Resistance training for migraine in females: mechanistic review of hormonal, CGRP, autonomic, vascular and nociceptive pathways

Migraine is the second leading cause of years lived with disability worldwide and disproportionately affects women, in whom the disorder tends to be more frequent, longer-lasting and functionally more disabling than in men. This female preponderance, which emerges after menarche, is tightly linked to changes in estrogen levels, reproductive phases and sex-specific responsiveness of the trigeminovascular and calcitonin gene-related peptide (CGRP) systems. Against this backdrop, non-pharmacological interventions that modulate the same physiological processes involved in migraine are particularly attractive. Resistance training (RT) has emerged from recent systematic reviews and network meta-analyses as one of the exercise modalities with the largest effect sizes on monthly migraine frequency, yet its mechanistic rationale in women is rarely addressed as a coherent biological argument. In this narrative review we integrate the pathophysiology of migraine in females with the adaptations induced by structured RT across four convergent axes: autonomic regulation, neurovascular and endothelial function, systemic and neurogenic inflammation, and endogenous pain modulation. We interpret the current clinical evidence in light of these mechanisms, outline how the hormonal milieu in females may shape individual responsiveness, and propose a translational framework for prescribing RT as part of a comprehensive, sex-informed migraine management plan. We explicitly distinguish between robust findings, emerging signals and hypotheses that remain to be tested, and highlight the main methodological barriers that should be addressed before RT can be firmly embedded in clinical guidelines for women with migraine.