SEEDS for success: Lifestyle management in migraine

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Release date: November 1, 2019
Expiration date: October 31, 2020
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Primary care physicians can help their patients with migraine modify their triggers, and thereby mitigate the severity and frequency of their symptoms, by offering lifestyle modification counseling based on the mnemonic SEEDS (sleep, exercise, eat, diary, and stress). The authors review evidence associated with each of these factors and provide best-practice recommendations.


  • Sleep: Standard sleep hygiene recommendations to maximize sleep quantity and quality.
  • Exercise: 30 to 60 minutes 3 to 5 times a week.
  • Eat: Regular healthy meals, adequate hydration, and low or stable caffeine intake.
  • Diary: Establish a baseline pattern, assess response to treatment, and monitor analgesia to improve accuracy of migraine diagnosis.
  • Stress: Cognitive behavioral therapy, mindfulness, relaxation, biofeedback, and provider-patient trust to minimize anxiety.



Migraine is the second leading cause of years of life lived with a disability globally.1 It affects people of all ages, but particularly during the years associated with the highest productivity in terms of work and family life.

Migraine is a genetic neurologic disease that can be influenced or triggered by environmental factors. However, triggers do not cause migraine. For example, stress does not cause migraine, but it can exacerbate it.

Primary care physicians can help patients reduce the likelihood of a migraine attack, the severity of symptoms, or both by offering lifestyle counseling centered around the mnemonic SEEDS: sleep, exercise, eat, diary, and stress. In this article, each factor is discussed individually for its current support in the literature along with best-practice recommendations.


Advice to patients with migraine: SEEDS for success
Multiple sleep comorbidities are associated with migraine, including sleep apnea and insomnia.2 Poor sleep itself has been described as a migraine trigger. Those with both migraine and poor sleep report having lower quality of life, more mood disorders, lower socioeconomic status, higher stress, and higher tendency for poor lifestyle habits.3 The number needed to treat by initiating routine lifestyle behaviors including sleep, diet, and exercise is 2, indicating that every other person could benefit from this type of intervention.4

Before optimizing sleep hygiene, screen for sleep apnea, especially in those who have chronic daily headache upon awakening. An excellent tool is the STOP-Bang screening questionnaire5 ( Patients respond “yes” or “no” to the following questions:

  • Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
  • Tired: Do you often feel tired, fatigued, or sleepy during the daytime?
  • Observed: Has anyone observed you stop breathing during your sleep?
  • Pressure: Do you have or are you being treated for high blood pressure?
  • Body mass index greater than 35 kg/m2?
  • Age over 50?
  • Neck circumference larger than 40 cm (females) or 42 cm (males)?
  • Gender—male?

Each “yes” answer is scored as 1 point. A score less than 3 indicates low risk of obstructive sleep apnea; 3 to 4 indicates moderate risk; and 5 or more indicates high risk. Optimization of sleep apnea with continuous positive airway pressure therapy can improve sleep apnea headache.6 The improved sleep from reduced arousals may also mitigate migraine symptoms.

Sleep hygiene and behavior modification

Behavioral modification for sleep hygiene can convert chronic migraine to episodic migraine.7 One such program is stimulus control therapy, which focuses on using cues to initiate sleep (Table 1). Patients are encouraged to keep the bedroom quiet, dark, and cool, and to go to sleep at the same time every night. Importantly, the bed should be associated only with sleep. If patients are unable to fall asleep within 20 to 30 minutes, they should leave the room so they do not associate the bed with frustration and anxiety. Use of phones, tablets, and television in the bedroom is discouraged as these devices may make it more difficult to fall asleep.8

The next option is sleep restriction, which is useful for comorbid insomnia. Patients keep a sleep diary to better understand their sleep-wake cycle. The goal is 90% sleep efficiency, meaning that 90% of the time in bed (TIB) is spent asleep. For example, if the patient is in bed 8 hours but asleep only 4 hours, sleep efficiency is 50%. The goal is to reduce TIB to match the time asleep and to agree on a prescribed daily wake-up time. When the patient is consistently sleeping 90% of the TIB, add 30-minute increments until he or she is appropriately sleeping 7 to 8 hours at night.9 Naps are not recommended.

Let patients know that their migraine may worsen until a new routine sleep pattern emerges. This method is not recommended for patients with untreated sleep apnea.


Exercise is broadly recommended for a healthy lifestyle; some evidence suggests that it can also be useful in the management of migraine.10 Low levels of physical activity and a sedentary lifestyle are associated with migraine.11 It is unclear if patients with migraine are less likely to exercise because they want to avoid triggering a migraine or if a sedentary lifestyle increases their risk.

Exercise has been studied for its prophylactic benefits in migraine, and one hypothesis relates to beta-endorphins. Levels of beta-endorphins are reduced in the cerebrospinal fluid of patients with migraine.12 Exercise programs may increase levels while reducing headache frequency and duration.13 One study showed that pain thresholds do not change with exercise programs, suggesting that it is avoidance behavior that is positively altered rather than the underlying pain pathways.14

A systematic review and meta-analysis based on 5 randomized controlled trials and 1 nonrandomized controlled clinical trial showed that exercise reduced monthly migraine days by only 0.6 (± 0.3) days, but the data also suggested that as the exercise intensity increased, so did the positive effects.10

Some data suggest that exercise may also reduce migraine duration and severity as well as the need for abortive medication.10 Two studies in this systematic review15,16 showed that exercise benefits were equivalent to those of migraine preventives such as amitriptyline and topiramate; the combination of amitriptyline and exercise was more beneficial than exercise alone. Multiple types of exercise were beneficial, including walking, jogging, cross-training, and cycling when done for least 6 weeks and for 30 to 50 minutes 3 to 5 times a week.

These findings are in line with the current recommendations for general health from the American College of Sports Medicine, ie, moderate to vigorous cardio­respiratory exercise for 30 to 60 minutes 3 to 5 times a week (or 150 minutes per week). The daily exercise can be continuous or done in intervals of less than 20 minutes. For those with a sedentary lifestyle, as is seen in a significant proportion of the migraine population, light to moderate exercise for less than 20 minutes is still beneficial.17

Based on this evidence, the best current recommendation for patients with migraine is to engage in graded moderate cardiorespiratory exercise, although any exercise is better than none. If a patient is sedentary or has poor exercise tolerance, or both, exercising once a week for shorter time periods may be a manageable place to start.

Some patients may identify exercise as a trigger or exacerbating factor in migraine. These patients may need appropriate prophylactic and abortive therapies before starting an exercise regimen.


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