MIGRAINE: and neck pain

Neck pain as a cause for headaches has been discussed in our article “Headaches: Cervicogenic (from the neck)“.

As a quick recap, neck pain can also trigger migraine headaches via the nerve input from the neck to the Trigeminal Cervical Complex (TCC) in the brainstem.

• Studies have said that neck pain is a trigger for migraine headache in  32-57% of patients.
• Their are many nerves around the neck and head that relay back to cervical nerve roots C1, C2 and C3; C1, C2 and C3 feed into the TCC.
• The TCC also accepts nerve fibres coming from the coverings of the brain.
• The TCC is an important center in initiating the experience of migraine headaches.

Neck issues causing nerve irritation of the nerves that travel to the scalp and face are often described as stabbing or sharp pains.

Neck issues that are caused by local muscle pain are often described as pressure-like or achy.

• Studies show that up to 70% of people with migraine may report neck pain during their attack, and 48% actually report neck pain before their attacks (Ashina, 2021).
• Neck pain can occur in any phase of migraine (premonitory, headache, postdrome) (link to sensitivity article).
• Neck pain can occur due to migraine, even when people don’t get a headache (but just have the other phases of migraine); and in this case the neck pain will still respond to migraine treatments.

Because of this overlap, sometimes migraines are misdiagnosed as cervicogenic headaches.

• headaches caused by neck issues and neck issues caused by migraine have a lot of overlap.
• A lot of people have neck issues that you can see on an x-ray or an MRI (especially an MRI as they have such high definition and can easily pick up a lot of detail)
  • in fact, most people by their mid-20’s are starting to show signs of arthritis in their necks.
  • The factors that add up – past the migraine threshold – in triggering a migraine are not always obvious

To differentiate a migraine from a cervicogenic headache, it helps to keep in mind that:

• migraine often has associated features that are not as common in cervicogenic headache (i.e., photophobia, nausea & vomiting, phonophobia, throbbing pain)
  • there are other diagnostic criteria that can help differentiate the two like if pain block injections in the neck remove the headache, then it’s likely a cervicogenic headache.
• Migraines tend to last for 4-72 hours but neck issues (e.g., a herniated disc) can last weeks to months
• Chronic migraine can cause a vicious cycle of  migraine ⇔ neck pain

Occipital neuralgia is a headache type that can often occur with migraines, or be confused with migraines.

The occipital nerves come from the C2 and C3 cervical nerve roots, and come out of the skull a little bit above where the back of the head meets the neck.

These nerves can become injured or inflamed, e.g., bad posture, sensitization from migraine, etc.

Pain from these nerves usually recur seemingly “out-of-the-blue” or “all-of-a-sudden”, and lasting usually anywhere from a few seconds to minutes. The pain is usually described by our patients as shooting, stabbing, and sharp.

The diagnosis is clinched when you inject some freezing (a.k.a. peripheral nerve block) around the nerve and the pain abates entirely.

There are many treatments for Occipital Neuralgia including peripheral nerve blocks, ergonomic interventions, physiotherapy and medication. There are other treatments with more stubborn cases of Occipital Neuralgia.

What are peripheral nerve blocks?

Peripheral nerve blocks have been used for the acute and preventative treatment of a variety of headache disorders for decades. In fact, it was being used over 100 years ago although doctors didn’t understand how it worked.

Peripheral nerve blocks involves injecting a little amount of freezing over nerves.

Certain nerves are targeted because of their position in the nervous system.

• For example, the GON (Greater Occipital Nerve) is the most commonly targeted nerve.
  • This is because its signals relay back to the 2nd and 3rd cervical nerve roots
  • The 2nd and 3rd cervical nerve roots relay back to the TCC (Trigeminal Cervical Complex)
  • The TCC is an important center in how migraine pain is experienced
  • So, “freezing” the GON allows us to exploit this “highway” into the TCC and reducing the signal strength that can result into migraines
• Other nerves that are frequently targeted for peripheral nerve blocks (all of the following are easily reached as they are superficially-positioned, laying just under the skin) include:
  • LON (Lesser Occipital Nerve)
  • ATN (Auriculotemporal Nerve)
  • SON (Supraorbital Nerve)
  • STN (Supratrochlear Nerve)

People wonder how a little bit of freezing – like the kind you get at the dentist’s office that wears off after a few hours – can cause pain relief for longer than a few hours?

• This is thought to be due to a change in the way the Central Nervous System modulates pain (Bartsch et al., 2002)

Sometimes, peripheral nerve blocks are used to diagnose the role the neck is playing in the patient’s headaches. Other times, peripheral nerve blocks can still help even though the neck is not playing a causal role in the patient’s headaches; the peripheral nerve is just a convenient “highway” into the TCC and the pain network that can be exploited by peripheral nerve blocks to help improve pain.

What are trigger point injections?

Trigger points are exquisitely tender spots in muscles that are often found along with headache disorders (Graff-Radford et al., 2004).

Why trigger points develop is poorly understood (Robbins et al., 2014).

It is thought that this sensitivity in the muscles, if sustained on a chronic basis, leads to long-term electrophysiological changes that results in the Central Nervous System becoming hypersensitive (Robbins et al., 2014).

Treatment of trigger points include:

• manual therapy
• TENS (transcutaneous electrical nerve stimulation)
• trigger point injections
• dry needling

Trigger point injections are used to alleviate headache and neck pain.

Trigger point injections involve injections of numbing medications with the help of needles into trigger points, thus relieving the muscle pain and also relieving the worsening of the headache, if the neck pain is related to migraine.

The effect of the trigger point injections can have a variable duration. It can last anywhere from two weeks to four months or six months or longer at times.

There are many treatments of neck pain associated with headache.

They really don’t differ much from the treatment of just neck pain alone other than if patients also have headaches, then the headaches require treatment also.

Often, headache treatment is more likely to cause better impact in improving one’s symptoms although, in our experience, we find people spend more time and effort treating the neck pain with traditional neck-focused therapy (e.g., massage, neck physiotherapy, etc.)

Often, patients get so focused on their neck that they start thinking about their necks all the time. They may be constantly repositioning their necks, or “checking in” with their necks, or avoiding many day-to-day activities that they see as problematic for their necks. All of this for most patients becomes counterproductive.

When you were in your best shape, how much attention did you pay to your neck?

The goal is to get people employed in fun, fluid, efficient movement, and allow them to focus on the movement or the purpose of their moving about, rather than on the neck.

Here is a list of several treatments that can help treat the neck:

• Hot and cold packs
  • for some patients, heat works better; for others, cold works better
  • people discover which works better for them by trial-and-error
• Electrotherapeutic devices like TENS (transcutaneous electrical nerve stimulation)
• Regulating your sleep
• Neuromuscular training of the neck
  • we have had a lot of success in using this approach (basically making people more powerful).
• Medications like NSAIDs
• Ergonomic assessment and interventions
  • There is no evidence that neck collars help.
• Relaxation training
• Biofeedback
  • sEMG training is often used to train the neck
  • HRV training and temperature training is often used to treat the headache
• Weight loss
• Physiotherapy
• Massage
• Trigger point injections
• Acupuncture, acupressure, dry needling
• There are more invasive injections that trigger structures deeper down (i.e., epidural steroid injections, facet joint blocks, radiofrequency ablations)

An ergonomic assessment (usually done by an OT) is also a good idea as most of us spend at least a quarter of our time at the office, and poor posture may lead to chronic muscle tension that can contribute to neck pain and headaches, including migraine.

Good posture can make a significant difference not just to how you physically feel, but also to how you perform.

Basically, the goal of ergonomics is to arrange your environment in a way that encourages you to maintain a neutral anatomical posture (a posture that is most efficient, and not taxing). Ergonomics is relevant to any activity in which you may find yourself, e.g., driving, working at the desk, lying in bed, working in the kitchen, etc.

Even if your screen height is just right so that it is not encouraging you to slouch forward, maintaining a position (even if it is a neutral position) for long periods of time can still cause problems.

For example,

• tissues in your neck like intervertebral discs can still get compressed the longer you adopt a position for
• it’s not always possible to get our neutral posture “perfect” so that joints may sort of pinch together in a way that we can get away with for a time, but longer than that, it starts to cause more significant microtrauma and inflammation that takes longer to recover
• the way we breath (e.g., if we use accessory muscles around the neck rather than the diaphragm) can introduce a negative force on our necks that cause tension to increase in our necks, or cause our posture to drift into a biomechanically disadvantageous posture
• when we adopt a specific posture for longer periods of time, or core muscles (the most supportive and resilient muscles) tend to get relatively deactivated. When you are missing the strongest part of your biomechanical foundation, other parts of your body start to “wilt” and take on more tension than is idea.
• Whenever you do anything repeatedly, you are inevitably “training” that activity
  • if you have a poor ergonomic setup, this means you are training unideal postures which can start filtering into your other activities, e.g., you may be more prone to running injuries because you have inadvertently trained an inconvenient posture for running when you sit at your workstation for 8 hours a day
  • if you have and ideal ergonomic setup, we tend to find shortcuts in doing things that make things easier for us in the short-term (because the long-term is far away, right?☺️) like not using our diaphragm when we breath, or slouching, which may take less energy
• oversleep can cause tension in muscles, and this can worsen headaches.
  • Finding the right pillow or a sleep position that works for you can be a challenging task
  • There is no evidence-based pillow or sleeping position.
  • Pillows vary greatly by height and material, and so you need to find one which suits best to you — and it depends on your personal experience.
  • Sleeping positions also vary greatly with many of us moving around a lot overnight, or some of us being able to tolerate certain sleeping positions better than others.
  • Also, obsessing over our sleeping position and ergonomics can be counterproductive.
  • Ideally, you can set up your sleeping environment to help you adopt a neutral spine.

To check sedentariness:

• Awareness of your anatomy and biomechanical principles involves are helpful
• Often education can be learned in the context of neuromuscular retraining which is an excellent practical approach to learning it as you will also learn the skills on how to engage muscles in your body in a way that is idea.
• Getting up and changing your positions frequently is very helpful. Dr. Stuart McGill from Waterloo university has done studies that led him to conclude that if you change your position every 10 minutes, your body will thank you.
  • There are apps you can download onto your computer to remind you to take a break, or even and “exercise snack”.
• Organizing your day so that you that you break up stretches of sedentariness
• Regular exercise has been shown to increase muscle tone in core muscles for as long has half a day in those that exercise infrequently, and a whole day in those who exercise more frequently.
  • this will have the effect of protecting more vulnerable structures in your body (e.g., facet joints in your neck, intervertebral discs, etc.)
  • it will also follow that this makes an argument for the utility of exercising in the morning or at least breaking up your work day with an exercise session
• if you can harness the power of diaphragmatic breathing and ideal neuromuscular control, diaphragmatic breathing can serve as a pump that regularly “breathes” your whole body and injects “turgor pressure” or support to your posture.

Less thought of factors that can affect ergonomics revolve around how your eyes, ears and emotions are engaged while you are performing a task.

It is well known that if you have to strain to see because ambient lighting is not good enough, or the screen is positioned un-ergonomically, it will “hijack” your posture. Similarly, a stressful environment are likely to have negative reactions on your posture. This is nothing new; it has been a topic of interest for thousands of year, i.e., Fung Shui, Vastu, etc.

There are some screen adjustments you can make and some other rules-of-thumb that you can employ to help mitigate the negative influences of screens.

Ashina, S., (2021, Mar 23). When Migraine Starts or Stays in Your Neck. Migraine World Summit 2021. https://migraineworldsummit.com/
Bartsch T, Goadsby PJ. Stimulation of the greater occipital nerve induces increased central excitability of dural afferent input. Brain. 2002;125:1496-1509.
Blumenfeld, A., Ashkenazi, A., Napchan, U., Bender, S. D., Klein, B. C., Berliner, R., Ailani, J., Schim, J., Friedman, D. I., Charleston IV, L., Young, W. B., Robertson, C. E., Dodick, D. W., Silberstein, S. D., & Robbins, M. S. (2013). Expert consensus recommendations for the performance of peripheral nerve blocks for headaches – A narrative review. Headache, 53(3), 437–446. https://doi.org/10.1111/head.12053
Charles, A., (2019, Mar 23). Neck Pain and Migraine. Migraine World Summit 2019. https://migraineworldsummit.com/
Graff-Radford SB. Myofascial pain: Diagnosis and management. Curr Pain Headache Rep. 2004;8:463- 467.
Robbins, M. S., Kuruvilla, D., Blumenfeld, A., Charleston, L., Sorrell, M., Robertson, C. E., Grosberg, B. M., Bender, S. D., Napchan, U., & Ashkenazi, A. (2014). Trigger point injections for headache disorders: Expert consensus methodology and narrative review. Headache, 54(9), 1441–1459. https://doi.org/10.1111/head.12442