Musculoskeletal Science and Practice xxx (xxxx) xxx

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Musculoskeletal Science and Practice

journal homepage: www.elsevier.com/locate/msksp

Neck pain repercussions in migraine – The role of physiotherapy

Debora Bevilaqua-Grossi a, *, Carina F. Pinheiro-Araujo a, Gabriela F. Carvalho b,
Lidiane L. Florencio c
a
Health Sciences Department, Ribeirão Preto Medical School, University of São Paulo, Bandeirantes Avenue, Monte Alegre, Ribeirão Preto, SP, Brazil
b
Institute of Health Sciences, Academic Physiotherapy, Pain and Exercise Research Luebeck (P.E.R.L.), University of Luebeck, Ratzeburger Allee 160, 23562, Luebeck,
Germany
c
Department of Physiotherapy, Occupational Therapy, Physical Medicine and Rehabilitation, King Juan Carlos University, Madrid, 28922, Alcorcón, Spain

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Migraine is a neurological and disabling disease whose peripheral manifestations can be addressed
Musculoskeletal diseases with physiotherapy. These manifestations can include pain and hypersensitivity to muscular and articular
Migraine palpation in the neck and face region, a higher prevalence of myofascial trigger points, limitation in global
Neck pain
cervical motion, especially in the upper segment (C1–C2), and forward head posture with worse muscular
Physiotherapy specialty
performance. Furthermore, patients with migraine can present cervical muscle weakness and greater co-
activation of antagonists in maximum and submaximal tasks. In addition to musculoskeletal repercussions,
these patients can also present balance impairment and a greater risk of falls, especially when chronicity of
migraine frequency is present. The physiotherapist is a relevant player in the interdisciplinary team and can help
these patients to control and manage their migraine attacks.
Purpose: This position paper discusses the most relevant musculoskeletal repercussions of migraine in the cra­
niocervical area under the perspective of sensitization and disease chronification, besides addressing physio­
therapy as an important strategy for evaluating and treating these patients.
Implications: Physiotherapy as a non-pharmacological treatment option in migraine treatment may potentially
reduce musculoskeletal impairments related to neck pain in this population. Disseminating knowledge about the
different types of headaches and the diagnostic criteria can support physiotherapists who compose a specialized
interdisciplinary team. Furthermore, it is important to acquire competencies in neck pain assessment and
treatment approaches according to the current evidence.

Migraine is more than just a headache. Despite the central patho­
genesis, its functional and musculoskeletal repercussions have made the
Physiotherapy profession (PT) a specialty with much to contribute to the
management of this condition. Migraines’ main manifestations are
recurrent moderate-to-severe headache attacks accompanied by nausea,
vomiting, light and/or sound sensitivity, and pain aggravation during
routine physical activity (Headache Classification Committee of the In­
ternational Headache Society, 2018). The patients can also present
transient neurological disturbances, well known as aura, or develop
chronic migraine, in which attacks become very frequent (Eigenbrodt
et al., 2021).
Although the migraine pathophysiology is not directly related to
musculoskeletal disorders, neck pain is reported by patients with
migraine (Florencio et al., 2014) more often than nausea, which is a
major criteria in the migraine diagnosis (Calhoun et al., 2010). Albeit
neck pain is not necessary for the migraine diagnosis, the IHS classifi­
cation describes muscle tension in the neck as a possible premonitory
symptom of migraine (Headache Classification Committee of the Inter­
national Headache Society, 2018).
However, neck pain can be present not just during the premonitory
phase of migraine, but also during the headache phase or between the
attacks (Lampl et al., 2015). According to Viana et al. (2018), 91% of
patients with self-reported neck pain also report headache attacks,
which are diagnosed as migraine or probable migraine. Interestingly,
these patients do not exhibit any evidence of pathological conditions of
the cervical spine, which could be attributed to etiology of the

* Corresponding author. Health Sciences Department, Ribeirão Preto Medical School, University of São Paulo, Av. Bandeirantes, 3900, Jd Monte Alegre, Ribeirão
Preto, SP, 14049-900, Brazil.
E-mail addresses: deborabg@fmrp.usp.br (D. Bevilaqua-Grossi), carinafp@hotmail.com (C.F. Pinheiro-Araujo), g.ferreiracarvalho@uni-luebeck.de
(G.F. Carvalho), lidiane.florencio@urjc.es (L.L. Florencio).

https://doi.org/10.1016/j.msksp.2023.102786
Received 28 April 2023; Received in revised form 26 May 2023; Accepted 27 May 2023
Available online 3 June 2023
2468-7812/© 2023 Elsevier Ltd. All rights reserved.

Please cite this article as: Debora Bevilaqua-Grossi et al., Musculoskeletal Science and Practice, https://doi.org/10.1016/j.msksp.2023.102786
D. Bevilaqua-Grossi et al.
symptoms. This aspect reveals the importance of knowing the clinical
presentation of migraine. In this way, although it may be present, a
disease or dysfunction in the cervical spine is not a fundamental finding,
since migraine seems to induce its sensitization and initiates cranio­
cervical muscle pain by its nature.
It is not uncommon for migraine patients to have difficulties dis­
tinguishing migraine attacks from neck pain attacks. In patients with
migraine with aura, this confusion is less prevalent (Viana et al., 2018).
It is also very common for physiotherapists to mix these conditions in
clinical practice, especially with other headache types, such as cervi­
cogenic headaches. In patients with cervicogenic headache, the neck is
the headache etiology and has a temporal relationship with it. Some
physiotherapists often show less concern with the diagnosis of the
headache and more concern with the cervical manifestations. However,
the treatment and prognosis for these different headache types are far
from being the same.
It is still unclear whether neck pain is part of the migraine prodromal
symptoms and, therefore, part of an attack or if it acts as a migraine
trigger (Lampl et al., 2015). Neck pain also can be considered an
aggravating and/or perpetuating pain factor. On the other hand, it can
also be considered a referred pain as a result of central sensitization of
the trigeminocervical complex. The mechanisms that may explain the
relationship between migraine and neck pain involve the convergence of
inputs from the first and second cervical segments into the trigemino­
cervical complex (Florencio et al., 2014). These bidirectional neural
connections might promote the transition from acute to chronic
migraine (Goadsby, 2005). Various studies support this view by
reporting more severe neck involvement and musculoskeletal findings in
patients with chronic migraine compared to those with episodic
migraine (Carvalho et al., 2020), as discussed in the following.
As already demonstrated, musculoskeletal dysfunctions are very
prevalent among migraineurs and cause additional disability due to
neck pain (Florencio et al., 2016). Further than, it has also been proven
that neck pain is also associated with greater levels of migraine
disability, to a poorer pharmacological treatment prognosis, and to a
higher frequency of migraine attacks (Carvalho et al., 2014; Florencio
et al., 2014; Bragatto et al., 2019).
Our study group was a pioneer in demonstrating that disability due
to neck pain is highly prevalent in migraine, showing that the frequency
of attacks is correlated with Neck Disability Index scores. In other words,
patients with more attacks are more likely to have a disability due to
neck pain than individuals with episodic attacks. However, when we
stratified patients according to the presence of neck pain, the disability
levels between episodic and chronic groups were similar. This suggests
that neck pain is the driver of the disability. Patients with chronic
migraine are more likely to have neck pain than individuals with
episodic migraine, but in the presence of neck pain, the disability is
similar (Florencio et al., 2014). The high disability levels among head­
aches can also be attributed to the several comorbidities that patients
may present, including neck pain, mental health disorders, vestibular
symptoms, and balance alterations (Carvalho et al., 2020).
Different musculoskeletal presentations of the migraine are seen
between patients with episodic and chronic migraine, but this is not
verified when we consider the presence and absence of aura. Interesting
results were found when we investigated whether the presence of aura
would be related to cervical alterations, including greater impairment of
upper cervical range of motion, lower neck muscle performance, and
greater self-report of neck pain and disability. Unlike what we might
assume, the aura was not associated with worse neck mobility or with
poor performance of the cervical muscles. Besides, the presence of neck
pain and neck disability was also not greater in patients with aura.
Therefore, though patients with migraine with aura present more bal­
ance alterations and vestibular symptoms in comparison to patients
without aura, we cannot generalize regarding the involvement of the
cervical spine (Carvalho et al., 2021a).
Recent data allowed us to distinguish two subgroups of migraine
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Musculoskeletal Science and Practice xxx (xxxx) xxx
from a musculoskeletal point of view: the subgroup with postural con­
trol impairment (vertigo and dizziness) and the most studied and known
subgroup with cervical dysfunction, where pain, disability, sensitiza­
tion, muscle weakness, and poor performance may be part of the clinical
presentation of migraine.
Up to 20 different clinical musculoskeletal tests have been described
in order to investigate musculoskeletal differences between individuals
with migraine and controls (Carvalho et al., 2020). However, using a
single test or singularly interpreting tests is of limited value (Jull and
Hall, 2018) since basing on single markers of group differences often
lead to misinterpretation. In an international consensus-based approach,
at least 11 tests were suggested as a standard for physically examining
musculoskeletal dysfunctions in patients with headaches (Luedtke et al.,
2016a). Disseminating, teaching, and orienting physiotherapists using
these tests is a mission for everyone involved in this field.
It is important to highlight that identifying these cervical signs,
symptoms, and clinical tests that differentiate migraineurs from controls
made it possible to reinforce the role of such dysfunctions in headaches,
especially in migraine whose evidence for the presence of this
dysfunction was refuted up to then.
The discussion of the role of musculoskeletal dysfunctions in
migraine is not recent. Robertson and Morris (2008) claimed that the
available studies at that time showed several methodological in­
adequacies and deficiencies that prevented definitive conclusions. They
affirmed that although the growing body of evidence from animal
studies supporting that cervical dysfunction may facilitate migraine
pain, this awaited human verification. Fortunately, the evidence has
become more robust in recent years, and the findings support a recip­
rocal interaction between the trigeminal and the cervical systems as a
trait symptom in migraine (Florencio et al., 2016; Luedtke et al., 2018).
Neck pain is 12 times more prevalent in patients with migraine than
in non-headache controls (Al-Khazali et al., 2022). Even though the role
of neck pain in migraine has not yet been established, the high preva­
lence cannot be ignored, which will require an effective approach from
specialized professionals such as physiotherapists to improve the
well-being of these patients.
The definition of cervical musculoskeletal dysfunction is very
important for future studies, so researchers can use the term appropri­
ately and put effort into research that defines measures that can together
stratify musculoskeletal disorders (Jull and Hall, 2018). Furthermore, it
is equally important for clinicians dealing with these patients, to
demonstrate which signs, symptoms, and clinical tests would help them
define the patients’ subgroups. We still have a long way to walk towards
the definition of a cluster of tests to assess cervical dysfunction. Mean­
while, we must demonstrate to the clinicians which aspects should be
assessed and managed in patients with migraine.
The physiotherapist who does not know the classification of head­
aches may understand migraine only from the musculoskeletal point of
view and this may compromise the treatment outcomes and prognosis.
The craniocervical dysfunctions are part of the clinical presentation of
migraine and must be interpreted accordingly. The patients present
higher sensitization levels that require a multimodal approach, as also
discussed later in this paper. The musculoskeletal dysfunctions were
explored by our research group under many aspects which included the
main two fields of chronification and sensitization.
1. Chronification
In our journey researching the cervical-related impact, signs, and
symptoms in patients with migraine is that most of the findings or their
worse clinical presentation are observed in the groups with chronic
migraine (or the transformed migraine considering the previous IHS
classifications). It is important to point out that for primary headaches,
the concept of chronic refers to the number of days of headache (>14
days/month) and not the time or duration of the disease.
Although the neck pain symptom is very prevalent in women with
D. Bevilaqua-Grossi et al.
migraine, its prevalence in chronic migraineurs is higher than in those
with episodic forms (Al-Khazali et al., 2022). Chronic migraine is also
associated with a greater risk of reporting neck-related disability
compared to episodic migraine, and this association increases in the
most severe disabilities (Carvalho et al., 2014; Florencio et al., 2014).
Several findings reinforce that some signs of altered musculoskeletal
function can be related to the high frequency of migraine attacks.
Regarding cervical muscle function, reduced strength in the cervical
extensor muscles has been observed only for the chronic migraine group
but not the episodic group (Florencio et al., 2015a). Moreover, the fre­
quency of migraine attacks along with the neck pain intensity in
migraine can explain up to 18% of the variability of the strength
measured for cervical extensors and lateral flexors (Tolentino et al.,
2018). Lower neck muscle endurance has also been demonstrated in
women with migraine (Florencio et al., 2019). When compared to
controls, women with chronic migraine presented lower neck flexors
endurance even to maintain a lower amount of force (25% of the
maximal), while those with episodic migraine only differed from con­
trols when they had to maintain contractions proportional to 75% of
their maximal capacity (Florencio et al., 2021a). Our data suggest that
migraineurs present poorer muscular performance than controls, but the
greater the migraine frequency, the greater is the reduced resistance of
these muscles.
Cervical muscle activity can also be altered in patients with
migraine. Both episodic and chronic migraine may present greater an­
tagonists’ co-activation during maximal isometric voluntary contrac­
tions (Florencio et al., 2015a). However, only the chronic migraine
group presented greater neck extensor activity during the craniocervical
flexion test, indicating that this subgroup can present a different strategy
to maintain cervical muscle motor control under low-load tasks (Flor­
encio et al., 2016).
Conversely, the relationship is unclear between the frequency of
migraine attacks and the cervical joint-related measures, such as ROM,
flexion rotation test, and symptoms over the upper cervical spine. Some
of our findings suggest that the cervical range of motion seems to be
equally reduced in both episodic and chronic migraine (Carvalho et al.,
2014; Ferracini et al., 2017a; Pinheiro et al., 2021a, 2021b). However,
other studies suggest that the chronic subgroup presents worse impair­
ments of cervical mobility (range of motion and angular velocity) since
they differs from controls more frequently than episodic migraine
(Bevilaqua-Grossi et al., 2009a; Oliveira-Souza et al., 2019; Pinheiro
et al., 2021b). When only the upper cervical joint is assessed, both
chronic and episodic migraine present a reduced ROM in the Flexion
Rotation Test (passive rotation) (Ferracini et al., 2017a; Oliveira-Souza
et al., 2019). Nonetheless, the ROM reduction observed for chronic
migraine is twice that observed for episodic migraine compared to
controls (Oliveira-Souza et al., 2019). We can therefore suggest that
migraineurs have impaired cervical ROM, but those who present more
frequent attacks are likely to present greater tension and lower mobility
of the upper cervical spine.
The chronic migraine groups do not seem to differ from the episodic
forms regarding the peripheral and/or central sensitization measures
such as pressure pain threshold (PPT) (Grossi et al., 2011; Palacios-Ceña
et al., 2016) and the presence and severity of cutaneous allodynia
(Benatto et al., 2017). They also present a similar proportion of active
trigger points in the neck, head, and shoulder muscles (Ferracini et al.,
2017b).
2. Sensitization
Another way to understand the musculoskeletal dysfunctions in pa­
tients with migraine is by looking at sensitization levels, assessed
throughout the pain thresholds and presence of cutaneous allodynia.
In the migraine pathophysiology, the trigeminal nerve conveys sen­
sory afferent information from extracranial and intracranial structures
to the spinal trigeminal nucleus. The activation of second-order
3
Musculoskeletal Science and Practice xxx (xxxx) xxx
trigeminovascular neurons can lead to pain perception over the cra­
niocervical and orofacial regions, interpreted as peripheral sensitization.
Meanwhile, the sensitization of the third-order trigeminovascular neu­
rons leads to central sensitization, characterized by the presence of
extracephalic pain and allodynia. (Olesen et al., 2009; Noseda and
Burstein, 2013; Castien et al., 2018). A dysfunction of pain modulation
enhances the central sensitization phenomena, contributing to cuta­
neous allodynia and headache persistence (de Tommaso et al., 2014;
Castien et al., 2018).
Several studies have demonstrated central sensitization measured by
pressure and thermal thresholds as a feature associated with migraine,
regardless of clinical features such as attack frequency, intensity and
duration. Our data showed a lower PPT in migraineurs than controls in
the upper trapezius, temporalis, sternocleidomastoid, suboccipital,
scalene, levator scapulae, and frontal muscles (Grossi et al., 2011;
Florencio et al., 2015b). Castien et al. (2018), confirmed these data in a
systematic review and found that the upper trapezius and suboccipital
are the muscles with the lowest PPT in individuals with migraine,
highlighting the importance of its identification at craniocervical sites in
clinical practice.
Regarding sensitization levels and neck dysfunction, Gonçalves et al.
(2015) found a moderate and negative correlation between neck
disability and craniocervical PPTs. Despite this correlation, there was no
association between the outcomes, demonstrating that one measure may
not vary linearly in function from the other. Recent data further
demonstrated a negative, weak-to-moderate correlation between cuta­
neous allodynia and cervical muscle force (Florencio et al., 2021b).
Although an equivalent prevalence of neck pain between genders is
observed in migraine (71% for men and 72% for women) (Lipton et al.,
2018), one study (Xavier et al., 2021) observed a lower prevalence of
self-reported neck pain, presence and severity of cutaneous allodynia in
men. However, there were no differences between men and women in
the clinical presentation of migraine, migraine disability, neck
disability, and in the results of clinical tests that examined the cervical
function and mobility, showing that these musculoskeletal conditions
may be associated with migraine, regardless of gender.
Interestingly, some craniocervical musculoskeletal conditions can
mediate and augment the central sensitization in migraine. Individuals
with migraine and concomitant temporomandibular disorder (TMD), for
example, present higher severity of cutaneous allodynia, and lower
mechanical and thermal pain thresholds than those with the isolated
conditions (migraineurs without TMD) (Chaves et al., 2016). Similarly,
when the migraine is associated with neck pain, the prevalence of
cutaneous allodynia is higher than in patients with migraine alone
(Bragatto et al., 2019; Florencio et al., 2021b). Additionally, the asso­
ciation between migraine and neck pain increases the risk of presenting
any severity of cutaneous allodynia by 3.5 times (Bragatto et al., 2019).
Some aspects should be considered in this context: I) TMD is suggested
as a factor related to migraine chronification (Bevilaqua Grossi et al.,
2009b; Florencio et al., 2017); II) The cutaneous allodynia is a
well-known aspect associated with the risk of chronification (May and
Schulte, 2016); and III) the association of both cutaneous allodynia and
neck pain are related to a negative migraine prognosis (Aguila et al.,
2018; Lipton et al., 2017). Accordingly, these interactions should always
be investigated in clinical practice. We recommend that the evaluation
of patients with migraine should consist of an evaluation of the entire
craniocervical system and often include the scapular girdle.
The coexistence of migraine and neck pain also has other re­
percussions. Patients with migraine and neck pain present greater neck
muscle tenderness (Yu et al., 2019; Hvedstrup et al., 2020), reduced
cervical range of motion (Pinheiro et al., 2021b), reduced cervical
muscle strength (Florencio et al., 2021b), reduced upper cervical
mobility, and worse performance in the craniocervical flexion test
(Bragatto et al., 2019) than patients with migraine only. These findings
suggest that the association of migraine and neck pain may aggravate
local tenderness but may predispose to musculoskeletal impairments
D. Bevilaqua-Grossi et al.
(Florencio et al., 2021b). In addition, patients with migraine are more
likely to report migraine attacks and neck pain after a maximum cervical
endurance test regardless of self-reported neck pain, demonstrating the
role of the neck as a trigger of migraine attacks (Carvalho et al., 2021b).
Another aspect of sensitization is the presence of active trigger points
in the craniocervical muscles, which are highly prevalent in migraineurs
(Do et al., 2018). The most common sites are the muscles temporalis,
upper trapezius, sternocleidomastoid, and suboccipital
(Fernández-de-Las-Peñas et al., 2006; Giamberardino et al., 2007; Tali
et al., 2014). The same muscles also present latent trigger points (Fer­
racini et al., 2016). The trigger points can act as both trigger and/or
perpetuating factors for migraine attacks (Ferracini et al., 2017b; Do
et al., 2018). All these aspects must be considered in the migraine
management, as we will detail below.
3. Role of physiotherapy strategies in the management of
migraine
A tailored physiotherapy prescription should target both peripheral
and central sensitization signs and symptoms among patients. Strategies
may include bottom-up modalities, aiming to reduce the nociceptive
afferents that ascend to the central nervous system. It also should
embrace top-down modalities such as education and aerobic exercises,
aiming at the activation of systems that improve the functioning of the
pain modulation systems.
Previous randomized clinical trials developed by our research group
aimed to test the effectiveness of different physiotherapy modalities on
the clinical improvement of patients with migraine-associated neck pain
(Bevilaqua-Grossi et al., 2016; Benatto et al., 2022). The first trial
evaluated the additional effect of a tailored treatment that included
breathing exercises, stretching, and manual therapy techniques, such as
cervical joint mobilization, cervical traction, myofascial release and
digital compression of trigger points (Bevilaqua-Grossi et al., 2016).
Both groups received tailored conventional pharmacological treatment
delivered by one neurologist, and the physiotherapy group received 8
additional PT sessions over 4 weeks. Both groups experienced a reduc­
tion in headache frequency and despite no differences being demon­
strated between groups, the patients who received physiotherapy
reached a clinically relevant reduction of the headache frequency earlier
in the post-treatment evaluation. Both groups demonstrated clinically
relevant reduction of the headache frequency in the follow-up, without
differences between groups. Despite no evidence of headache
improvement in comparison to a conventional therapy group, patients
who received physiotherapy demonstrated a greater perception of
change and improvement of pressure pain thresholds over the cervical
area in contrast to the conventional therapy group (Bevilaqua-Grossi
et al., 2016).
The second study assessed the effect of strengthening training of the
craniocervical muscles in patients with migraine and a placebo group
that received a turned-off ultrasound therapy was used as a comparator
(Benatto et al., 2022). All patients received the placebo or the PT
intervention for 8 weeks. No differences were evident between groups
regarding headache frequency and intensity at all study time points. On
the other hand, differences were seen between groups in pain threshold
and electromyographic outcomes during the craniocervical flexion test
and endurance test (Benatto et al., 2022).
These results, taken together, are in line with the inconsistent evi­
dence provided by recent systematic reviews and meta-analyses per­
formed on the topic. Two meta-analyses did not demonstrate any
additional benefit of dry-needling (Pourahmadi et al., 2021) and manual
therapy (Beier et al., 2022) on migraine treatment. On the other hand,
polled results of three different meta-analyses suggest the use of manual
therapy and relaxation therapy improves the quality of life and disability
levels (Falsiroli Maistrello et al., 2019), and reduces migraine pain in­
tensity and frequency (Luedtke et al., 2016b; Falsiroli Maistrello et al.,
2018; Jung et al., 2022). Another meta-analysis recently published
4
Musculoskeletal Science and Practice xxx (xxxx) xxx
indicates that active and stretching exercises may reduce pain intensity
and disability (Mukhtar et al., 2022). Nonetheless, all studies high­
lighted the presence of a high risk of bias and low quality of evidence.
Better evidence indicates additional benefits of general/aerobic
physical activity (Lemmens et al., 2019; Beier et al., 2022) and pain
neuroscience education in the reduction of migraine frequency (Meise
et al., 2023) and improves self-rated health and quality of life (Beier
et al., 2022). Furthermore, a more consistent effect intervention is seen
when combinations of physiotherapy modalities are employed (Jung
et al., 2022).
While there is consistent evidence of musculoskeletal repercussions
in the cervical spine of migraineurs as well as a neurophysiological
plausibility to treat these structures, evidence is still contradictory in the
recommendation of physiotherapy to manage migraine headaches.
These can be due to challenges in the study design of non-
pharmacological RCT’s, such as employment of double-blinding
(Opara et al., 2013), treatment adherence, and enhancement of pla­
cebo effects (Kaptchuk et al., 2006; Hróbjartsson and Gøtzsche, 2004;
Meissner et al., 2013). Furthermore, there is evidence that certain
physiotherapy modalities, especially when overdosed, may trigger
migraine symptoms in a short-term period (Carvalho et al., 2021b). This
can be an obstacle when assessing the treatment effectiveness based on
research parameters.
To overcome these limitations, well-designed clinical trials with high
quality should explore the effect of physiotherapy considering multi­
modal and tailored intervention. Subgrouping is also an interesting
strategy to attenuate the high heterogeneity in migraine presentation
regarding i.e., neck pain, headache outcomes, sensitization levels, and
yellow flags. Furthermore, the headache phase could influence the
physical variables assessed, and adequate power for study outcomes
such as disability and quality of life is strongly advised. Real-world ev­
idence provided by routine data collection may also offer promising
sources of evidence to supplement RCTs once its methodological limi­
tations and reporting standards are taken into consideration (van Trijffel
et al., 2019). Last but not least, patients’ preferences and multidisci­
plinary migraine management deserve outstanding attention in
patient-centered care.
4. Conclusion
- Neck pain is part of the clinical presentation of migraine, mainly
during the attack, but it may also precede and remain after the attack
in some patients, negatively influencing the natural history of the
disease by increasing the risks of migraine chronification.
- Neck pain may also play a precipitating or perpetuating role for
migraine attacks and these patients may be part of a disease sub­
group where higher levels of sensitization in the whole craniocer­
vical system can be present.
- Neck pain associated with increased levels of sensitization, muscle
weakness, and decreased range of motion, especially of the upper
cervical spine, can be associated with the chronification of migraine.
- Prolonged nociceptive stimuli originating in the neck structures
could produce continuous afferent input in the nucleus caudalis of
the trigeminal nerve, and, thus, activate the trigeminovascular sys­
tem. This prolonged sensitization itself may result in the worsening
of cervical dysfunctions.
- The physiotherapist must acquire the competencies to assess and
treat these dysfunctions among patients with migraine, considering
the inclusion of pain education programs, so patients are instructed
on how to manage cervical pain and improve their lifestyle and
perpetuating factors associated with the occurrence of migraine
attacks.
Funding
This research did not receive any specific grant from funding
D. Bevilaqua-Grossi et al. Musculoskeletal Science and Practice xxx (xxxx) xxx

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