In my clinical evaluations of patients during my doctoral dissertation process in Turkey, neck pain (NP) and migraine was a frequently observed combination. When these two conditions coexist, they contribute to the burden of chronic pain, which is why I realized the importance of emphasizing this connection in evaluation and treatment. As we observe June, the month of migraine awareness, let us draw attention to the evaluation of NP and interventions that can alleviate the pain burden in migraine patients.
People with migraines who also experience NP may develop neck disability as a means to cope with the pain. Consequently, stability, mobility, and strength in the cervical spine and craniocervical muscles may decrease. The cervical muscles, ligaments, and joints may endure abnormal loads, leading to compensatory forward head posture. Activities requiring head and neck stabilization, such as reading, driving, or personal care, may pose challenges for migraine patients with NP. If nociceptive stimulation persists, the cervical stabilization deficiencies during daily activities can become chronic, contributing to the emergence of chronic pain.
Neck disability is a predictive factor for the impact of headaches in patients with chronic migraine. Unfortunately, there are limited studies exploring neck problems in the context of chronic migraine. A study focusing on chronic migraine patients evaluated using the Neck Disability Index (NDI), which includes NP, headache intensity, sleep, lifting, reading, driving, working, leisure activities, and concentration, found that headache intensity had the highest disability impact, with intensity being influenced by neck disability. Reading and lifting activities followed in terms of pain impact. Additionally, our clinical-based study revealed that a 1 cm increase in headache intensity compared to the Visual Analog Scale (VAS) in chronic migraine patients with moderate neck disability according to NDI could lead to complete neck disability.
Globally, migraine contributes to 45.1 million YLDs (years of life lived with disability), highlighting its significance as a cause of disability. NP-accompanying migraines also plays a role in this disability burden. According to a meta-analysis study, NP is twelve times more prevalent in patients with migraines compared to individuals without headaches, with a prevalence of 77% among migraine patients. Chronic migraine is associated with neck pain, possibly due to the chronicity and shared trigeminocervical pain pathways of migraine and NP. Furthermore, the chronic nature of this complex pain condition can lead to disability and reduced quality of life. Overall, headache disorders rank 1st among all age groups and sexes between 15-49 years old, and 3rd among all age groups and sexes overall, according to the 2019 Global Burden Disease study. NP ranks 4th among global disability-causing conditions.
However, the burden of neck pain in migraine patients remains unknown both globally and in Turkey. Headache in general remains to be underestimated, under-recognized, and undertreated worldwide, especially in low- and middle-income countries. Based on my clinical experience, individuals who frequently experience migraines often report neck pain before and during their attacks. It is essential to find solutions for this pain and address secondary problems such as disability. Therefore, migraine patients should undergo thorough evaluations to assess neck pain and related issues. Comprehensive evaluations may lead to the implementation of physical therapy and rehabilitation approaches, including exercises, soft tissue applications for the neck region, pain education, and interventions such as OnabotulinumtoxinA, all of which can be beneficial in treating migraine and neck-related problems. Our goal should be to reduce the burden of neck pain in migraine patients.
To summarize, there is a high global burden of migraine, and affected individuals frequently experience additional neck-related issues. Nevertheless, this comorbidity is often neglected in daily routine, contributing to the burden of chronic pain and leading to reduced quality of life and subsequent disability. Physical therapy, rehabilitation interventions, and the application of OnabotulinumtoxinA have demonstrated potential in addressing these neck problems and alleviating pain. While research in this field remains limited, conducting long-term follow-ups, comprehensive evaluations, treatment studies, and focused research on physical therapy can provide valuable insights to researchers, allowing for more effective identification and management of neck pain in migraine patients. A holistic approach should be taken to also address and reduce the burden of chronic pain globally, as headache in general still remains to be underestimated, under-recognized, and undertreated worldwide, particularly in low- and middle-income countries.
Dilara Onan has been working as a research fellow at Hacettepe University Faculty of Physical Therapy and Rehabilitation since 2016, and she is a Ph.D. in the same department since 2023. In late 2022, she was at the Rome Sapienza University Sant’Andrea Hospital headache clinic as a Ph.D. Erasmus student and strengthened her academic and clinical experience. Her research interests include chronic pain (headaches and spinal pain), exercise and rehabilitation practices. Since 2016, she has participated in many national and international congresses and meetings related to her research areas and has also published numerous research articles.