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ABSTRACT
RESUMO
Descritores: Psicologia; Distúrbios da dor de cabeça; Estilo de vida saudável;
Comportamento Sedentário; Exercício.
ORIGINAL ARTICLE
“No Pain, More Gain”? Affect and Adherence to Exercise
in Migraine Patients: A Prospective Cohort Study
“No Pain, More Gain”? Resposta Afetiva e Aderência ao
Exercício em Pacientes com Migrânea: Um Estudo Prospectivo
Arão Belitardo Oliveira
1,2
Dhiego Luigi Gringõn
1
Mario Fernando Prieto Peres
2,3
1
Universidade Federal de São Paulo,
Departamento de Neurologia e Neurocirurgia,
Brazil.
2
Universidade de São Paulo, Faculdade de
Medicina, Instituto de Psiquiatria, Brazil.
3
Hospital Israelita Albert, Instituto do Cérebro,
Brazil.
*Correspondence
Arão Belitardo Oliveira
E-mail: araoliva@gmail.com
Received: May 15, 2019.
Accepted: May 27, 2019.
Objectives: To compare the affective and perceptual responses to a
standardized exercise session between episodic migraine patients and non-
headache persons, and its inuence on adherence to an 12-week exercise
training program. Methods: In a secondary analyses of a prospective cohort
enrolled in a clinical trial, we assessed the affective response at rest, at 15th min
of exercise, and immediately after an acute 40-min exercise session previously
the training program. All measurements were undertaken in headache-free
days. Participants were subsequently randomly assigned to a 12-week aerobic
exercise-training program, or to a waitlist. In a multiple linear regression
model, variables tested as possible predictors of adherence were body mass
index, cardiorespiratory tness, and the perceived exertion and affect scores
elicited in the previous exercise session. Results: Fifty-four participants were
analyzed for acute exercise session data (mean±SD age: 37.37±11.5; mean±SD
BMI: 26.7±4.5). Patients (N=28) and controls (N=26) showed no differences
in anthropometric characteristics and cardiorespiratory tness. Compared
to controls, migraine patients showed reduced affective response during
and after exercise, but showed no differences in perceived exertion. Twenty-
ve participants (patients: N=13; controls: N=13) concluded the 12-week
exercise-training program. Adherence was lower in migraine group (p = 0.1, d
= 0.641). Multiple linear regression analysis showed post-exercise affect score
as the only predictor variable of adherence to the exercise-training program
(β =0.405, p = 0.040). Conclusions: This study indicates that migraine patients
have lower affective response to exercise, which was associated with adherence
to the training program.
Keywords: Psychology; Headache Disorders; Healthy Lifestyle; Sedentary
Behavior; Exercise.
Objetivos: Comparar as respostas de valência afetiva e percepção do esforço
entre pessoas com migrânea e sem cefaleias durante uma sessão de exercício
padronizada e sua inuência na aderência a um programa de 12 semanas de
treinamento aeróbio. Métodos: Em análise secundária de uma coorte prospectiva
de um estudo clínico, controlado e randomizado, avaliamos a resposta afetiva
basal, no 15º minuto de exercício e imediatamente após uma sessão aguda de
exercício aeróbio previamente ao programa de treinamento aeróbio. Todas
as mensurações foram conduzidas interictalmente. Um modelo de regressão
linear múltipla testou as variáveis basais de IMC, aptidão cardiorrespiratória
e percepção do esforço e escores afetivos da sessão aguda de exercício
como preditoras de aderência ao programa. Resultados: Cinquenta e quatro
participantes foram avaliados (média±DP idade: 37,37±11,5; média±DP IMC:
26,7±4,5). Pacientes (N=28) e controles (N=26) não apresentaram diferenças
nas características antropométricas e aptidão cardiorrespiratória. Comparado
aos controles, pacientes com migrânea exibiram uma resposta afetiva reduzida
durante e após a sessão de exercício aguda, mas sem diferenças signicativa na
percepção do esforço. Vinte e cinco participantes (pacientes: N=13; controles:
N=12) concluíram o protocolo de treinamento aeróbio. Aderência foi menor no
grupo de pacientes (p = 0,1, d = 0,641). A análise de regressão mostrou a resposta
afetiva após a sessão aguda de exercício como única variável preditora de
aderência (β = 0,405, p = 0,040). Conclusão: Esse estudo sugere que pacientes
com migrânea apresentam uma resposta afetiva reduzida ao exercício, a qual
está associada a menor aderências ao programa de treinamento aeróbio.
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Headache Medicine, v.10, n.2, p.43-50, 2019
INTRODUCTION
Even though regular aerobic exercise has been shown
effective for migraine prevention (1–4), as a chronic pain
condition, migraine may represent an obstacle to physical
activity participation. Epidemiological data have shown
increased risk for having migraine among individuals in
the lowest quintile of cardiorespiratory tness level (5)
and a negative association between migraine prevalence
and physical activity levels (6–10). Migraine attacks per
se can hinder physical activity participation, and physical
activity is considered a trigger factor for around 50-
60 % of patients, while 75.6 % and 84.2 % of patients
believe that moderate and vigorous exercise can
worsen attacks, respectively (11,12). Thus, the prevailing
argument to explain this negative relationship between
physical activity and migraine has been ascribed to fear-
avoidance behavior or kinesiophobia (6–12).
Alternatively, another explanation for this negative
association between physical activity and migraine
might lie in the affective response to exercise. Affective
response to exercise refers to a basic affect domain, or
the pleasure/displeasure one may feel when exercising,
and it has been established as a determinant factor of
future adherence to physical activity participation (13,14).
Its theoretical framework encompasses the rewarding,
self-reinforcing (hedonic) component of the physical
activity behavior (15–17). Exercise performed in the
positive valence is associated with higher adherence,
whereas exercise eliciting negative responses are more
likely to be discontinued (15–17). The affective response
to exercise is believed to be operationalized under the
so-called dual-mode theory (16-18). This theory proposes
a dimensional, rather than categorical, measure of affect,
which in its turn depends on whether the exercise is
performed below, at, or above the ventilatory threshold
(16-18). The ventilatory threshold represents a ventilatory
parameter that indicates the cardiometabolic turning
point marking the transition from aerobic to anaerobic
energy metabolism, above which by-products from
anaerobic metabolism (e.g., CO
2
, protons, etc.) build-up
in the working skeletal muscles, contributing to metabolic
acidosis, hyperventilation, limb pain, and early fatigue (16-
18). Overall, the affective response is stable and kept on
positive valence when the exercise is performed slightly
below the ventilatory threshold (or mild to moderate
exercise), it largely varies among individuals at the
ventilatory threshold (moderate exercise), and decreases
to negative valence as exercise intensity surpasses the
ventilatory threshold (e.g., vigorous exercise) (18).
Affective response to exercise has never been
assessed in migraine patients. Understanding
psychological factors related to physical activity
behavior in people with migraine has become
particularly relevant, since accumulating evidence points
to increased risk for mental and cardiovascular diseases
in this population (19–22), which in turn can be reduced
by regular physical activity (23). Thus, we wondered
whether migraine patients would exhibit altered affective
response to a single bout of exercise (i.e., acute session)
performed at the ventilatory threshold (moderate
intensity) compared to non-headache individuals, and
whether this previous measure of affect would predict
adherence to a subsequent aerobic exercise-training
program performed at the same exercise intensity. We
hypothesized that individuals with migraine would rate
lower affective scores in the exercise session compared
to non-headache individuals, and the affective response
to exercise would be positively associated with future
adherence to the exercise-training program.
METHODS
This is a prospective cohort study using secondary,
post hoc analyses of affect and perceptual measures
during an exercise session, and their inuence in
adherence to future exercise participation in a supervised
exercise training program. Data were retrieved from
patients enrolled in a clinical trial registered in the
National Institute of Health (www.ClinicalTrials.gov)
under #NCT01972607, and part of the clinical trial results
has been published elsewhere (2). The study protocol
complied with the Good Clinical Practice Principles
and the Helsinki Declaration, and was approved by the
Research Ethics Committee of the Federal University of
São Paulo/Brazil, registered under #08152011.
Participants
Participants were recruited from São Paulo
Hospital´s Headache Unit and a tertiary clinic, The
inclusion criteria were: individuals aged 20 to 60 years, of
both sexes, physically inactive (dened as ≤ 1 day/week
of leisure-time physical activity the previous 12 months),
non-headache individuals and patients with episodic
migraine (having 1-14 attacks per month), including
migraine without aura, migraine with aura, or presenting
both migraine subtypes, according to the 2nd edition of
the International Classication of Headache Disorders
(24). Exclusion criteria were: taking any prescribed
preventive medication, except abortive medication during
migraine attacks, taking dietary supplements, pregnancy,
clinical history of cardiovascular, pulmonary, metabolic,
rheumatic, musculoskeletal, and others neurological
diseases, including other headaches. All participants
had a neurological and cardiac (electrocardiographic)
examination before inclusion in study and gave signed
informed consent.
After being screened for inclusion in the study by
two headache-trained neurologists (authors RTR and
MFPP), all participants were given a headache diary and
were examined every 4 weeks (clinical visits) until the
end of the study for checking headache status (paper-
based headache diaries). Participants who self-reported
never having migraine, without any headache in the past
3 months, and did not present any headache in their
diaries, were considered as controls.
Procedures and Measures
The cardiopulmonary exercise tests, affect measures,
and the aerobic exercise-training program were
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conducted at the Center for Studies in Psychobiology
and Exercise, a University-based center, on two
separated experimental visits. About 1-2 weeks after
the screening visit, participants were scheduled for the
cardiorespiratory tness assessment. Around a week later,
participants performed an acute, 40-min aerobic exercise
session for assessment of the affective response. Figure 1
summarizes the study’s design. All measurements were
undertaken between 8:00AM and 11:00AM, interictally. All
women were assessed within the follicular period of the
menstrual cycle for the affective response.
After the acute exercise session, researcher ABO
randomly assigned participants (simple randomization,
1:1 assignment rate) to receive a 12-week aerobic exercise-
training program or enter a waitlist. An online software
generated random numbers, previously attributed as
follows: odd numbers = exercise-training program, even
numbers = waitlist.
Cardiorespiratory Fitness Assessment
Participants underwent a maximal cardiopulmonary
exercise test on a treadmill (Centurion 300, MICROMED,
Brasília, DF, Brazil) with ramp protocol for determination
of peak oxygen uptake (VO
2Peak
), a gold-standard
measure of cardiorespiratory tness, and the ventilatory
threshold, an amply used cardiometabolic parameter of
submaximal exercise intensity. The ventilatory threshold
consist of a ventilatory indicator reecting the skeletal
muscle energy metabolism, which set the turning point
of exercise intensity above which the metabolic acidosis
from anaerobic metabolism supplementation cannot
be buffered (25). Determination criteria for VO
2Peak
consisted of meeting at least two of the following
criteria: 1) to reach the maximal age-predicted heart rate
(220-age); 2) respiratory exchange ratio > 1.1; 3) rate of
perceived exertion (RPE) ≥ 18. The ventilatory threshold
was determined adopting the ventilatory equivalents
method, dened as the stage where the rst rise in the
ventilatory equivalent of O2 (VE/VO2) occurs without
concurrent rise in the ventilatory equivalent of CO2 (VE/
VCO2) (25). Tests were conducted by a cardiologist and
exercise physiologist, not informed about participants
assignment and independent of the study.
Affective Response and Perceived Exertion
Assessment
Participants were informed that they would perform
a moderate aerobic exercise session according to the
current guidelines for exercise prescription. They were
also aware that the main goal at this visit was to assess
psychological aspects of exercise.
The exercise session consisted of 40 minutes of
moderate walking/jogging on treadmill (depending on
participant’s initial tness level), composed by 5 minutes
of warm-up, 30 minutes inside the aimed intensity, and
5 minutes of cool down period. Intensity was set at the
work rate (m.min
-1
), rate of perceived exertion (RPE),
and heart rate (HR) corresponding to the ventilatory
threshold. The HR was monitored by a heart rate
monitor(Polar® Electro, model F5, Finland) and the RPE
was assessed by the 20-point Borg’s scale (26) . The
RPE score measured at the last minute of the exercise
session was used in the analyses.
Feeling Scale (FS) was used as a measure of affect.
FS is a bipolar, Likert-type scale amply used as a broad
dimension of pleasure/displeasure (basic affect) during
exercise (27). It is composed by 11 points ranging from
+5 to -5, with anchors at zero (“Neutral”) and at each
odd integer, from “Very Good” (+5) to “Very Bad” (-5).
The affective response was assessed by two experienced
exercise physiologists (ABO, DLG), randomly assigned
(coin ipping) to conduct each experiment. FS was
employed at three time points: at rest, just before the
exercise initiates (FSREST), at the 15th minute of exercise
(FSEXE), and immediately after the exercise cessation
(FSPOST). Conversation was limited to answering
participants’ questions regarding the protocol, and
participants were not allowed to listen to music, or to
use any portable electronics. Participants experiencing
migraine attacks during the exercise sessions were
excluded from the analysis.
Aerobic Exercise-Training Protocol
Exercise sessions reproduced the acute exercise
session protocol with regard duration and intensity, and
were delivered 3 times per week. All exercise sessions
were supervised by exercise physiologists (ABO, DLG,
and MTM).
Statistical Analyses
Differences between migraine and control groups for
anthropometric variables, cardiopulmonary tness, and
adherence for the exercise-training groups were analyzed
by independent t-test. Comparisons between groups for
affective response were analyzed by repeated-measures
ANOVA,with 2 groups x 3 time points (FSREST, FSEXE, and
FSPOST); Bonferroni’s adjustments were computed for the
condence intervals of multiple pairwise comparisons. If
Figure 1. Study´s design.
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the assumption of sphericity was violated in the repeated-
measures ANOVAs, the degrees of freedom were adjusted
by Greeenhouse-Geisser´s correction.
A multiple linear regression model was applied to
test the predictors of adherence to exercise (dependent
variable). Adherence was dened as the percentage of
attendance to the exercise protocol sessions. Predictors
variables were, body mass index (BMI), VO
2Peak
, RPE,
FSREST, FSEXE, and FSPOST. A stepwise method for
variables selection was employed in the regression
model. Analyses were computed by the SPSS software
(IBM SPSS Statistics for Windows, Version 20.0. Armonk,
NY), and graphs were designed by GraphPad Prism®
software (GraphPad Software Inc., Version 5.0, San Diego,
CA). A p < 0.05 was considered statistically signicant.
RESULTS
Participants’ ow in the study is shown in
Figure 2. Fifty-four participants (Male: N = 10, Female: N
= 44; mean±SD age: 37.37±11.5 and BMI: 26.7±4.5) were
included in the analyses. Migraine (n = 28) and control
(n = 26) groups were homogenous regarding sex, age,
BMI, cardiorespiratory tness, as well as there were no
difference between groups for the cardiorespiratory data
and work rate elicited at the ventilatory threshold (both
~ 55 % of maximal cardiorespiratory tness, and ~70 % of
maximal heart rate) (Table 1).
Figure 2. Participants’ ow in the study.
Table 1. Participants` anthropometrical, clinical, and
cardiorespiratory data.
Variables
Migraine
(N=28)
Control
(n=26)
Anthropometric Data
Sex (%)
Male 5(17.9) 5(19.2)
Female 23(82.1) 21(80.8)
Age (years) 38.6±12.4 35.9±10.5
Body Weight (kg) 72.1±16.0 69.7±11.7
Height (m) 1.62±0.08 1.63±0.08
BMI (kg/m
2
) 26.9±5.0 26.4±3.9
Clinical Data
Living w/ Disease (yrs) 17.6±11.1 0
Days with Headaches (/month) 9.5±6.0 0
Migraine Frequency (/month) 8.6±6.0 0
Pain Intensity (0-3) 1.58±0.3 0
Cardiopulmonary Data
At Peak
VO
2Peak
(mL.kg.min
-2
) 31.8±6.7 32.5±7.5
HR (b.p.m) 181.7±15.1 182.8±9.5
HR (% age predicted) 100.3±6.6 99.5±4.8
WR (watts) 110.0±32.5 116.2±34.5
RPE 19.4±0.9 19.3±0.9
At the Ventilatory Threshold
VO
2
(% VO
2Peak
) 55.2±9.4 55.4±7.3
HR (b.p.m) 127.7±17.7 125.1±15.6
WR (watts) 66.1±20.2 64.2±16.6
RPE 10.3±
2.5 10.1±2.3
VO
2Peak
: Peak oxygen uptake. HR: Heart rate. WR: Work rate.
RPE: Rate of perceived effort.
For the affective response to acute exercise,
repeated-measures ANOVA of FS showed a main
effect of time [F(1, 52) = 37.5; p < 0.001; η
2
= 0.64], a
main effect of group [F(1, 52) = 10.6; p < 0.002; η
2
=
0.41], and interaction [F(2, 104) = 5.9; p < 0.048; η
2
=
0.2] (Fig. 3a). Multiple pairwise comparisons showed
no differences between migraine and control groups
for FSREST (mean±SD = 3.5±1.9 vs 4±1.1, respectively,
p = 0.262), while there was a signicant progressive
decline from FSREST to FSPOST for both groups (Fig.
3a). The migraine group had a steeper decline, which
was signicantly lower than control group for FSEXE
(mean±SD = 2.0±1.3 vs 2.9±1.3, p < 0.031, respectively)
and FSPOST (mean±SD = 1.4±1.4 vs 2.7±1.3, p = 0.001,
respectively) (Fig. 2a). The RPE at the end of the
exercise session was not different between control and
migraine groups (mean±SD = 11.6±1.4 vs 12.4±1.4, p >
0.05, d = 0.1, respectively) (Fig. 3b).
For the adherence data, twenty-ve (migraine: n
= 13; control: n = 12) completed the exercise-training
program and were analyzed in the regression model.
There was no difference between groups for adherence
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Although physical activity behavior is determined
by a myriad of social, cultural, and affective-cognitive
factors, the affective response to exercise is a relevant
and well-established topic in behavioral research, since it
is associated with physical activity participation, and its
public health implications in terms of management and
prevention of mental and cardiovascular diseases (14-
17). Indeed, in recognition of the relevance of affective
response on future exercise participation, current exercise
prescription guidelines have included the feeling scale as
a complementary parameter of exercise intensity (28).
We recognize that physical activity behavior is
complex, and in migraine patients, attack-related pain per
se can hinder physical activity participation and contribute
to fear-avoidance behavior/kinesiophobia (11-13). In fact,
anxiety-related processes seem to play a relevant role in
physical activity behavior in this population. For example,
in a cohort of 100 patients, Farris et al (2019) showed
that intentional avoidance of physical activity is prevalent
in up to 78 % of patients, and it positively correlates with
migraine frequency (11). Still in this study, over 70 % of
patients reported avoiding both moderate and vigorous
exercise on average 3 times per week in the previous
month, indicating that intentional avoidance constitutes
a relevant factor contributing to lower physical activity in
this population (11). In another analysis, the same group
found that physical activity avoidance is inuenced
by anxiety sensitivity, and higher anxiety score were
associated with a signicant increase in the odds of PA
avoidance at both moderate and vigorous intensities,
with stronger associations between the domains
physical concerns and vigorous exercise avoidance (up
to 7.5-fold increase) (12). Although we did not inquire our
patients about their believes/perceptions of exercise as a
trigger, or anxiety sensitivity scores, migraine frequency
or days with migraine had no correlation with adherence
Figure 3. Affective response (a) and perceived effort (b) of a 40-min. aerobic exercise session; Data are expressed as
mean±SE. *: p < 0.05 vs REST; **: p < 0.01 vs REST; #: p < 0.05 vs Control; ##: p < 0.01 vs Control; Multiple pairwise
comparisons of repeated-measure ANOVA.
to the exercise program [55.9±18.4 % vs 66.4±13.0 %,
respectively; t(23) = 1.6, p = 0.1, d = 0.64], although a large
effect size was observed.
In the whole exercise-training cohort, multiple linear
regression analysis showed FSPOST the only predictor
variable of adherence to subsequent exercise-training
program (β = 0.405, p = 0.04). Based on the adjusted R
2
data of our model, 12.9 % of variance in adherence was
explained by FSPOST. Also, the coefcients of this model
showed that, if all the other variables were kept constant,
every 1-point drop in the FS score resulted in 4.2 % drop
in adherence.
In order to further explore whether adherence could
be affected by migraine attacks frequency, we used
Pearson’s correlations test (as these variables presented
normal distribution) for analyses between clinical
variables and adherence in the exercise-training migraine
cohort. There were no signicant correlations between
adherence and changes in pre-post values (Δ values)
for days with migraine (r = -0.01, p = 0.981), or migraine
frequency (r = -0.18, p = 0.544) (Table 2). Neither there
were correlations between clinical and affective variables.
DISCUSSION
Our study shows for the rst time a reduced
affective response to aerobic exercise, both during
and after an acute exercise session, in individuals with
migraine compared to non-headache individuals. Also,
we provided further evidence to the idea considering the
affective response to exercise captured by the feeling
scale as a potential determinant factor of physical
activity behavior (14-17), by showing a predictive value
of post-exercise affect on future adherence to an
exercise program.
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to the training program or affective response, and our
sample was composed by patients voluntarily interested
in exercise who did not report any attack attributed
to physical exercise (based on headache diaries data).
As such, the results found here add a new perspective
in understanding the negative relationship between
migraine and physical activity levels, which to date has
been unanimously ascribed to fear-avoidance/anxiety
mechanisms. The affect-based process contemplates the
hedonic, self-reinforcing properties of physical activity
(14-18), which are thought to be mediated by common
neurophysiological mechanisms disrupted in migraine
pathophysiology, such as monoaminergic, opioidergic,
and endocannabinoidergic signaling (2,4). Therefore, it
is likely that altered affective processes occurring during
the physical exercise session could also inuence this
negative relationship between migraine and physical
activity. This merits further investigation.
Lastly, but not least, anxiety-related processes
may eventually underlie the negative affect-exercise
adherence relationship, as anxiety sensitivity has shown
to moderate the affective response to exercise in other
clinical populations (29). Farris’s group showed that
in low-active smokers seeking treatment for smoking
cessation, anxiety sensitivity negatively associated with
physical activity enjoyment scale (PACES) and correlated
with anxiety and mood in the 1-mile walk test (29). The
authors ponder that anxiety sensitivity may attenuate
positive physical feelings (enjoyable feelings) elicited by
physical activity, exacerbate the forcasting of negative
affective and physical outcomes, resulting in affective
states that contribute to avoidance behavior (29).
With regard the exercise intensity and its implication
on the affect-adherence relationship, a consistent line
of evidence suggests a negative association between
vigorous exercise and long-term adherence to physical
activity (14-18). These authors criticize the “no pain, no
gain” pop culture, arguing that in terms of public health,
pursuing higher exercise intensity may be detrimental
for assuring long-term adherence to physical activity
participation. Exercise performed at the ventilatory
threshold, as used here, prevents the build-up of by-
products and metabolites from anaerobic metabolism,
and hence hyperventilation, limb pain, and early fatigue
(19). It also promotes cardiorespiratory tness and is
a standardized cardiometabolic parameter of exercise
intensity. Nonetheless, affective response at this intensity
largely varies in the population (19). On the other hand, as
vigorous exercise may also promote specic therapeutic
effects, recent work has aimed at manipulating exercise
prescription in order to conceive vigorous exercise with
positive affect, and hence, promote long-term adherence
to high intensity exercise (30). These authors have
employed repeated, short high-intensity bouts of exercise
(also known as high intensity interval training, or “HIIT”)
(30). In the context of migraine, data from clinical trials
have shown preventive effects with either moderate (i.e.,
at the ventilatory threshold) (2-4), or vigorous exercise
performed as HIIT (≥ 90% of maximal HR) (31). In the later
study, vigorous exercise performed with the HIIT approach
promoted superior clinical effects on migraine frequency,
cardiorespiratory tness, and retinal blood vessels dilation,
suggesting greater clinical and cardiovascular effects
compared to moderate exercise (31). Because to date
there is no study comparing long-term adherence between
vigorous vs moderate exercise in migraine patients, these
data underscore the need for further studies aiming at
investigating psychological and physiological outcomes
from different exercise prescriptions in migraine trials,
and developing new strategies to increase the affective
component of physical activity.
The affective response and adherence to exercise
should be further investigated in people with migraine.
As outlined by Farris et al (2019), clinicians should aim at
managing the subjective appraisal of bodily sensations
by incorporating psychoeducation strategies to reinforce
the clinical benets of regular physical activity (2-3),
adjusting current exercise prescriptions frames to t
gradual exposure approaches (i.e., desensitization),
and by comparing beliefs of migraine trigger effects of
physical activity with objective data (12). We propose
for the newbie patient that is physically inactive or low-
active (i.e., those not meeting the minimum amount
of physical activity recommended by health and
exercise guidelines), practitioners should preconize a
reduced session time for aerobic exercise (e.g., up to
Table 2. Correlations between adherence and migraine clinical data.
Adherence to
Exercise
Migraine Days
Migraine
Frequency
Δ Migraine Days
Δ Migraine
Frequency
Adherence
- -
-
Migraine Days
r -.35 -
p .23
Migraine Frequency
r -.37 .86 -
p .20 <.001
Δ Migraine Days
r -.00 .36 .30 -
p .98 .22 .31
Δ Migraine Frequency
r -.18 .17 .20 .88 -
p .54 .57 .49 <.001
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20 minutes), with gradual, progressive load increment
until targeted perceptual (e.g., keep between 11 and 13
on 20-point Borg´s scale, the verbal anchors “Light” and
“Somewhat hard”, respectively), affective (e.g., no lower
than +1 on feeling scale, the verbal anchor “Good”), and
cardiovascular parameters (e.g., not above ventilatory
threshold, or ~70 % of maximal age-predicted HR). Other
exercise prescription approaches (e.g., HIIT) should be
also tested in this population to establish safe, enjoyable,
and realistic exercise routines that assure adherence.
One should be aware of several limitations in this
study while interpreting these ndings. This study found
a large effect size for the affect variables outcome, but
the small sample size yielded underpowered data (β =
0.73), and limit extrapolation from the regression model.
From clinical practice, we perceive that migraine patients
interested in participating in studies with physical exercise
represent a minority of this population, and this may
constitute selection bias. Additionally, based on headache
diaries checking, physical activity was not a trigger
among the patients of this study, most participants were
women, and there were some restrictive inclusion criteria.
All these factors limit the generalizability of our results.
Importantly, the expectation towards improvement in
headaches through exercise training might have rendered
patients more motivated than control individuals. Yet,
if this was true, our results would be underestimated.
Another limitation concerns to performance bias, as
the experimenters that conducted the exercise sessions
were not blinded to participants’ conditions. This could
have resulted in unequal attention delivered by the
experimenters to the participants, inuencing the affect
scores. Lastly, although the exercise protocol tried to
reproduce a regular aerobic exercise session, it is not
possible to exclude the inuence of factors related to the
laboratory/experimental settings.
The strengths of this study are the prospective design,
the use of gold-standard measure of cardiorespiratory
tness, and standardized exercise testing and prescription
based on ventilatory threshold, which allowed us to
compare subjective psychological parameters in response
to an objective, physiologic stimulus.
CONCLUSIONS
In conclusion, the affective response to an aerobic
exercise of equivalent physiological intensity is reduced in
migraine patients compared to non-headache individuals,
and predicted adherence to future participation in an
exercise-training program. Interventions with physical
activity/exercise should adopt the feeling scale as a
complementary parameter of exercise intensity and
exploit activities that elicit higher affective responses.
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