Current Journal of Neurology

Current Issue

By Issue

By Author

By Subject

Author Index

Keyword Index

About Journal

Aims and Scope

Editorial Board

Publication Ethics and Malpractice Statement

AI policies

Indexing and Abstracting

Peer Review Process

Journal Metrics

Mechanisms and clinical applications of the valsalva maneuver in migraine relief: A mini-review

Articles in Press

Document Type : Short Communication

Authors

1 Hôpital Robert-Debré, Paris, France

2 Department of Neurology, School of Medicine, Qom University of Medical Sciences, Qom, Iran

3 Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran Headache Department, Neurology Ward, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Background: Migraine headaches (MH) are often managed with pharmacologic treatments, but there is growing interest in non-pharmacologic approaches that can reduce reliance on medications. The Valsalva Maneuver (VM) may offer a novel approach to managing MH.
Methods: We conducted a comprehensive literature review in this regard using Google Scholar and PubMed. The search focused on studies examining the relationship between VM and MH, various aspects of VM, and studies regarding migraine etiology.
Results: Our search reviewed 4,659 articles and included 57 that discussed the relevant topics. The findings suggest that VM may serve as an effective non-pharmacological technique for reducing MH severity. Several potential mechanisms may contribute to this event, including: 1- Autonomic Nervous System (ANS) Modulation: VM influences cardiac function and the trigeminovascular system (TVS), which are dysregulated in migraine patients. 2- Vascular Regulation: Abnormal vascular resistance in the dura mater and cerebral arteries, important in migraine pathophysiology, may be alleviated
through VM-induced readjustment of vasodilation and modulation of the vasoconstrictor index (VI). 3- Intracranial Pressure and Neurochemical Modulation: Controversial but intriguing mechanisms suggest that VM regulates internal air pressure within the skull sinuses, manipulates cerebrospinal fluid (CSF) pressure, induces transient hypoxic effects, and triggers the release of endogenous pain modulators, all of which could contribute to shortening MH duration. 
Conclusion: The VM demonstrates potential symptom-relieving benefits in MH, supported by both verified evidence and some unexplained findings. However, large-scale clinical trials on this topic are lacking to clarify the mechanism of the role of VM in MH and to establish a standardized protocol for its application.

Keywords

Main Subjects

References
  1. Ashina M, Katsarava Z, Do TP, Buse DC, Pozo-Rosich P, Özge A, et al. Migraine: epidemiology and systems of care. Lancet 2021; 397(10283): 1485-95.
  2. Olla D, Sawyer J, Sommer N, Moore JBt. Migraine Treatment. Clin Plast Surg 2020; 47(2): 295-303.
  3. Puledda F, Silva EM, Suwanlaong K, Goadsby PJ. Migraine: From pathophysiology to treatment. J Neurol 2023; 270(7): 3654-66.
  4. Silberstein SD. Preventive Migraine Treatment. Continuum (Minneap Minn) 2015; 21(4 Headache): 973-89.
  5. Haghdoost F, Togha M. Migraine management: Non-pharmacological points for patients and health care professionals. Open Med (Wars) 2022; 17(1): 1869-82.
  6. Licina E, Radojicic A, Jeremic M, Tomic A, Mijajlovic M. Non-Pharmacological Treatment of Primary Headaches-A Focused Review. Brain Sci 2023; 13(10): 1432.
  7. Pstras L, Thomaseth K, Waniewski J, Balzani I, Bellavere F. The Valsalva manoeuvre: physiology and clinical examples. Acta Physiol (Oxf) 2016; 217(2): 103-19.
  8. Srivastav S, Jamil RT, Dua A, Zeltser R. Valsalva Maneuver. [Updated 2025 May 4]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2025. Available from: URL: https://www.ncbi.nlm.nih.gov/books/NBK537248/.
  9. Baker JR, Hira R, Uppal J, Raj SR. Clinical Assessment of the Autonomic Nervous System. Card Electrophysiol Clin 2024; 16(3): 239-48.
  10. Junqueira LF, Jr. Teaching cardiac autonomic function dynamics employing the Valsalva (Valsalva-Weber) maneuver. Adv Physiol Educ 2008; 32(1): 100-6.
  11. Nahm FK, Freeman R. Autonomic Nervous System Testing. In: Blum AS, Rutkove SB, editors. The Clinical Neurophysiology Primer. Totowa, NJ: Humana Press; 2007. p. 447-60.
  12. Davies DJ, Yakoub KM, Su Z, Clancy M, Forcione M, Lucas SJE, et al. The Valsalva maneuver: An indispensable physiological tool to differentiate intra versus extracranial near-infrared signal. Biomed Opt Express 2020; 11(4): 1712-24.
  13. Miglis MG. Migraine and Autonomic Dysfunction: Which Is the Horse and Which Is the Jockey? Curr Pain Headache Rep 2018; 22(3): 19.
  14. Frank F, Faulhaber M, Messlinger K, Accinelli C, Peball M, Schiefecker A, et al. Migraine and aura triggered by normobaric hypoxia. Cephalalgia 2020; 40(14): 1561-73.
  15. Shirbache K, Shirbacheh A, Hashemi MS, Pishgahi G, Shirbacheh MV, Mirmosayyeb O, et al. The Effect of Valsalva Maneuver on Migraine Headache. Arch Clin Biomed Res 2022; 6(4): 632-8.
  16. Pavelić AR, Zebenholzer K, Wöber C. Reconceptualizing autonomic function testing in migraine: A systematic review and meta-analysis. J Headache Pain 2024; 25(1): 54.
  17. Elmenshawi I, Sakr S. Autonomic dysfunction in migraine; what do we need to know? Egypt J Neurol Psychiat Neurosurg 2009; 46(2): 489-96.
  18. Zhang L, Qiu S, Zhao C, Wang P, Yu S. Heart Rate Variability Analysis in Episodic Migraine: A Cross-Sectional Study. Front Neurol 2021; 12: 647092.
  19. Schürks M, Rist PM, Bigal ME, Buring JE, Lipton RB, Kurth T. Migraine and cardiovascular disease: Systematic review and meta-analysis. Bmj 2009; 339: b3914.
  20. Rossi DM, de Souza HCD, Bevilaqua-Grossi D, Vendramim ACC, Philbois SV, Carvalho GF, et al. Impairment on Cardiovascular Autonomic Modulation in Women with Migraine. Int J Environ Res Public Health 2022; 20(1): 763.
  21. Öztürk M, Turan OE, Karaman K, Bilge N, Ceyhun G, Aksu U, et al. Evaluation of ventricular repolarization parameters during migraine attacks. J Electrocardiol 2019; 53: 66-70.
  22. Melek IM, Seyfeli E, Duru M, Duman T, Akgul F, Yalcin F. Autonomic dysfunction and cardiac repolarization abnormalities in patients with migraine attacks. Med Sci Monit 2007; 13(3): Ra47-9.
  23. Kurth T, Schürks M, Logroscino G, Gaziano JM, Buring JE. Migraine, vascular risk, and cardiovascular events in women: prospective cohort study. Bmj 2008; 337: a636.
  24. Ng CYH, Tan BYQ, Teo YN, Teo YH, Syn NLX, Leow AST, et al. Myocardial infarction, stroke and cardiovascular mortality among migraine patients: A systematic review and meta-analysis. J Neurol 2022; 269(5): 2346-58.
  25. Valecha J, Khandait H, Sk A, Gupta V, Kumawat S, Anamika F, et al. Migraine and heart: A reality check. Glob Cardiol Sci Pract 2023; 2023(3): e202320.
  26. Akter T, Ferdousi S. Autonomic dysfunction and migraine: Assessed by time series analysis of heart rate variability. J Bangladesh Soc Physiol 2017; 12(2): 57-60.
  27. Ramachandran R. Neurogenic inflammation and its role in migraine. Semin Immunopathol 2018; 40(3): 301-14.
  28. Spekker E, Tanaka M, Szabó Á, Vécsei L. Neurogenic Inflammation: The Participant in Migraine and Recent Advancements in Translational Research. Biomedicines 2021; 10(1): 76.
  29. Levy D, Moskowitz MA. Meningeal Mechanisms and the Migraine Connection. Annu Rev Neurosci 2023; 46: 39-58.
  30. Dodick DW. A Phase-by-Phase Review of Migraine Pathophysiology. Headache 2018; 58 Suppl 1: 4-16.
  31. Olesen J, Burstein R, Ashina M, Tfelt-Hansen P. Origin of pain in migraine: Evidence for peripheral sensitisation. Lancet Neurol 2009; 8(7): 679-90.
  32. Biscetti L, Cresta E, Cupini LM, Calabresi P, Sarchielli P. The putative role of neuroinflammation in the complex pathophysiology of migraine: From bench to bedside. Neurobiol Dis 2023; 180: 106072.
  33. Kursun O, Yemisci M, van den Maagdenberg A, Karatas H. Migraine and neuroinflammation: the inflammasome perspective. J Headache Pain 2021; 22(1): 55.
  34. Liang F, Liu H. Simulation of hemodynamic responses to the valsalva maneuver: An integrative computational model of the cardiovascular system and the autonomic nervous system. J Physiol Sci 2006; 56(1): 45-65.
  35. Chow KE, Dhyani R, Chelimsky TC. Basic Tests of Autonomic Function. J Clin Neurophysiol 2021; 38(4): 252-61.
  36. Yoshida S, Tanaka H, Mizutani M, Nakao R, Okamoto N, Kajiura M, et al. Autonomic nervous system function in adolescent migraineurs. Pediatr Int 2017; 59(9): 991-5.
  37. Olesen J. Cerebral blood flow and arterial responses in migraine: History and future perspectives. J Headache Pain 2024; 25(1): 222.
  38. Yang D, Zhang C, Omran SS, Cucchiara B, Rundek T, Wright CB, et al. Basilar artery curvature is associated with migraine with aura in the Northern Manhattan Study. J Neurol Sci 2022; 432: 120073.
  39. Otu E, Şen S, Örmeci T, Yüzbaşıoğlu N. Association between vertebral artery dominance and basilar artery curvature in migraineurs: an anatomical magnetic resonance imaging study. Neuroradiol J 2024; 37(3): 314-22.
  40. Martelletti P, Jensen RH, Antal A, Arcioni R, Brighina F, de Tommaso M, et al. Neuromodulation of chronic headaches: position statement from the European Headache Federation. J Headache Pain 2013; 14(1): 86.
  41. Song D, Li P, Wang Y, Cao J. Noninvasive vagus nerve stimulation for migraine: A systematic review and meta-analysis of randomized controlled trials. Front Neurol 2023; 14: 1190062.
  42. Bäcker M, Grossman P, Schneider J, Michalsen A, Knoblauch N, Tan L, et al. Acupuncture in migraine: Investigation of autonomic effects. Clin J Pain 2008; 24(2): 106-15.
  43. Li Y, Liang F, Yang X, Tian X, Yan J, Sun G, et al. Acupuncture for treating acute attacks of migraine: a randomized controlled trial. Headache 2009; 49(6): 805-16.
  44. Hadjikhani N, Albrecht DS, Mainero C, Ichijo E, Ward N, Granziera C, et al. Extra-Axial Inflammatory Signal in Parameninges in Migraine with Visual Aura. Ann Neurol 2020; 87(6): 939-49.
  45. Louveau A, Herz J, Alme MN, Salvador AF, Dong MQ, Viar KE, et al. CNS lymphatic drainage and neuroinflammation are regulated by meningeal lymphatic vasculature. Nat Neurosci 2018; 21(10): 1380-91.
  46. Rustenhoven J, Drieu A, Mamuladze T, de Lima KA, Dykstra T, Wall M, et al. Functional characterization of the dural sinuses as a neuroimmune interface. Cell 2021; 184(4): 1000-16.e27.
  47. Kaag Rasmussen M, Møllgård K, Bork PAR, Weikop P, Esmail T, Drici L, et al. Trigeminal ganglion neurons are directly activated by influx of CSF solutes in a migraine model. Science 2024; 385(6704): 80-6.
  48. Nelson-Maney NP, Bálint L, Beeson AL, Serafin DS, Kistner BM, Douglas ES, et al. Meningeal lymphatic CGRP signaling governs pain via cerebrospinal fluid efflux and neuroinflammation in migraine models. J Clin Invest 2024; 134(15): e175616.
  49. Whedon JM, Glassey D. Cerebrospinal fluid stasis and its clinical significance. Altern Ther Health Med 2009; 15(3): 54-60.
  50. Frank F, Kaltseis K, Filippi V, Broessner G. Hypoxia-related mechanisms inducing acute mountain sickness and migraine. Front Physiol 2022; 13: 994469.
  51. Britze J, Arngrim N, Schytz HW, Ashina M. Hypoxic mechanisms in primary headaches. Cephalalgia 2017; 37(4): 372-84.
  52. Olesen J. The role of nitric oxide (NO) in migraine, tension-type headache and cluster headache. Pharmacol Ther 2008; 120(2): 157-71.
  53. Mondal S. Proposed physiological mechanisms of pranayama: A discussion. J Ayurveda Integr Med 2024; 15(1): 100877.
  54. Maini K, Schuster NM. Headache and Barometric Pressure: A Narrative Review. Curr Pain Headache Rep 2019; 23(11): 87.
  55. Kimoto K, Aiba S, Takashima R, Suzuki K, Takekawa H, Watanabe Y, et al. Influence of barometric pressure in patients with migraine headache. Intern Med 2011; 50(18): 1923-8.
  56. Jerath R, Edry JW, Barnes VA, Jerath V. Physiology of long pranayamic breathing: Neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system. Med Hypotheses 2006; 67(3): 566-71.
  57. Chauhan S, Johnson J. A Pain Relieving Approach: Valsalva Maneuver. Int J Hum Rights 2024; 11(2): 42-5.
  58. Hosseini SJ, Manzari ZS, Karkhah S, Heydari A. The effects of Valsalva maneuver on pain intensity and hemodynamic status during short peripheral cannula insertion in adults: A systematic review and meta-analysis. J Vasc Access 2024; 25(4): 1051-62.
  59. Lane RJ, Davies PT. Modified Valsalva test differentiates primary from secondary cough headache. J Headache Pain 2013; 14(1): 31.
  60. González-Quintanilla V, Madera J, Pascual J. Update on headaches associated with physical exertion. Cephalalgia 2023; 43(3): 3331024221146989.
Current Journal of Neurology

Articles in Press, Accepted Manuscript
Available Online from 18 October 2025
Files
Share
How to cite
Statistics