Neck Pain and Migraine: Causality or a Migraine Symptom?

Neck pain is highly prevalent among individuals with migraines and significantly contributes to disability. But is it merely a migraine symptom, or does it play a causal role?

This question was notably raised in a 2009 commentary titled “Cervicogenic headache: a pain in the neck for some neurologists?” The article¹ suggested that neck pain (NP) might be a symptom of migraine or an epiphenomenon. It concluded with a crucial statement: “The only way forward is collaboration to test clinical history and examination, underpinned by local procedures… unless neurology and pain medicine can work together on prospective studies of diagnosis and treatment, this question will be as controversial in two decades from now as it has been in the past two decades.”(p.876). Unfortunately, genuine collaboration remains scarce, so the controversy continues.

The medical model views the relationship between neck pain and migraine as complex and only partially understood. Sometimes, NP is seen as a manifestation of migraine. The convergence of trigeminal and cervical afferents in the trigeminocervical complex (TCC) explains NP as a symptom: trigeminal noxious afferents are misinterpreted as arising from the cervical field, producing NP. This pathway is bi-directional, exemplified by cervicogenic headache (CGH), where noxious cervical afferent information is assumed to be from the trigeminal field, resulting in NP.

Support for causal NP would be stronger if evidence showed a shared pathophysiology with migraine. Allodynia, a common symptom of chronic migraine, and it is recognised that NP represents allodynia.^2-4 Since allodynia influences the chronicity of migraine, this may explain why NP is more often observed in patients with frequent migraine attacks.^2-5 Additionally, the efficacy of triptan medication in treating NP in migraine patients⁴ supports a common pathophysiology.

In addition, empirical observations show that patients experiencing migraine in their neck (without head pain) but with nausea and vomiting report resolution with triptan medication.

Furthermore, recent research involving 14,492 migraine patients found that nearly 70% reported NP. Those with NP during migraine episodes experienced higher levels of disability, depression, anxiety, and cutaneous allodynia compared to those without NP. Moreover, individuals with NP had lower quality of life, reduced work productivity, and a poorer response to acute treatments. The study concluded that neck pain is a severe issue for migraine sufferers, exacerbating the negative impacts of migraines.

Does this suggest that cervical afferents are mere bystanders, or are they key players in migraine pathophysiology?

While the role of NP in migraine remains ambiguous, a skilled, experienced manual therapy approach can readily differentiate between symptom expression and causality.

References:

1. Goadsby PJ. Cervicogenic headache: a pain in the neck for some neurologists? Lancet Neurol. Oct 2009;8(10):875-877.
2. Calhoun AH, Ford S, Millen C, Finkel AG, Truong Y, Nie Y. The prevalence of neck pain in migraine. Headache. Sep 2010;50(8):1273-1277.
3. Calhoun AH, Ford S, Pruitt AP. Presence of neck pain may delay migraine treatment. Postgrad Med. Mar 2011;123(2):163-168.
4. Calhoun AH, Ford S. Double-blind, placebo-controlled, crossover study of early intervention with sumatriptan 85/naproxen sodium 500 in (truly) episodic migraine: what’s neck pain got to do with it? Postgrad Med. Mar 2014;126(2):86-90.
5. Baldacci F, Vedovello M, Ulivi M, et al. Triggers in allodynic and non-allodynic migraineurs. A clinic setting study. Headache. Jan 2013;53(1):152-160.