Understanding the Relationship Between Neck Pain and Migraine

Patients often present reporting “migraine”, which after further assessment turns out to be cervicogenic or tension-type headache. But what about patients who have true migraine as well as neck pain, and want to know how the two relate?

This is the case Dr Zhiqi Liang explores in her Case Study. This blog highlights a few foundational things physios should understand about migraine when managing patients with headache and neck pain.

If you want to see exactly how an expert reasons through a case like this, watch Dr Zhiqi Liang’s full Case Study here.

What is migraine?

One of the biggest misconceptions about migraine is that it is simply a severe headache. In reality, migraine is a neurological disorder characterised by altered sensory processing. During certain periods, the brain becomes more sensitive and has difficulty integrating sensory information, leading to a range of symptoms that extend beyond head pain.

Patients may experience nausea, dizziness, fatigue, difficulty concentrating, sensitivity to light and sound, mood changes and neck pain. Migraine is also cyclical, with symptoms often fluctuating through different phases of an attack.

Migraine can be classified in two overarching ways. Based on frequency, episodic migraine is defined as 1–14 headache days per month, while chronic migraine involves headache on 15 or more days per month for more than 3 months. It can also be classified according to symptom presentation, including migraine without aura, migraine with aura, probable migraine, and less common forms associated with gastrointestinal disturbance, benign paroxysmal vertigo or torticollis.

A particularly important phase for patients to understand is the prodrome, which can occur 2-48 hours before migraine onset. During this phase, patients may experience symptoms such as fatigue, yawning, anxiety, low mood, difficulty concentrating, food cravings, increased thirst, increased urination, nausea, or heightened sensitivity to sensory stimuli. Recognising these early warning signs can help patients identify when a migraine is developing and take steps to better manage their symptoms.

The case

The patient was a 30-year-old female doctor with a long history of headache and neck pain.

Over the previous six months, she reported headache on 10 days per month and neck pain on 14 days per month. She described a past history of increased headache and neck pain frequency during periods of increased workload, and had recently increased her night shifts. Her key question was: “Is my neck contributing to my migraine?”

Her neck pain was rated 5/10 and described as an aching tightness. She scored 28% on the Neck Disability Index. Her headache was rated 7/10 and described as throbbing. It started at the base of the skull and travelled into the back of the eye.

Assessment of headaches

A thorough headache assessment requires physios to go deeper than simply asking where the pain is.
Pain around the base of the skull, eye and neck can occur in both migraine and cervicogenic headache, so location alone is not enough to determine the diagnosis. Physios need to understand the duration, intensity, frequency and quality of the headache, as well as any associated symptoms. See Zhiqi describe the diagnostic criteria for migraine without aura in this clip from her Case Study:

This is also where an understanding of headache neurophysiology becomes important. Watch Zhiqi explain this in the clip from her Case Study:

In this case, the physical assessment found:

• Pain with right cervical rotation and extension
• Slightly impaired cervical movement accuracy
• Slight motion sickness when using a virtual reality device
• Pain with right rotation during the flexion-rotation test
• Normal craniocervical flexion test and strength testing with reproduction of slight general neck pain and mild headache
• Inconsistent joint position sense testing with vague dizziness
• General tenderness in the right upper cervical region on manual examination
• No clear cervical hypomobility or hypermobility

At first glance, some of these findings could appear to support cervical involvement. The patient had neck pain, some symptoms were reproduced during testing, and there was tenderness in the upper cervical region.

However, the key point is that the physical findings did not strongly support a cervical musculoskeletal disorder. There were no clear articular signs. Strength was largely normal. Manual assessment found tenderness, but not a clear joint impairment.

Instead, the findings were more consistent with cervical pain hypersensitivity. The neck was sensitive, and the assessment reproduced symptoms, but there was not strong evidence that the cervical spine was driving the headache.

Was the neck contributing to the migraine?

Zhiqi’s reasoning was that, due to the lack of clear physical impairments on assessment, the patient’s neck pain was more likely a symptom of migraine rather than a trigger. Watch her explain her reasoning in this clip from her Case Study:

So, does physio still have a role in management? Treatment may still help with pain modulation, education, pacing and symptom management. But the goal is different. Watch Zhiqi’s full Case Study to learn how she approached management for this patient.

Wrapping up

Migraine and neck pain commonly coexist, but that does not mean the cervical spine is necessarily driving the headache. Understanding the nature of migraine, applying appropriate diagnostic reasoning, and ensuring physical findings genuinely support cervical involvement can help physios avoid incorrect assumptions and provide more targeted management.

Want to know exactly how an expert reasons through a migraine case? Watch Dr Zhiqi Liang’s full Case Study here.