Yoga an Effective Adjunct to Standard
Migraine Treatment

Michael Vlessides

May 11, 2020

Adding yoga to a standard medication regimen is significantly better than medication alone in providing migraine relief, results of a randomized controlled trial show.  

Findings from the largest trial of its kind to date showed patients with episodic migraine who added yoga to their standard medication regimen experienced a significantly greater reduction in migraine frequency and intensity.

"At the end of 3 months, we found that patients in both groups improved," Gautam Sharma, MD, DM, of the All India Institute of Medical Sciences, New Delhi, India, told Medscape Medical News.

"But the benefit was significantly higher in the yoga group in all areas, including headache frequency, pain, pain intensity, use of medications, and how much migraine interfered with the daily personal life or professional life," Sharma added.

The study was published online May 6 in Neurology.

Medication Often Fails

Migraine is one of the most common disabling primary headache disorders, affecting about 13% of people worldwide. The disorder can also have a marked impact on quality of life, causing patients to miss work and impair performance.

Furthermore, migraine is a risk factor for other disorders, including ischemic cerebrovascular disease, depression, and suicidality.

Although first-line therapy for patients with migraine is medication, only about half of patients with migraine experience a clinically meaningful response.

In addition, up to 10% of patients discontinue medication because of adverse events, and nearly one in two are reportedly dissatisfied with their current treatment.

"Modern medicine doesn't really have an optimal treatment for migraine as of now, and we thought if we could try something that might work, it might be a win-win situation for the physicians and also for the patients," said Sharma.

For its part, yoga — which continues to grow in popularity around the world — has been shown to have beneficial effects on various migraine measures, including frequency, intensity, and duration of pain.

"There have been small observational studies performed, but to my knowledge, this is the largest randomized controlled trial evaluating the effects of yoga practice in migraine," said Sharma.

To help tease out the potential effects of yoga as an adjuvant therapy in patients with episodic migraine, the researchers conducted a prospective, randomized, open-label superiority trial at a single center between April 2017 and August 2018.

In total, 160 patients with a diagnosis of episodic migraine between the ages of 18 and 50 were randomly assigned to either medical treatment alone or medical treatment with yoga.

Reduced Frequency, Less Pain

Both groups also received counseling regarding lifestyle changes that may help with migraine, including the benefits of sleep, diet, and exercise. Patients in the yoga intervention group participated in a pre-designed yoga intervention, which they performed for 3 months.

Patients in the yoga group participated in three weekly 1-hour sessions at the institution for the first month, facilitated by a qualified yoga therapist.

This was followed by five weekly at-home sessions for the following 2 months. Participants received a booklet containing the details of the practice and maintained a yoga log. Compliance was ensured by twice-weekly calls from the yoga center to patients.

Patients also kept a headache log book, which included details about headache and medications. Headache severity was assessed via Visual Analogue Scale; the Migraine Disability Assessment questionnaire (MIDAS) and the Headache Impact Test (HIT)-6 were both used to document changes in headache-specific disability.

It total, 114 patients completed the trial, 57 in each group. Baseline characteristics were comparable between groups, except for a higher mean headache frequency among those in the yoga group.

At the 3-month follow-up, results shows that patients in the yoga group experienced greater improvements in every measure, including:

  • headache frequency (4.41 ±3.99 vs 0.89 ±2.27; P < .001)

  • headache intensity (2.61 ±2.45 vs 1.31 ±2.05; P < .001)

  • HIT score (12.76 ±12.04 vs 4.76 ±8.23; P < .001)

  • rescue pill count (3.11 ±4.62 vs 0.83 ±3.06; P < .001)

  • MIDAS score (16.7 ±13.45 vs 11.5 ±10.10; P = .006)

Headache frequency in the yoga group fell from an average of 9.1 per month to 4.7 per month at the end of the 3 months.

In comparison, those who received medication experienced an average decrease in headache frequency from 7.7 per month to 6.8 at the end of the 3 months.

"Like a Polypill"

The average number of pills consumed by participants in the yoga group decreased by 47% after 3 months, compared with a decrease of approximately 12% for those in the medication-only group.

In addition, a significantly higher proportion of patients in the yoga group were headache-free at the end of the 3 months vs their counterparts who received medication only (P =.006).

Adverse events were uncommon — only three individuals in the control group reported adverse effects, two with weight gain and one patient with mouth dryness.

In the yoga group, one patient reported weight gain. None of the participants reported headache, nausea, or vomiting during the yoga sessions.

The trial findings are consistent with those from other studies in which yoga was used as an intervention for migraine management.

The authors also propose there is a plausible physiologic explanation for the results. Yoga’s positive effects, they note, may be related to a multidimensional effect on both central and peripheral mechanisms, including physical, biochemical, psychological, and autonomic pathways that mediate the generation and spread of pain.

Previous research has shown that yoga can significantly improve vagal tone, reduce sympathetic activity and also increase nitric oxide levels.

Other potential benefits of yoga for migraine patients include an increase in parasympathetic drive and suppression of the stress response systems. The practice may also reduce tension in the head, neck, shoulder, and temporal areas, and loosen the stiff muscles that may also trigger headaches.

"Yoga is like a polypill; it works in different ways. It decreases sympathetic drive, enhances the parasympathetic drive, smoothens the autonomic nervous system, and brings about calm awareness in a person," said Sharma.

"In terms of pain relief, yoga releases endorphins and endogenous opioids, and decreases peripheral substance P. So it decreases pain and brings about a feeling of wellness," he added.

Welcome Findings

The findings came as little surprise to Jennifer L. Bickel, MD, chief of the Headache Section at Children’s Mercy Hospital in Kansas City, Missouri.

"Sometimes people try to simplify yoga down into just the motor movements," Bickel, who was not involved in the study, told Medscape Medical News. "But in this study they incorporated the yoga that included breathing exercises and relaxation techniques. It wasn't just about the exercise.

"So just how we see with other mindfulness techniques, it makes sense to me that we would see improvement and reduction in migraine," added Bickel, who is also a fellow of the American Academy of Neurology.

"We've seen yoga help in other pain conditions as well," she added. "So I found it very encouraging to see another modality that's available for our patients with no side-effect profile."

Sharma added that perhaps the biggest by-product of the study has been the acceptance of yoga as an effective adjunctive therapy in patients with migraine.

"In our clinic, yoga is now an option for patients who respond poorly to medications. This is a safe intervention, it costs nothing, and patients are not stopping their medication. So as a physician, if I want to help a patient who's not improving with medications, I would be happy to prescribe yoga," he said.

The study had no specific funding. Sharma and Bickel have disclosed no relevant financial relationships.

Neurology. Published online May 6, 2020. Abstract

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