Head and neck
These are two issues that get confused constantly, and are managed very differently once you know which one you are dealing with.
Migraine and neck pain sit close together, but the relationship between them is more often than not just assumed without proper assessment. What a proper headache assessment gives you is an answer on whether your neck is contributing to your headaches, and treatment of it if it is.
Working out which of the two you have is the biggest part of the assessment. Migraine and cervicogenic headache respond to different treatment, and treating one as though it were the other is the most common reason people conclude that nothing works.
On this page
Cervicogenic headache is a secondary headache caused by a disorder of the cervical spine and its associated structures. The headache starts in the neck and is felt in the head. It is usually one sided, stays on that side, worsens with neck movement or sustained positions, and comes with reduced neck movement.
Secondary means the headache is a symptom of something else, and in this case the something else is usually a neck problem that can be identified and treated. That is a good position to be in, because it is the type of headache that responds best to the work I do.
Migraine is a primary neurological disorder in its own right. Cervicogenic headache is a secondary headache driven by a neck disorder. They are not the same condition, and neck pain being present does not make a headache cervicogenic. Migraine typically brings nausea and light or sound sensitivity, which cervicogenic headache usually does not.
Cervicogenic headache tends to stay on the same side attack after attack, to be brought on by neck movement or by holding a position, and to come with restricted neck rotation that can be measured. Migraine tends to throb, to worsen with ordinary physical activity, to bring nausea or sensitivity to light and sound, and to run in attacks with a beginning and an end.
A large number of people have both, which is what makes the assessment important to successfully managing the specific type.
Diagnosis requires clinical or imaging evidence of a cervical disorder known to cause headache, plus at least two of: headache developing in temporal relation to that disorder, headache improving alongside improvement in it, reduced cervical range of motion with headache clearly worsened by provocative testing, or headache abolished by diagnostic blockade of a cervical structure.
Those are the current international criteria. The last one, blockade, means an anaesthetic injection into a specific neck structure under imaging guidance, done by a specialist radiologist. It is a medical procedure and not something I do, so in practice the assessment leans on the first three: the timing, the response to treatment, and the movement testing, including flexion-rotation testing of the upper neck and assessment of the surrounding soft tissue.
How you respond to treatment is itself diagnostic information. Generally, cervicogenic headaches respond well to conservative care over a short space of time.
Not in the way it is usually described. Migraine is a primary neurological disorder, so the neck is not its cause. What is well supported is that neck symptoms are very common in migraine, and that some people with migraine also have a separate neck problem that contributes on its own and is worth treating.
Neck pain is roughly 12 times more prevalent in people with migraine than in people without headache, and about twice as prevalent in chronic migraine as in episodic migraine. The association is quite strong. The direction of it is not necessarily what health care would have you think.
A 2025 narrative review proposes two overlapping subgroups. In the first, neck pain is primarily a symptom of the migraine itself, driven by central mechanisms, and those people respond mainly to migraine-specific treatment. In the second, a person with migraine also has a real neck problem, such as joint hypomobility, muscle tenderness or altered motor control, which contributes on its own and responds to manual therapy and loading.
Treating the first group as though they were the second has not produced the same benefits in trials that the same techniques produce in cervicogenic headache. Being clear about who hands-on treatment is likely to help, and who it is not, is important in the management of these conditions.
Because the nerves supplying your upper neck and the nerves supplying your head converge on the same second-order neurons in the upper spinal cord, in a region called the trigeminocervical complex. A migraine event can therefore produce neck symptoms directly. The neck pain is part of the attack rather than the cause of it.
This explains something patients describe often and rarely get an answer for. The neck can tighten up hours before the headache arrives, which feels for all the world like the neck starting it. The same wiring junction is involved in both, and, unfortunately, by that point the attack has already begun.
It is important to understand this clinically because if neck symptoms only appear alongside attacks and settle completely in between, treating the neck as a mechanical problem is unlikely to change the headaches. If your neck is sore between attacks as well, then that is a different picture with a different management plan.
Three things generally point towards the neck: the headache stays on the same side each time, it is brought on by neck movement or sustained positions rather than by light, sound or exertion, and your neck is symptomatic between headaches as well as during them. Reduced neck rotation and tender points support this further.
Three things point away from the neck: nausea, sensitivity to light or sound, and a headache that swaps sides between attacks.
The assessment helps to test all of that, including cervical range of motion, flexion-rotation testing, and sites of muscle tenderness. If you fit the migraine picture, your care is mostly medical, and my role is the neck component and the lifestyle work, alongside your doctor.
For cervicogenic headache, yes, and the evidence for manual therapy is reasonably good. For migraine, I treat the neck component where one exists, and support the non-medication side of migraine management. Migraine-specific medical treatment is generally managed by your doctor or a neurologist.
For cervicogenic headache, systematic reviews and a 2025 network meta-analysis support manual therapy approaches, including manipulation, mobilisation and sustained natural apophyseal glides, for pain, disability and quality of life. The evidence does not clearly favour one technique over another.
For migraine, what is supported outside medication is a package: sleep regularity, hydration, regular meals, aerobic exercise, headache diaries, weight management, workplace and lighting adjustments, and stress management. It is unglamorous, but it is what the evidence is showing works best.
Where I add the most value is the assessment that tells you which subgroup you are in, and the treatment of a neck that is contributing. Co-management with your GP or neurologist is pretty normal when it comes to the migraine type headache.
How I work
The first job is the differential, because treatment tends to diverge sharply after it. Cervicogenic headache gets upper cervical and thoracic manual therapy with cranio-cervical and scapular loading alongside soft tissue work. Migraine gets neck treatment only where a real neck problem exists, alongside co-management with your doctor.
01
Firstly, a careful history of the headache pattern, including which side, what brings it on, what comes with it, and whether your neck is symptomatic between attacks. Then cervical range of motion and flexion-rotation testing along with soft tissue assessment. The history and assessment determine the management thereafter, so it does not get rushed.
02
For a neck that is contributing: upper cervical and thoracic manual therapy, dry needling, ischaemic compression to the suboccipital, upper trapezius and temporalis groups, and cranio-cervical and scapular loading. Trials of combined manual and exercise therapy for cervicogenic headache consistently use both together rather than either alone.
Aerobic exercise and progressive strength training reduce headache frequency across several headache disorders, which puts them in the plan whichever subgroup you fall into.
03
Trigger and pattern education, so that you can see your own headaches coming and manage the load around them. Regularity in sleep, meals and hydration is gold here and goes a long way to self-management, so it is important you understand that early on in order to benefit long term.
Four things. Keep a diary that separates headache days, neck symptom days and medication days. Hold your sleep, meals, hydration and caffeine steady. Build aerobic exercise up gradually. And watch whether your neck symptoms come before, during or between your headaches.
Headache days, neck symptom days, medication days. Aim for four weeks of regular diarising. Most people have never separated those three columns, and the pattern is usually visible by week two.
Sleep and wake times, meals, hydration, and caffeine. Migraine dislikes change more than it dislikes any particular input, so a consistent Saturday counts as much as a consistent Tuesday.
It reduces headache frequency, and sudden intense exertion can be a trigger in its own right. So exercise goes up in small steps rather than in one enthusiastic week.
Are symptoms there before the headache, during it, or present between attacks as well. Make a note and bring your findings in with you. It is one of the most useful pieces of information you can tell me.
Green
Neck soreness after treatment or exercise that settles within 24 hours and is not climbing session on session. Carry on.
Amber
Headache frequency or neck soreness creeping up week on week. Hold the dose where it is and tell me, because the plan needs adjusting rather than abandoning.
Red
A headache unlike any you have had before, or any of the symptoms in the section below. Stop and get assessed the same day.
Go to an emergency department the same day for a sudden severe headache unlike any before, particularly with neck stiffness, fever, confusion or visual loss, and for new neurological symptoms after a head or neck injury. See a doctor promptly for a first severe headache after 50 or a clear change in a long-standing pattern.
See a doctor promptly too for aura features that are new, that last longer than an hour, or that always appear on the same side, and for any headache accompanied by new weakness, numbness or difficulty speaking.
If you are using acute headache medication on more than about two days a week, raise it with your doctor or pharmacist, because frequent use can drive medication-overuse headache.
Although I have an extensive knowledge of pain pharmacology, questions about medication are better aimed at your doctor or pharmacist rather than at me. I am not allowed to script any medication.
Next step
If you have been getting headaches for months and nobody has worked out where they are coming from, that is what the first consultation is for. It runs 45 to 60 minutes, no referral is needed, and I see patients from across the Upper Highway and Outer West. Bring a four week diary if you have one.
Phone 031 035 1165 · WhatsApp 064 820 5203 · A1a Meyrickton Park, 2 Meyrickton Pl, St Helier, Hillcrest, 3610
This page is general information and is not a substitute for personalised medical advice. Always consult a healthcare provider about your specific condition.
