How to Tell if a Migraine is Coming from Your Neck

A recent systematic review in the prominent journal Headache showed that spinal manipulation could have an effect on headache days and pain intensity in patients with migraine headaches. While this is old news to many practicing chiropractors, this is one of the first instances that a major headache journal has acknowledged that manipulation could have a legitimate positive effect in patients suffering with migraines.

When it comes to migraine headaches and chiropractic, there’s a big gap in knowledge between what clinicians see in the field everyday and what the published literature says about our effectiveness. The published literature has generally shown that chiropractic might be good for tension headaches, but clinical trials on migraines have suggested that it’s not significantly better than placebo.

On the other side, patients with migraine headaches are often our most successful cases in upper cervical chiropractic. It’s not even that we tend to be just a little bit successful with chronic migraines patients, many of us expect these 85-90% of these patients to get a lot better in a matter of weeks. It’s usually not the easy migraine patient that comes into our offices either. Typically people don’t find an upper cervical chiropractor until they’ve tried a wide variety of treatments and medications.

So what gives? Why is there such a gap between private practice and published research?

I believe there’s 2 main reasons:

  1. Most spinal manipulations done in research have used non-specific contact, general manipulation of the neck, where as upper cervical techniques use a very precise and targeted force to one part of the neck. To date, there are no clinical trials investigating migraine headache and upper cervical work. (But this is a soap box for another day)
  2. Previous clinical trials haven’t done a great job in identifying patients that have the signs of a cervical spine dysfunction.

Identifying Cervical Spine Dysfunction in Migraine Patients

While getting your spine corrected is healthy in of itself and anyone could benefit from it, I only take on cases that I believe can significantly improve your quality of life. In order to do that, I always screen patients to make sure that I am going to have a high likelihood of success in helping you reach your goal.

In the case of a migraine patient, we are looking for clues that tell us that your migraine symptoms are primarily being generated by the neck. Migraines can have different causes:

  • Some have a biochemical issue in the brain and may benefit from something like a ketogenic diet.
  • Some have a higher hormone component and need to be addressed by modifying the endocrine system
  • And many have a major cervical spine component

How can you tell if it’s coming from the neck? Beyond just looking for neck pain, here are some major clues that have been identified in migraine research:

  1. Worse ability to turn their upper neck side to side – A test of upper neck rotation called the flexion rotation test has been shown to be more asymetrical in some migraine patients compared to normal controls [Source]
  2. Decreased sensitivity to 2 point discrimination in the upper neck – A study showed that migraine patients have decreased ability to differentiate between 2 points when applied to their neck. [Source]
  3. Increased pain and tenderness in the upper neck – patients with cervical spine issues show increased tenderness to touch in their upper neck. It becomes even more significant if pressing on a sensitive area recreates the pattern of head pain [Source]

Can The Neck Be Fixed?

A 2015 study looked at the effects of an atlas realignment in patients with chronic migraine headaches. The study showed that a gentle correction to the upper neck showed significant improvements in headache days and quality of life in migraine patients over the course of 8 weeks.

We rely on 3 big factors for improving the neck.

  1. We need to see a structural change in the biomechanical alignment of the neck after an atlas correction.
  2. We want to see a global change in posture in response to correcting the alignment of the neck
  3. We want to see a change in the tenderness of the muscles and nerves stemming from the upper neck. Just as we saw that those tender spots predicted migraine, when we feel those tender points subside right after a correction, it’s a strong marker that we are on the right track.

While we can’t fix everyone, there’s a large segment of the migraine population that would do well with this form of care, but we have to make sure we identify the right candidates.

Long Term Outcomes from Treating Cervical Hypolordosis

I’ll admit that I’ve gone back and forth on the importance of cervical curves in my career. When I was in chiropractic school I was adamant about the importance of cervical curves and how the loss of a curve could affect the progression of spinal arthritis.

Then once I was in practice for a few years, I saw that most neck curves wouldn’t really change very much. Despite the fact that it didn’t change, I’d see really great changes and improvements of many of my patients, so I assumed that it is a nice feature, but probably not necessary to resolving a complaint. You can read some of my previous thoughts on cervical curves here:

I Have Military Neck: Now What?

So What Has Changed my Mind?

I still stand by my previous writings and say that having a proper neck curvature is a really good and positive thing, but you can still get really great results with most secondary conditions even if the neck curve doesn’t come back.

However, I have started to come around on the importance of having a proper neck curvature for the health of the human brain and nervous system. So what changed my mind?

Here are three pretty recent studies looking at the impact that cervical curve changes have on dizziness and cerebral blood flow.

Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis

The first paper is a study that looked at consecutive patients getting imaging of the arteries going into the brain. Magnetic resonance angiography (MRA) measured the intensity of blood flow with the neck in patients with a straight or military neck pattern. The patients were then placed on a foam orthotic to produce a curve in the neck and a new MRA was taken with the neck in a curved position.

Before and after changes in blood flow to the brain using a device to improve cervical curve.

The patients’ MRA scans showed significant improvements in blood flow in the brain when they were lying on the orthotic with an improved cervical curve! The interesting thing is that it’s been known for years that a loss of cervical curve was associated with decreased blood flow in the brain, but there was no evidence showing that improving the curve would change blood flow. Now there is.

The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study.

While the previous paper is interesting, it’s limited by the small sample size and lack of controls. It was also a proof of concept study, and not one where an intervention was performed and tested to see if it made a difference long term. However, it may help explain why patients can get significant improvement in pain and dizziness.

This next paper features a randomized clinical trial of cervical curve correction along with cervical manual therapies compared to manual therapy alone for cervical dizziness.

The study looked at the results for patients with neck pain and dizziness for short term improvement at 10 weeks, and to see if they sustained improvement at a 1 year follow-up. The results are below.

 

Differences in patients with cervical dizziness at 10 weeks and 1 year. Changes after 10 weeks were similar to regular physical therapy, but the changes were hugely different at 1 year when there was an improved curve in the neck

The chart shows that the patients who were in the cervical curve correction group had significant improvements in head posture and curvature at 10 weeks, but the scores in pain and dizziness were pretty similar for both groups. Both groups got better, but they had similar improvements.

However, the changes at 1 year were impressive, and highlighted in red. While the control group had some regression into neck pain and dizziness, the cervical curve group maintained their symptomatic improvement much better. The mean improvements for both groups all crushed statistical significance, and the mean difference of the Dizziness Handicap Inventory (DHI) was by almost a whopping 30 points. That’s massive!

Does improvement towards a normal cervical sagittal configuration aid in the management of cervical myofascial pain syndrome: a 1- year randomized controlled trial.

A similar study was published on patients with persistent neck pain where physical manual therapy was compared to manual therapy and curve correction.

Just like the study involving dizziness, this paper on neck pain showed that both groups had similar improvements in scores on the Neck Pain Disability Index (NDI).

Changes in neck pain with manual thearpy and exercise alone vs manual therapy, exercise, and cervical curve restoration. Cervical curve patients were a little btter at 10 weeks, but were much better at 1 year follow up!

Again, like in the previous study, the 1-year follow-up is where things got interesting. The group that had treatment to improve their cervical curve had a much stronger ability to maintain their improvements in neck pain, while the control group started to return to their original pain scores. This was also largely statistically significant.

Long-Term Improvements Matter

So the big thing that changed my mind is that there is a growing body of work that supports the idea that creating structural changes in your cervical curve seem to help improve long term outcomes.

So while I still believe you can get significant improvement with or without a curve in your neck, your chances of maintaining your results over time seem to increase a LOT when you rehabilitate that curve.

Then you have the possible added benefit of improved blood flow to your brain, and that provides a potential bonus of better brain health.