high-intensity|||

|Frequency|2-4 times per|week, for 6 weeks|with a follow-up of|3 months|||||Daily|||||2 times/week for|12 weeks||||||||||2 times/week for|12 weeks||||||

|Group|Progressive|Muscle|Relaxation||||||Relaxation group|||||HIIT|||||||||||HIIT|||||||

|Design|RCT||||||||RCT|||||RCT|||||||||||RCT|||||||

|Trial|Minen et al. 2020|[60]|||||||Varkey et al. 2011|[67]||||Hanssen et al. 2017|[50]||||||||||Hanssen et al. 2018|[49]||||||

|Type of|intervention|||||||||||||High-Intensity|aerobic Interval|Training||||||||||||||||

|Exercise testing|-VO 2 max||||||||||-||||HRmax|||||||-||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity|High-intensity inter-|val Borg's rating from|1 st to 8 th wk: 11, 12,|14, 15, 16, 17, 18, 18|High-intensity inter-|val % VO 2 max from 1 st to 8 th wk: 60, 60,|60-65, 65-70, 70-75,|70-75, 75-80, 80|Low-intensity inter-|vals: No info|-||||= 60% Main training HRmax||||||-||||||||

|Duration|Main training from|1 st to 8 th wk (min):|10, 15, 20, 25, 30, 35,|40, 40|High-intensity inter-|val duration: No info|Low-intensity inter-|val duration: No info||||Total dura-|tion = 40 min||Total dura-|tion = 40 min|||||Total dura-|tion = 60 min|||||||

|Frequency|3 times/week for|8 weeks||||||||||3 times/week for|12 weeks|||3 times/week for|6 weeks||||||3 times/week for|6 weeks|||||

|Distribution|Supervised exercise|Warm-up = 10 min Main training|Cool down = 10 min Training modality:|Possibly outdoor and|indoor cycling|||||Unsupervised|exercise|Warm-up exercises|Main training = Fast walking outdoors|Unsupervised|exercise|Warm up = 10 min Main train-|ing = 20 min aerobic exercise|Resting|period = 10 min Training mate-|rial = No info|Supervised exercise|Warm-up = 10 min stationary cycling|Aerobic exer-|cise main train-|ing = 30 min station-ary cycling|Cool down = 5 min stationary cycling|Progressive muscle|relaxation = 15 min|

|Group|High-Intensity Inter-|val Aerobic Exercise,|B12 and Magnesium|Supplementation|Group|||||||Amitriptyline and|Aerobic Exercise|Group||Exercise group (no|control group)||||||Moderate Intensity|Continuous Aerobic|Exercise and Progres-|sive Muscle Relaxa-|tion Group||

|Trial Design|Matin et al. 2022 RCT|[57]||||||||||Santiago et al. 2014 RCT|[65]|||Köseoglu et al. 2003 q-RCT|[53]||||||Butt et al. 2022 [46] RCT||||||

|Type of|intervention|||||||||||Low-intensity aero-|bic exercise||||||||||Exercise and relaxa-|tion techniques|||||

|Exercise testing|-||||||||-|||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity|-||||||||-||||||||||||||

|Duration|Total dura-|tion = 60 min||||||Total dura-|tion = 40 min||||||||||||||

|Frequency|2 times/week for|6 weeks|||||||Daily for 3 months||||||||||||||

|Group|Exercise group||||||||Physiotherapy and|Standard Drug|Therapy|(Relaxation and|exercise)||||||||||

|Design|RCT||||||||RCT||||||||||||||

|Trial|Dittrich et al. 2008|[48]|||||||Mehta et al. 2021|[58]|||||||||||||

|Type of|intervention||||||||||||||||||||||

|Exercise testing||-||||||||||||||||||||-||||||||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity||-||||||||||||||||||||-|||||||||||||||||||||

|Duration||-||||||||||||||||||||Total dura-|tion = 60 min||||||||||||||||||||

|Frequency||2 sessions/day for|8 weeks|Supervised by a|physiotherapist once|a week for 20 min|in an individual ses-|sion. The rest of the|program was done|at home||||||||||||5 times/week for|12 weeks|Participants in Tai Chi|group kept at least 1|session/week in the|following 12 weeks|after the end of treat-|ment||||||||||||||

|Distribution||First 6 weeks: 2 sets|of 10 repetitions with|10 s of endurance|for the deep cervical|flexor and extensor|muscles. Progression|in series, repetitions|and endurance was|based on absence of|complaint or pain,|and/or execution of|movement without|compensation in|each volunteer|Last 2 weeks: add to|the previous exercise|3 sets of 15 repeti-|tions for flexor and|extensor superficial|cervical muscle|3 times/week super-|vised, and 2 times/|week unsupervised|Warm-up with|stretching = 10 min Main train-|ing = 45 min. In the first 15 supervised|lessons (first|5 weeks), participants|learned individual|parts of the Modified|33-short form Yang-|style Tai Chi Chuan.|From the 16th|session, participants|performed the whole|exercise program|3 times per session|(15 min each)|Cool down with|stretching = 5 min Training mate-|rial = Not needed|

|Group||Neck strength|exercise|||||||||||||||||||Exercise group|||||||||||||||||||||

|Design||RCT||||||||||||||||||||RCT|||||||||||||||||||||

|Trial||Bennato et al. 2022|[43]|||||||||||||||||||Xie et al. 2022 [69]|||||||||||||||||||||

|Type of|intervention|Neck strength|exercise|||||||||||||||||||Tai Chi|||||||||||||||||||||

|Exercise testing||RM|||||||||||||||-||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity||Main training per-|formed from 45% RM|to 75% RM gradually|progressed through|the 8 weeks|||||||||||-|||||||||||||||

|Duration||Total dura-|tion = 30-45 min|||||||||||||Total dura-|tion = 10 min at least|||||||||||||||

|Frequency||3 times/week for|8 weeks||||||||||||||-Daily home practice|-Two subsequent|face-to-face sessions|every 30 days||||||||||||

|Distribution||Supervised exercise|Warm up = 5 min jogging, 5 min|stretching and 5 min|weightlifting|Main training = 2-3 sets of 8-15 rep-|etitions of arm pull|down, arm pull over,|sit up, leg extension,|leg curl|Cool down = 5 min active cooling and|stretching move-|ments|Training modality:|No info|Supervised exercise|-First face-to-|face exercise|sequence = Ju Fu (Gentle Wind)|-Qigong exercise|DVD duplicating|the content of the|first and subsequent|lessons for home|practice = 10 min minimally|-Two subsequent|face-to-face sessions|to reinforce training|and add complexity|and length to the|Kiko sequence|

|Design Group||RCT Resistance|Training||||||||||||||Case series Qigong Exercise|||||||||||||||

|Type of Trial|intervention|Resistance exercise Aslani et al. 2021|[42]||||||||||||||Elinoff et al. 2019 Qi-gong|[74]|||||||||||||Abbreviations: bpm|

|Exercise testing Grade of|recommendation|-B in favour of|intervention|||||||||||||||||||||||||||||-B in favour of|intervention||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity||-||||||||||||||||||||||||||||||Main training|performed at|a moderate to|submaximal|intensity||||||||

|Duration (per|session)|Total duration of|60-75 min|||||||||||||||||||||||||||||Total duration of|20-60 min|||||||||||

|Frequency||3-7 times/week|for 6-12 weeks|||||||||||||||||||||||||||||3-7 times/week|for 6 weeks|to more than|6 months|||||||||

|Type of exercise Distribution||Yoga: First part: Starting|Full program prayer, breathing,|under supervision; stretching and|the first session relaxation exer-|or first month is cise (including|supervised and Instant Relaxation|the rest of the Technique and|program is per-Quick Relaxa-|formed at home tion Technique).|with audio-visual Eye-related and|guidance if pos-backward bend-|sible, or ensuring ing exercise|compliance with Second part:|the routine with Asanas, savana,|a telephone pavanmok-|call every week tasanas,|or two months pranayama or|and/or with a pre-pranayama,|diary checking neti exercise,|compliance or standing-sitting|self-reported yoga and lying out|log screw position,|maintained by kriya (Jalaneti|the patient, and/ followed by|or with the pos-Kapalbhanti), suk-|sibility of visiting shma vyayama,|professionals surya namaskar|Final part:|Shavasana or|relaxation|Home-based exer--|cise, stretching,|light weightlifting|training, endur-|ance training|(mainly using|sport gym equip-|ment), or any|modality of daily|aerobic exercise|that raise the|heart rate|

|Migraine Trials|diagnosis|Episodic migraine N = 6 RCTs (6): Kumar|2020 [54], Kisan|2014 [52], Borou-|jeni 2015 [45],|John 2007 [51],|Mehta 2021 [58],|Wells 2021 [68]|||||||||||||||||||||||Episodic and N = 5 chronic migraine RCTs = 2 Bond 2018 [44], Lemstra|2002 [55]|Cohort = 3 Seok 2006 [72],|Wodeamanuel|2016 [73] Gaul|2011 [70]||||||||

|Type of|intervention|Yoga||||||||||||||||||||||||||||||Exercise and|lifestyle recom-|mendations||||||||||

|Exercise testing Grade of|recommendation|-C in favour of|intervention|||||||||||||||-Individual C in favour of|anaerobic intervention|lactate-threshold|-HRmax|-VO 2 max|(supervised)|-Borg|||||||||||HR C in favour of|intervention||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity||-||||||||||||||||High intensity:|Progression from|Borg 11 to 18 or|from 60% VO 2|max to 80% in|8 weeks|Maximum high-|intensity reached|90%-95% HR Max|Maximum active|rest period inten-|sity reached: 70%|HRmax|||||Main training per-|formed at 60%|HRmax||||

|Duration (per|session)|Total duration|of 15 min to|120 min||||||||||||||Main train-|ing = 10-40 min High intensity|-moderate|intensity intervals|(min) = 4-3 High-moderate|intensity intervals|were repeated 4|times||||||||Total duration of|40 min|||||||

|Frequency||1-6 times/week|for 6-12 weeks|||||||||||||||2-3 times/week|for 8-12 weeks||||||||||||||||3 times/week for|6-12 weeks|||||

|Type of exercise Distribution||-6 relaxation|exercises based|on breathing and|stress-manage-|ment techniques,|from 5 to 20 min|of duration|each exercise,|or Progressive|Muscle Relaxation|including 16 mus-|cle exercises or|Smartphone app|with Progressive|Muscle Relaxation|program|Running on a Warm-up = 400 m treadmill easy running on|Bicycle a treadmill and 2|Supervised skipping exercises|or 10 min cycling|Main train-|ing = High-intensity interval|running on a|treadmill or|bicycle|Cool|down = 400 m easy running|on a treadmill|and stretching|exercises or 5 min|cycling|Home active Warm-up exer-|exercise or fast cises for 10 min|walk outdoors, Main training|not supervised performed for|20-40 min|Resting period|performed for|10 min|

|Migraine Trials|diagnosis|Episodic and RCTs (n = 3): chronic migraine Varkey 2011 [67],|Meyer 2016 [59],|Minen 2020 [60]|||||||||||||Episodic migraine N = 3 RCTs = 3 Hanssen 2017|[50]|Hanssen 2018|[49]|Matin 2022 [57]|||||||||||Episodic migraine N = 2 RCT (1): Santiago|2014 [65]|Q-RCT (1): Köse-|glu 2003 [53]||||||

|Type of|intervention|Relaxation|techniques|||||||||||||||High-intensity|aerobic interval|training|||||||||||||||Low-intensity|aerobic exercise|||||

|Exercise testing Grade of|recommendation|-C in favour of|intervention||||||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity||-||||||||||||||||||||

|Duration (per|session)|Total duration of|45-60 min|||||||||||||||||||

|Frequency||2-3 times/week|for 6-12 weeks|||||||||||||||||||

|Type of exercise Distribution||Relaxation Warm|exercise and up = 5-10 min stationary cycling, Main train-|or gymnastics ing = 30 min with music, of moderate|aerobic and aerobic exercise|strength training, or 15-25 min of|or stretching, aerobic training|isometric exercise and 10-20 of|and walking strength training|Not reported if Or self-stretching|supervised or not of neck muscles|(30 s hold 3|repetitions), neck|isometric exercise|(5 s hold, 10|repetitions) and|30 min walking|Progressive|muscle relaxa-|tion = 15 min Cool down or|stretching = 5 min|

|Trials||RCT (n = 2): Dittrich 2008 [48]|Mehta 2021 [58]|Q-RCTs (n = 1) Butt 2022 [46]||||||||||||||||||

|Migraine|diagnosis|Episodic and|chronic migraine|||||||||||||||||||

|Type of|intervention|Exercise and|relaxation tech-|niques||||||||||||||||||

|Exercise testing Grade of|recommendation|-C against the|intervention|||||||||||||||||||||-C in favour of|intervention||||||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity||-||||||||||||||||||||||-||||||||||||||||||||

|Duration (per|session)|Total duration of|20 min|||||||||||||||||||||Total duration of|60 min|||||||||||||||||||

|Frequency||1 day per week|under supervision|and 2 times/day|everyday with|home exercises|for 8 weeks|||||||||||||||||5 times/week for|12 weeks|||||||||||||||||||

|Type of exercise Distribution||Strength exercise First stage:|for superficial deep muscle|and deep flexor training, 2 sets|and extensor of 10 repetitions|craniocervical for deep flexor|musculature with and extensor|home exercise musculature, for|for craniocervical 6 weeks. Individu-|musculature and ally progressed in|stretching number of series,|repetitions and|endurance|Second stage:|deep and|superficial muscle|training for the|next 2 weeks,|including 3 sets of|15 repetitions for|superficial flexor|and extensor|musculature|Modified 33-short Warm-up with|form of Yang-style stretching for|Tai Chi Chuan, 10 min|(including the Main training|form "closing") of 45 min, with|The protocol the first 5 weeks|included both learning indi-|supervised and vidual exercises|unsupervised of the Tai Chi|exercise exercise program|The following|6-12 weeks par-|ticipants perform|the whole Tai-Chi|exercise program,|3 times per ses-|sion|Cool-down with|stretching for|5 min|

|Migraine Trials|diagnosis|Episodic migraine RCT (n = 1): Ben-atto 2002 [43]|||||||||||||||||||||Episodic migraine N = 1 RCTs (n = 1): Xie 2022 [69]|||||||||||||||||||||

|Type of|intervention|Neck strength|exercise|||||||||||||||||||||Tai Chi||||||||||||||||||||

|Exercise testing Grade of|recommendation|RM C in favour of|intervention|||||||||||||||||-D in favour of|intervention||||||||||||||||| |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|

|Intensity||Main training|gradually per-|formed from 45%|RM to 75% RM|||||||||||||||-||||||||||||||||||

|Duration (per|session)|Total duration of|30 to 45 min|||||||||||||||||Total duration of|10 min at least|||||||||||||||||

|Frequency||3 times/week for|8 weeks|||||||||||||||||Daily home prac-|tice, for 3 months|Two subsequent|face-to-face|sessions every|30 days|||||||||||||

|Type of exercise Distribution||Resistance Warm up for|exercise with 15 min with jog-|dumbbells, arm ging, stretching,|pull down, arm and weightlifting|pull over, sit up, Main training|leg curl machine, performed from|and leg extension 30 to 45 min,|machine 2-3 sets of 8-15|Not reported if repetitions of arm|supervised or not pull down, arm|pull over, sit up,|leg extension and|leg curl|Cool down for|5 min with active|cooling and|stretching move-|ments|Supervised First face-to-face|exercise history of Qi-|Ju Fu (Gentle Gong explanation|Wind) method and exercise|sequence = Ju Fu (Gentle Wind)|-Qigong exercise|DVD duplicating|the content of the|first and subse-|quent lessons for|home practice|Two subsequent|face-to-face ses-|sions to reinforce|training and add|complexity and|length to the Kiko|sequence|

|Migraine Trials|diagnosis|Episodic migraine RCTs (n = 1): Aslani [42]|||||||||||||||||Episodic migraine Case series (n = 1): Elinoff 2019 [74]|||||||||||||||||||

|Type of|intervention|Resistance|exercise|||||||||||||||||Qi-Gong||||||||||||||||||

Acknowledgements

Score criteria for SIGN levels of evidence and grades of recommendation High-quality meta-analysis, systematic reviews of RCTs or RCTs with very low risk of bias A At least one meta-analysis, systematic review or RCT rated as 1

Modified Quality Assessment Scale for Systematic Review with the information regarding each item score and the total score for each systematic review

NOS scale for cohort studies with the information regarding each item score and the total score for each cohort study

Item Quality Assessment Tool for Case Series Studies Scale with the information regarding each item score and the total score for the case series study

SANRA scale for narrative reviews with the information regarding each item score and the total score for each

Systematic reviews and meta-analysis risk of bias assessment within studies based on the ROBIS tool

Summary table with each exercise modality and its respective studies

(continued)

continued) Migraine-Specific Quality of Life Questionnaire version 2.1, MVK pain scale Modified Von Korff pain scale, NPRS Numeric Pain Rating Scale, NRS Numeric Rating Scale, PDI Pain Disability Index, PLC Quality of Life Profile for the Chronically Ill, PMR Progressive Muscle Relaxation, q-RCT Quasi-Randomized Clinical Trial, RCT Randomized Controlled Trial, SF-12 Short Form-12 Health Survey, SF-36 Short Form-36 Health Survey, SR Systematic Review, VAS Visual Analogue Scale, WHO-5 Five Well-Being Index

Highlighted phrases to summarize the strength of recommendation for each exercise modality

Prescription parameters used in each of the included studies for each exercise modality

continued) Beats per minute, HIIT High-Intensity Interval Training, HR Heart Rate, HRmax Maximal heart rate, MCT Moderate Continuous Training, m/min Metres/minute, min Minute, q-RCT Quasi-Randomized Controlled Trial, RCT Randomized Controlled Trial, RM Repetition Maximum, VO2max Maximal oxygen uptake

continued) Beats per minute, HR Heart rate, HRmax Maximal heart rate, m/min Meters/minute, min Minutes, q-RCT Quasi-Randomized Clinical Trial, RCT Randomized Controlled Trial, RM Repetition Maximum, VO Page 57 of 60 La Touche et al. The Journal of Headache and Pain (2023) 24:68

Supplementary Information

The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s10194-023-01571-8.

Additional file 1.

Authors' contributions

RLT, ARV, and APA conceived and designed the clinical practice guideline; JFM, ISR, BRRR, and CDCL elaborated and performed the search strategy and inclusion of the articles; JFM and ISR evaluated the methodological quality and risk of bias of the included studies; RLT, ARV, JFM, ISR, BRRR, and CDCL developed and structured the operational definitions of each intervention, methodological quality, risk of bias, level of evidence, recommendation grade, prescription parameters, and intervention summary, and prepared the figures, tables, and the documentation for the consensus group; SLL, NRS, FAFM, IEG, JFC, LMG, JPM, APA constituted the consensus group and performed the validation of the different operational definitions of each intervention, methodological quality, risk of bias, level of evidence, recommendation grade, prescription parameters, and intervention summary; RLT, ARV, JFM, ISR, BRRR, CDCL, and APA have drafted the manuscript, and RLT, ARV, JFM, ISR, BRRR, CDCL, SLL, NRS, FAFM, IEG, JFC, LMG, JPM, APA have revised it. The author(s) read and approved the final manuscript.

Funding

Declarations Ethics approval and consent to participate

The present article is a clinical practice guideline that does not require an ethical approval.

Consent for publication

The present article has not included participants due to its design.

Competing interests

The authors declare that they have no competing interests.

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References

引用 / 出处

2023 循证临床实践指南：偏头痛治疗性运动处方. 2023.