Migraine and Headaches: A Physio’s Perspective
Headaches are incredibly common, but not all headaches are the same.
A migraine, a tension-type headache and a headache arising from the neck can all produce pain around the head and face, yet they are different conditions and may require very different approaches to treatment.
This distinction is important because headache treatment is not simply about finding a tight muscle, correcting posture or treating the spot that hurts.
In fact, migraine is a neurological disorder. Neck pain and stiffness are very common during migraine, but that does not necessarily mean the neck caused the migraine attack.
At the same time, some headaches genuinely can arise from structures in the cervical spine. Others may involve a mixture of migraine biology, neck pain, stress, sleep, activity and other contributing factors.
Understanding which type of headache you are experiencing is therefore the starting point.
How Common Is Migraine?
Migraine is one of the most common neurological conditions in Australia.
Current Australian estimates suggest approximately 14% of Australians live with migraine, representing millions of people across the country.
Migraine is more common in women and is particularly prevalent during the working years of life.
For some people, attacks are relatively occasional. For others, migraine can have a substantial impact on work, exercise, family life, sleep and general wellbeing.
What Does a Migraine Feel Like?
A migraine is more than simply a severe headache.
A typical migraine attack may involve moderate to severe head pain that lasts anywhere from several hours to several days if untreated. The pain is often described as throbbing or pulsating and commonly affects one side of the head, although migraine does not always follow this pattern.
Symptoms can include:
- Moderate to severe headache.
- Throbbing or pulsating pain.
- Pain that may be worse with normal physical activity.
- Nausea or vomiting.
- Sensitivity to light.
- Sensitivity to sound.
- Sensitivity to smells.
- Fatigue or difficulty concentrating.
- Neck pain or stiffness.
People can experience migraine quite differently, and not every attack includes all of these symptoms.
What Is Migraine With Aura?
Some people experience neurological symptoms called an aura before or during a migraine attack.
Visual aura is perhaps the best known and can include flashing lights, zig-zag patterns, blind spots or changes in vision.
However, aura can also involve:
- Changes in sensation or numbness.
- Tingling.
- Difficulty speaking or finding words.
- Less commonly, other neurological symptoms.
Aura symptoms generally develop gradually and are reversible. Many people with migraine never experience an aura at all.
New neurological symptoms should not automatically be assumed to be migraine, particularly if they are different from anything you have previously experienced. Medical assessment may be required to exclude other causes.
What Triggers Migraine?
This is where the conversation can become complicated.
People often identify particular foods, stress, dehydration, hormones or sleep as their migraine “trigger”. Sometimes these relationships are clear, but sometimes what appears to be a trigger may actually be part of the early stages of the migraine attack itself.
Commonly reported factors associated with migraine include:
- Changes in sleep.
- Stress or changes in stress levels.
- Skipping meals.
- Dehydration.
- Hormonal changes.
- Alcohol for some people.
- Changes in routine.
- Changes in physical activity.
Rather than attempting to avoid an ever-growing list of possible triggers, keeping a headache diary can sometimes help identify meaningful patterns.
What About Neck Pain During a Migraine?
Neck pain is extremely common in people who experience migraine.
However, this is an area where our understanding has changed.
Finding a stiff neck, tender muscles or painful upper cervical joints does not automatically mean the neck is causing the migraine.
Neck discomfort can occur before, during or after a migraine attack and may be part of the migraine itself.
At the same time, some people with migraine also have a genuine musculoskeletal neck problem. In these situations, addressing the neck may improve that component of their symptoms even though it does not necessarily remove the underlying migraine disorder.
This is why our headache physiotherapy assessment focuses on distinguishing between different headache presentations rather than assuming that all headache and migraine symptoms come from the neck.
What Is a Cervicogenic Headache?
A cervicogenic headache is different from migraine.
It is classified as a secondary headache, meaning the headache occurs because pain is being referred from structures within the neck.
This may involve the joints, muscles or other structures in the upper cervical spine.
Features that may raise suspicion of a cervicogenic headache include:
- Headache associated with neck pain or stiffness.
- Reduced neck movement.
- Headache reproduced or aggravated by particular neck movements.
- Headache reproduced by examination of structures within the upper neck.
- Pain that commonly begins around the neck or back of the head and refers forwards.
- A consistent relationship between neck symptoms and headache symptoms.
There is overlap between cervicogenic headache and migraine, which is why differentiating the two simply from where the headache hurts can be difficult.
How Can the Neck Refer Pain Into the Head?
The link between the neck and headache makes more sense when we look at how sensory information is processed by the nervous system.
Sensory information from the upper cervical spine and the trigeminal nerve comes together within an area of the nervous system often referred to as the trigeminocervical complex.
The trigeminal nerve provides sensation to large areas of the face and head, while the upper cervical nerves provide sensation from structures around the upper neck and back of the head.
Because these sensory pathways converge, the brain may sometimes interpret pain arising from structures in the upper cervical spine as pain occurring in the head or face.
This provides a biological explanation for how a neck problem can genuinely produce a headache.
Importantly, though, this same connection is also one reason neck pain can be prominent during migraine. The presence of neck symptoms alone is therefore not enough to determine whether the neck is the source of the headache.
What Is a Tension-Type Headache?
Tension-type headache is another very common primary headache disorder.
The typical description is quite different from migraine. Pain is often felt on both sides of the head and may feel like pressure, tightness or a band around the head rather than a strong pulsating sensation.
Tension-type headaches are generally mild to moderate and are usually not made significantly worse by routine physical activity.
Muscle tenderness around the head, neck and shoulders can be present, particularly in people who experience frequent tension-type headaches.
However, describing these headaches as simply being caused by “muscle tension” or poor posture is also an oversimplification. Like migraine, tension-type headache involves the nervous system and can be influenced by multiple biological, physical and lifestyle factors.
Migraine, Cervicogenic or Tension-Type: What Is the Difference?
There can be considerable overlap, but some broad patterns can help.
- Migraine: Often moderate to severe, may be throbbing or one-sided and can involve nausea, light sensitivity, sound sensitivity and worsening with activity.
- Cervicogenic headache: Pain originates from the neck and is often associated with restricted neck movement or reproduction of the headache during cervical assessment.
- Tension-type headache: More often produces bilateral pressure or tightness, is generally mild to moderate and typically lacks the prominent nausea and sensory sensitivity seen in migraine.
Real people do not always fit perfectly into diagnostic boxes. It is also possible for someone to experience more than one headache disorder.
Can Physiotherapy Help Migraine?
This needs a little nuance.
Physiotherapy is not a primary treatment for the neurological mechanisms underlying migraine. Migraine management may involve medical diagnosis, medication, lifestyle strategies and, for some people, preventative therapies prescribed by a GP, neurologist or other medical practitioner.
However, physiotherapy may still be useful when neck pain, cervical stiffness, muscular sensitivity or reduced physical capacity coexist with migraine.
In those situations, treatment is aimed at the musculoskeletal component of the presentation rather than claiming to “fix” migraine itself.
Our physiotherapy assessment can help determine whether there is a meaningful neck component that may be worth addressing as part of your broader migraine management.
Can Physiotherapy Help Cervicogenic Headaches?
This is where physiotherapy generally has a clearer role.
Because cervicogenic headache arises from structures in the cervical spine, treatment can be directed towards the relevant physical contributors identified during assessment.
This may include:
- Improving cervical movement where it is restricted.
- Manual therapy where appropriate.
- Exercise for the neck and shoulder girdle.
- Improving strength and endurance.
- Gradually restoring tolerance to work, exercise and daily activity.
- Addressing aggravating positions or workloads.
- Building confidence in normal neck movement.
There is no single posture, joint or muscle that explains every cervicogenic headache, so treatment should be based on what is actually found during assessment.
What About Posture?
Posture receives a lot of attention when headaches are discussed.
There is nothing inherently dangerous about sitting with your head forward, looking down at your phone or working at a computer. There is also no single “perfect posture” that prevents headaches.
However, spending long periods in any position can become uncomfortable, particularly when someone already has an irritable neck or headache disorder.
For many people, a more useful strategy is to focus on:
- Changing position regularly.
- Taking movement breaks.
- Building neck and upper-body capacity.
- Adjusting a workstation when the current setup consistently aggravates symptoms.
- Maintaining regular physical activity.
In other words, movement and capacity usually matter more than trying to hold yourself in a perfect position all day.
When Should a Headache Be Medically Assessed?
Most headaches are not caused by serious disease, but some presentations require medical assessment rather than physiotherapy alone.
You should seek urgent medical attention for symptoms such as:
- A sudden, extremely severe headache unlike anything you have previously experienced.
- A new headache associated with weakness, facial drooping, difficulty speaking or significant neurological changes.
- Headache following significant head trauma.
- Headache associated with fever, significant illness or neck rigidity.
- A new or rapidly changing headache pattern.
- New headache during pregnancy or the post-partum period that is concerning or severe.
- A headache associated with loss of consciousness or seizure.
If you are uncertain about a new or unusual headache, seeking medical advice is appropriate.
What Does a Physiotherapy Headache Assessment Involve?
A good headache assessment should start with the story rather than immediately treating the neck.
We may ask about:
- Where your headache is located.
- How long attacks last.
- How frequently they occur.
- Whether you experience nausea, aura or sensitivity to light and sound.
- Whether neck pain occurs before, during or after the headache.
- Factors that aggravate or relieve symptoms.
- Your sleep, exercise and activity patterns.
- Previous diagnoses and medications.
Where appropriate, the physical examination may then assess neck movement, strength, muscular sensitivity, upper cervical function and whether the person's familiar headache can be reproduced through examination of the cervical spine.
The aim is not simply to find something “tight”. It is to work out whether the neck is genuinely contributing to the headache presentation and whether physiotherapy has a useful role.
Living With Recurring Headaches or Migraine
Recurring headaches can be exhausting, especially when the cause feels unclear.
The most useful starting point is often getting the diagnosis right.
Migraine should be managed as a neurological disorder. Cervicogenic headache requires consideration of the neck. Tension-type headache may involve a different combination of nervous system, muscular and lifestyle factors again.
And sometimes people have elements of more than one.
If neck pain, stiffness or movement appears to be part of your headache presentation, a physiotherapy assessment can help determine whether there is a musculoskeletal component that can be addressed.
You can learn more about our approach to headaches and migraine or read more about our broader Physiotherapy services.
