Watson is sitting quietly, leafing through the latest Global Burden of Disease update, his expression unreadable. His colleague wanders in, a cappuccino in hand, curious as ever.
“You seem a little pensive, Watson. That usually means you’re either planning something… or disappointed by something.”
Watson sighs, folding the report. “Disappointed and planning something.”
His colleague raises an eyebrow. “That bad?”
The Reality Check
“Migraine,” Watson replies plainly. “Still ranked second globally for years lived with disability. First among young women.”
“That’s not new news, though.”
“No, but the missed opportunity is,” Watson says, tapping the page. “We, as manual therapists, are still largely absent from the table. Despite mounting evidence and clinical relevance, our professions remain underutilised in migraine care.”
Watson’s colleague leans against the counter. “But isn’t migraine mostly medical? Neurovascular, hormonal – outside your lane?”
The Awakening
Watson glances up, not unkindly. “That’s exactly the problem. That belief is the lane marker – and it is outdated. Migraine isn’t just a neurological blip; it’s modulated in part by upper cervical afferents. And guess who’s trained to address those?”
There’s a beat.
“I guess you’re going to say manual therapists, skilled in recognising the relevancy of and addressing upper cervical dysfunction.”
“Exactly.”
The Gap
Watson continues, the cadence of his voice shifting into conviction. “We see it all the time – patients presenting with associated neck symptoms, pain, tension, jaw issues. They’re not in a neurologist’s office. They are on our treatment tables. And too often, the potential role of cervical afferents is dismissed or ignored.”
“I’ve definitely seen that,” nods Watson’s colleague. “Patients bouncing between the neurologist, GP, dentist, psychologist, gastroenterologist, pain clinic, etc, everyone treating a piece of the puzzle, but few (including manual therapists), as you have pointed out previously, seeing the potential role of cervical afferent driven central sensitisation.”
Watson nods. “Because we haven’t been taught to look for it. And when we do suspect it, we don’t always feel equipped to assess and manage it.”
The Undervalued Role
Watson stands and walks over to the whiteboard. “Look – many see migraine as multifactorial. Altered sensory processing, dietary, psycho/social factors, stress, sleep disruption, physical inactivity, etc. However, basic neuroscience tells us that there are four primary influences on the trigemino-cervical complex (TCC). The Conditioned Pain Modulation system and serotoninergic influence (and research is ambiguous around both), as well as noxious trigeminal or cervical afferent input. These – cervical and orofacial trigeminal afferents – aren’t secondary – they’re modulating the condition. That’s our scope.”
Watson’s colleague interjects, “But aren’t manual therapists afraid of making it worse? Provoking an attack?”
“Absolutely. And that’s valid,” Watson agrees. “But that fear stems from a lack of education. When you understand mechanisms like the TCC, central sensitisation, and the cervico-trigeminal interface, you gain confidence. However, this alone is not sufficient; training in assessment and management of upper cervical dysfunction is essential. You move from hesitant to helpful.”
The Systemic Miss
Watson’s colleague exhales, deep in thought. “So, we’re not just missing opportunities with individual patients – we’re absent from a system that needs us.”
“You said it!” Watson exclaims. “True, interdisciplinary care is missing in migraine. But if we’re not educated, we’re not integrated. And if we’re not integrated, patients miss out on options that are safe, effective, and non-pharmacological.”
There’s a long pause.
The Professional Shift
“You know,” says his colleague slowly, “I guess many postgraduate manual therapists don’t think of migraine as their area. Now, I’m realising that beliefs and teaching were part of the problem.”
Watson smiles. “Yes. It’s a systemic blind spot. However, we can change that by recognising elementary neuroscience and the role of cervical afferent pathways in migraine pathophysiology, incorporating migraine into continuing professional development courses and postgraduate mentoring. It’s not just about better patient care. It’s about evolving manual therapy professions.”
Watson’s colleague nods, eyes lighting up. “That is, to stop seeing migraine as something outside of their ‘lane’, and start seeing it as something cervical manual therapy can meaningfully contribute to.”
The Call
“Exactly,” says Watson. “We need to move to collaborative care. From doubt to clinical reasoning. From invisibility to being seen as essential.”
A quiet moment passes.
Finally, Watson’s colleague picks up the Global Burden report, scanning the page. “So what are we calling this?”
Watson thinks for a moment. Then:
“The Awakening.”
