Is it your neck or your migraine?

You get a headache, your neck is stiff and you reach for the obvious conclusion: it must be my neck. Or perhaps the reverse and the neck is just along for the ride. Both are common ways of reading it yet neither is always right. Time is often wasted trying to figure out which direction things are coming from.

Neck pain is part of migraine more often than you would think

Many people with migraine feel neck pain or stiffness before, during or after an attack. A US study quoted in a 2023 review found neck pain in 38% of people with severe headache or migraine, against 11% of people without. The same review noted that it is more common in chronic migraine than in episodic migraine.

So a sore neck does not necessarily mean the headache starts in the neck. It can be an early sign that an attack is on its way, or indeed already part of the attack itself. That is one reason migraine gets mislabelled as "tension" or "a trapped nerve" for years with the patient left to live with it because there is nothing more than over the counter painkillers and neck exercises to help. Snore.

What cervicogenic headache actually is

Cervicogenic headache is a different thing. In the international headache classification (ICHD-3) it is a headache caused by a problem in the neck, in the joints, discs or soft tissues of the cervical spine. The diagnosis has to be found with objective clinical findings which is easier said than done. The criteria look for evidence of a neck disorder that is known to cause headache, a clear link in time between the two and a headache that eases when the neck problem does. They also look for reduced neck movement, and pain that is brought on by certain neck movements or positions.

In practice, the clues that point towards the neck include:

• Pain that stays on one side. Cervicogenic headache is typically side-locked. Migraine is too but can switch sides from one attack to the next and in a not-insignificant number of people occurs on both sides at the same time.
• Pain you can provoke. Certain neck movements or sustained postures bring it on almost immediately, and the neck might feel restricted.
• Less of the rest of the migraine picture. Nausea, light and sound sensitivity and aura point towards migraine, though unhelpfully they do not rule out a neck contribution.

Research also suggests that a specific movement test, the flexion-rotation test, and neck flexion strength can help differentiate the two. That is something a trained clinician will examine and is not something to try at home with a mirror.

Often it is both

The most difficult bit? The two are not tidy categories, and they can sit alongside each other interacting in a tangled web. Someone can have migraine and also a stiff, irritable neck that feeds into it. In my clinical judgement, that overlap is common in the people I see, particularly alongside disturbed sleep, long hours at a desk and jaw tension.

The key to this is that these two problems need different things. Migraine usually needs a proper acute and preventive plan, often through your GP or a headache specialist. A neck that is part of the picture can be assessed and treated directly alongside it and should not simply be dismissed as a common side effect if you believe it is playing a role in making your migraine attacks worse or indeed seeming to trigger them.

What helps

The evidence here is modest, so it shouldn't be oversold. The 2023 review suggests that reducing neck muscle tension through exercise, physiotherapy or acupuncture may reduce migraine frequency and that posture control and manual treatment of tender muscle points can play a part. Its authors also stress that the evidence is limited and that care should be individualised.

What that looks like for you depends on what an assessment finds. A sensible starting point is to notice what your neck is doing when attacks begin: does a position or movement set it off, or does the stiffness arrive with the other symptoms? Writing that down for a few weeks gives you something specific to bring to an appointment.

Why it is worth getting looked at properly

If you have been told it is "just tension", or that your scans are clear so nothing is wrong, that is not the same as having a diagnosis. A clear scan rules out some things but it does not explain your pain. A careful assessment of your history, your neck and your attack pattern can begin that conversation. Understanding what your picture truly looks like can be the beginning of getting a handle on it and reducing the burden you carry.

If neck pain and headache keep turning up together and nobody has pulled them apart, a full assessment can help. You are welcome to book an appointment or get in touch.

• Vicente BN, Oliveira R, Martins IP, Gil-Gouveia R. Cranial autonomic symptoms and neck pain in differential diagnosis of migraine. Diagnostics. 2023;13(4):590. doi:10.3390/diagnostics13040590
• International Classification of Headache Disorders, 3rd edition (ICHD-3). Section 11.2.1, cervicogenic headache. ichd-3.org
• National Institute for Health and Care Excellence (NICE). Clinical Knowledge Summaries: Headache assessment (red flags and urgent referral). cks.nice.org.uk

This article is general information, not a diagnosis or a substitute for individual medical advice.