Stimulated by Rees et al 2025.[1]
IF – impact factor
HIS – international headache society
doi – digital object identifier
TCC – trigeminocervical complex– key to acronyms
This narrative review in Cephalalgia (IF 4.6) caught my eye because the title describes a clinical conundrum I have wrestled with for most of my career. That is whether or not the neck pain that occurs immediately before a migraine attack is a trigger for the migraine headache or simply an associated epiphenomenon.
Cephalalgia is the official journal of the HIS, is published by Sage, and has been open access since 2023, having first been published in 1981. So, if you click on the doi for each reference below, you can read or download the full articles.
Figure 1 of this article gives a very useful graphical summary of the neuroanatomic connections relevant to this topic. My eye was drawn to a labelling error for C1, but that immediately led me to ask for an AI-generated summary of the tissues supplied by the C1 spinal nerve root, which was rather illuminating. For example, it is almost entirely a motor nerve with direct branches to a couple of muscles I had forgotten even existed (rectus capitis anterior and rectus capitis lateralis). It also supplies geniohyoid via the hypoglossal nerve, which is a muscle that lies close either side of the point CV23 and is the penultimate layer before your needle reaches the genioglossus (if the needle is long enough, since this is the 5th muscle layer). As readers may know, CV23 is my favourite tongue point – see Acupuncture for PSA from 2022, or try the PSA or PSD categories.
The key neuroanatomy of neck pain and headache revolves around the spinal trigeminal nucleus, which is essentially an extension of the dorsal horn of the cervical spinal cord. This paper uses the term trigeminocervical complex (TCC) to include the relevant part of the trigeminal nucleus extending down to C3.
The TCC is where pain and temperature sensation from the head and upper neck is processed and amplification of signals in second order neurones here is an important part of the migraine phenomenon. The overlap with upper cervical segments means that this amplification can involve structures in the neck innervated by C1 to C3. Of course, the latter will include most of the muscles we (as acupuncturists) target for treating both headache and neck pain; for example, GB21 in upper trapezius (nerve supply – XI, C1-6 motor; XI, C3-4 sensory) and GB20 in upper semispinalis capitis (nerve supply – C1 motor, C2-3 sensory).
Neck pain is 12 times more prevalent in patients with migraine compared with non-headache controls and twice as prevalent in chronic migraine compared with episodic migraine.[2]
This review references prospective studies using headache diaries that have identified neck pain as a premonitory symptom in up to 50% of cases. The rate seems to be lower in retrospective analyses, perhaps due to recall bias. If the migraine is bad enough (as most are) you may well forget about the neck pain that came before it. Interestingly, neck stiffness is also a rather frequent premonitory symptom in pharmacologically triggered migraine attacks (~30-60%). Neck pain often occurs within 2 hours of the headache phase and is more common in migraine without aura than with aura. Cervical musculoskeletal disorders as a source of neck pain are found in the minority of migraine patients (~40%).
Experimental studies demonstrate bidirectional interactions between trigeminal and cervical neurons in the TCC, so in some cases it is possible that neck pain in relation to migraine could be almost entirely related to central sensitization in the TCC.
I was intrigued by the discussion of neck pain as a possible trigger for migraine attacks in this review. Endurance tests performed on neck flexors and extensors in subjects with migraine and control subjects resulted in migraine headache in 42% of the migraine group within 24 hours. Neck pain was provoked in 45% of the migraine group and 16% of the control group.[3]
Over the years of running acupuncture courses and using acupuncture clinically, I have seen individuals attribute migraines to needling at certain points. GB20 performed in a seated position appears to be the most likely of the points we teach to result in a migraine in susceptible individuals. Ironically, it is also the point that I consider to be the most useful in successful treatment of chronic headaches.
The review has a useful table of differential diagnoses for neck pain along with the relevant findings from history and clinical examination and the diagnostic tests that might be useful. A further table gives details of other types of headaches that can be associated with neck pain including spontaneous intracranial hypotension, in which a headache tends to come on when changing from a lying to a standing position.
The physical examination recommended for evaluation of neck pain appears to simply entail an assessment of cervical RoM, but does not include the posterior cervical quadrants, which are provocative tests for facet joint pain and foraminal compression. BMAS members can find these tests demonstrated on Day 41 of the ‘What’s the point’ series of videos.
I was pleased to see that the treatment algorithm does include acupuncture, albeit at the very end of the list of preventative treatments, and that the authors are rather cautious about recommending the newer acute and preventative therapies targeting CGRP as their ‘efficacy… remains poorly characterised’.
References
1 Rees TA, Doukhi D, Wang VS, et al. Neck pain in migraine: A narrative review and steps to correct evaluation and treatment. Cephalalgia. 2025;45:3331024251387449. doi: 10.1177/03331024251387449
2 Al-Khazali HM, Younis S, Al-Sayegh Z, et al. Prevalence of neck pain in migraine: A systematic review and meta-analysis. Cephalalgia. 2022;42:663–73. doi: 10.1177/03331024211068073
3 Carvalho GF, Luedtke K, Szikszay TM, et al. Muscle endurance training of the neck triggers migraine attacks. Cephalalgia. 2021;41:383–91. doi: 10.1177/0333102420970184
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