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  • Writer's pictureSam Kelokates

Introductory Guide to Your Neck Pain and Migraine

Updated: Nov 2, 2022

Neck pain is most of the most common symptoms reported during migraine attacks.

It is estimated that about 76% of those with migraine report neck pain associated with attacks. This number is even higher for those who have more than one headache type, such as tension type headache!

The presence of neck pain in those with headache can lead to delayed or misdiagnosis because this symptom is common with several headache disorders. It’s important that neck pain receives appropriate physical examination.

Below I will elaborate on what neck pain means for those diagnosed with migraine, how potential sources of neck pain can be identified, and what treatment options you have available to address neck pain.

Neck Pain Does NOT Mean Anything Is Wrong With Your Neck!

Identifying Cervical Impairments Contributing To Your Migraine

Treatments for Neck Pain and Migraine


Neck Pain Does NOT Mean Anything Is Wrong With Your Neck!

One of the biggest misconceptions for those suffering from neck pain during a migraine attack is that the neck has a problem. Because of the neurophysiology of migraine it is possible that neck pain could have been generated in the absence of musculoskeletal dysfunction or impairment of the neck.

This is because of the convergence of nociceptive inputs from the trigeminal nerve and the cervical nerves within the trigeminocervical nucleus. It has been theorized that when the trigeminocervical nucleus is hyper-active during a migraine attack. During a migraine attack pain signals can be extended out the trigeminal and cervical nerves causing headache and neck pain, respectively.

This phenomenon is known as referred pain. It is similar to when someone having a heart attack experiences arm or jaw pain.

However, it is important to understand that this is a two-way street. Neck pain has been shown to refer to pain in the head and face. This is known as cervicogenic headache, and is fairly common type of mild headache.

Solely relying on the complaint of neck pain does not indicate neck dysfunction or pathology, but it does warrant further physical examination to investigate possible cervical origins of pain.

So how can we tell which structures may be implicated in neck pain and migraine?

Identifying Cervical Impairments Contributing to Your Migraine

Much research has gone into identifying cervical sources of pain and headache. A physical examination of the neck is very important because of the overlap with migraine, cervicogenic headache, and tension-type headache.

There are more than 20 physical tests and measures for evaluating neck pain in those with migraine. These tests include assessment of cervical range of motion (particularly of the upper cervical spine), muscular endurance of the deep cervical flexors and extensors, reproduction of pain via manual stimulation, joint mobility assessment, and trigger point identification.

Here is a quick set of tests that I use to examine patients with headache and neck pain that can help further elucidate the cause of neck pain. These tests are the Flexion-Rotation Test, the deep cervical flexor endurance test, and the palpation and sustain pressure over cervical spine.

I like to use these tests, because they provide a lot of information about cervical sources of pain, and they are able to be performed quickly. The information they provide hep guide the treatment plan!

The Flexion Rotation Test

The first is the Flexion-Rotation Test. The test places the patient in full neck flexion while they lay on their back. The head is turned to the right and left to identify limitations in rotation. This test creates a bias for the assessment of the joint between the 1st and 2nd vertebra.

Why I like this test:

  • Research has been done that shows a difference in this test between those with cervicogenic headache, those with migraine, and healthy controls (no pain)

  • The established references numbers for deficits of rotation helps to further differentiate cervicogenic headache from those with migraine

Deep Cervical Flexor Endurance Tests

The deep cervical flexor endurance test is a quick method to test endurance of cervical muscles that help to control the head. In the test that patient lays on their back, and lifts their head off of the table while maintaining a chin tuck position. The patient is timed for how long they can hold their head with chin-tucked 3 cm off the table.

Why I like this test:

  • There are established normative values for healthy controls, those with neck pain, and those with migraine.

  • Those with migraine may trigger an attack up to several hours following the test. This further confirms a migraine diagnosis.

Palpation & Sustained Pressure

The purpose of palpation & sustained pressure techniques are used to reproduce headache and neck pain symptoms in those with migraine to identify upper cervical spine structures contributing to the pathophysiology of migraine.

Manual assessment of the upper cervical spine occurs with palpation over the midline of C1, then the spinous processes of C2 and C3, and joints of C0/1 and C1/2 of both sides. Then Sustained Pressure is applied to the C1's lateral posterior arch, and then C2's articular pillar.

Why I like these manual techniques:

  • High Sensitivity and Specificity for neck pain in migraine due to musculoskeletal changes

  • Reproduction of symptoms with provocation testing helps to identify optimal treatment strategies.

It’s important to note that positive findings do not indicate that cervical structures are causing migraine. It only identifies them as sources of pain contributing to attacks. Palpation and Sustained Pressure identify cervical structures with generalized hyper-sensitivity due to central sensitization. This does NOT differentiate between cause or trigger of migraine.

Treatments for Neck Pain with Migraine

Rehabilitative interventions for identified musculoskeletal dysfunctions may combine manual therapy, exercise therapy, and relaxation techniques. The main goal of these interventions is to lessen pain and sensitivity of the neck, restore movement of the upper cervical spine, and enhance function.

Manual therapy encompasses many different techniques. The list includes spinal manipulation, massage, trigger point techniques, and soft tissue mobilization. This is not an exhaustive list of manual techniques. The goal of manual techniques are to improve mobility, increase pain thresholds, and decrease sensitization of neck structures.

Exercise strategies to address neck pain with migraine can be both specific neck exercises or generalized exercise. Neck specific exercise can help to address mobility deficits, range of movement, and strength & endurance deficits that could be contributing to pain. While generalized exercise has whole body benefits such as improved pain modulation, stress reduction, and improved sensory processing.

There are many relaxation techniques that can help to relieve neck pain. In particular, I tend to focus on progressive muscle relaxation. I like this technique because it helps bring more awareness to areas of muscle tension, and teaches you how to recognize neck tightness and how to relax the muscle. A study done in 2016 supports the use of the for the reduction in migraine attack frequency.


Neck pain is the most common symptom aside from headache related to migraine. But neck pain does not indicate that there is neck dysfunction or impairment. Due to convergence at the trigeminocervical nucleus of pain receptors, migraine can refer pain to the neck.

A comprehensive musculoskeletal examination can help to further identify musculoskeletal and neural structures of the neck that can be implicated in your specific migraine presentation.

If positive finding are found during exam then a comprehensive program treatment program, that includes manual interventions, exercise, relaxation technique, and education can help to desensitize the area and reduce migraine frequency and neck pain.


  1. Neck pain in episodic migraine: premonitory symptom or part of the attack?

  2. Prevalence of neck pain in migraine and tension-type headache: a population study

  3. A Neuroscience Perspective of Physical Treatment of Headache and Neck Pain

  4. Stratifying migraine patients based on dynamic pain provocation over the upper cervical spine

  5. Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis

  6. Cervical Muscular Endurance Performance in Women With and Without Migraine

  7. Muscle endurance training of the neck triggers migraine attacks

  8. Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice

  9. Progressive muscle relaxation reduces migraine frequency and normalizes amplitudes of contingent negative variation (CNV)