Neck pain in migraine: A narrative review and steps to correct evaluation and treatment

Abstract

BackgroundNeck pain is common in migraine patients, occurring during all migraine phases and between attacks. It can be a migraine symptom, trigger or a coexisting condition, and is associated with greater disability and poorer treatment response. There is evidence that neck pain associated with headaches can be frequently incorrectly diagnosed as a cervical disorder rather than migraine, resulting in a lack of appropriate treatment. Accurately assessing the connection between neck pain and migraine is crucial for effective treatment.MethodsThis narrative review aims to summarise existing research on the role and contribution of neck pain in migraine, both as a symptom and a trigger, and outlines future research needed to deepen our understanding of this relationship. It also proposes a structured approach for assessing neck pain in migraine and a treatment algorithm, offering guidance for clinical evaluation and treatment. For this purpose, a comprehensive narrative review was conducted using PubMed, covering preclinical, clinical, neurophysiological and imaging evidence on migraine and neck pain.ResultsMigraine patients frequently exhibit cervical dysfunction, tenderness and altered posture, with overlapping neuroanatomical pathways of the neck and trigeminal systems, suggesting shared mechanisms of nociception and migraine initiation. Clinical assessment involves a thorough history, physical exam and exclusion of secondary causes. Standard migraine therapies, such as amitriptyline and onabotulinumtoxinA, may help reduce neck pain and non-pharmacological treatments, such as physical therapy, acupuncture and behavioural strategies, show some promise. However, evidence on neck pain relief is limited.ConclusionsAccurately distinguishing whether neck pain is a symptom, trigger or comorbid condition in migraine is essential for guiding effective treatment strategies. Both pharmacological and non-pharmacological approaches may help manage migraine-associated neck pain. However, few studies have assessed the effects of acute or preventive migraine therapies, particularly calcitonin gene-related peptide-targeted treatments, on neck pain, highlighting a significant gap in our current knowledge. Future research should evaluate the effectiveness of these therapies on neck pain, both alone and in combination with non-pharmacological interventions.

Keywords: evaluation; migraine; neck pain; pathophysiology; treatment.