PRESENCE OF NECK PAIN ASSOCIATED WITH MORE SEVERE

CLINICAL PRESENTATION IN PATIENTS WITH MIGRAINE: A

CROSS SECTIONAL STUDY

INTRODUCTION:

A migraine is usually categorized according to the presence or absence of

aura and by the frequency (episodic or chronic) of migraine attacks as
suggested by the International Classification of Headache Disorders.1Neck
pain is a common symptom of migraine; it is more frequent than nausea1 and
highly predictive of migraine onset Two main mechanisms can explain neck
pain in migraine. Afferent input from the trigeminal and upper cervical (C1–3)
nerves converge in the trigeminocervical nucleus, creating potential for
headache to be referred into the neck and vice versa.2

Neck pain has been reported to be highly prevalent in migraine patients (1–3).
Whether a causal link exists between neck pain and migraine, or if it is just a
secondary phenomenon, is not fully clarified (4–6). Nociceptive input from
neck muscles and dura mater converge on second-order neuron in the
trigeminocervical complex (7–9). 3In a recent study, a 1-year prevalence rate
of neck pain was higher in patients with primary headaches (85.7%) as
compared to those without headache (68.4%). Among patients with primary
headaches, 88% of patients suffering from tension-type headache and 76% of
those suffering from migraine headache reported neck pain anytime during
the attack [9]. An association between migraine and cervical spine disorders
has been suggested. Relative to individuals without migraine, those with
migraine are more likely to self-report neck pain, to have more cervical trigger
points, and to report tenderness on the cervical muscles.4 During migraine
attacks, neck discomfort, stiffness, and pain are very common features (1,2).
Interestingly, pressure pain thresholds in the neck have been found to be
reduced in migraine patients even when they are not experiencing an attack
(3). Nociception from neck muscles may contribute to migraine headaches
experienced in the first trigeminal branch (4) via central convergence in the
trigeminal cervical complex (5)5Sometimes neck pain is the triggering factor,
and the myofascial pain in the neck is the initiation site of migraine attack.
This neck pain, after an initial trigger, may last during all phases of a migraine
attack. The exact pathophysiology behind this is not known. Some authors
term this type of migraine attack as “migraine cervicale.”[6] We prefer to call it
“cervical migraine.”6
Regarding the presence of other musculoskeletal signs and symptoms in
patients with migraine, studies have identified reduction in the amplitude of
global cervical motion or in the upper segment [10, 12–14], hypersensitivity
to muscular and articular palpation in the region of the face and the neck [15–
17], higher prevalence of myofascial trigger points [12, 18], alterations in
head posture [19], and poorer performance of the cervical muscles,
characterized by weakness, delay in force production, and greater
coactivation of antagonists in maximum and submaximum tasks [20, 21]. 7 A
migraine attack is characterized by hypersensitivity to light, sound, smell,
taste, touch, and even to physical activity [22,23]. Although it is a well-known
neurobiologic disease [14], it is also associated with musculoskeletal
disorders [24], which may also contribute to the development of fear
avoidance behaviors and kinesiophobia. Physical activity has a positive effect
on health and wellbeing (14) and is a widely used physiotherapeutic
treatment strategy. Migraine especially has a great impact on family life and
social activities (15), and co-existing TTH and NP may have a negative
influence on their burden of disease as the prognosis of migraine may worsen
with co-existing TTH (16), and NP has been found to be a predictor of
increased disability in persons with migraine (178

The aim of this study is to investigate that is there any association of neck
pain related to migraine. Patients who reported neck pain present with the
complain of severe migraine .And to study different clinical features among
patients suffering from cervical migraine .

LITERATURE REVIEW
This cross-sectional, single-blinded study was conducted by Zhiqi Liang
MPhty(etal) in a research laboratory at the University of Queensland, Australia in 2021.
Persons with migraine (total n = 124: episodic migraine n = 106, chronic migraine = 18),
healthy controls (n = 32), and persons with idiopathic neck pain (n = 21) were assessed
using a set of measures typically used in the assessment of a cervical musculoskeletal
disorder, including cervical movement range and accuracy, segmental joint dysfunction,
neuromuscular and sensorimotor measures .2:This study is conducted by Haidar
Muhsen Al-Khazali1 in 2021 The search identified 2490 citations of which 30 contained
relevant original population based and clinic-based data. Among these, 24 studies
provided data eligible for the analysis. The meta-analysis for clinic-based studies
demonstrated that the pooled relative frequency of neck pain was 77.0% (95% CI: 69.0–
86.4) in the migraine group and 23.2% (95% CI:18.6–28.5) in the non-headache control
group. Neck pain was more frequent in patients with chronic migraine (87.0%, 95% CI:
77.0–93.0) compared to episodic migraine (77.0%, 95% CI: 69.0–84.0). Neck pain was
12 times more prevalent in migraine patients compared to non-headache controls and
two times more prevalent in patients with chronic migraine compared to episodic
migraine. The calculated heterogeneity (I2 values) ranged from 61.3% to 72.0%3

This study is conducted by Gökhan Özer &

 Necla Benlier in 2018 50 migraineurs volunteered to participate in our

study of whom 82% were female and 18% were male. 31 (62%) patients had
migraine with aura and 19 (38%) had migraine without aura. The severity of
pain was mild in 2%, moderate in 16% and severe in 82% of the patients.
Sensitivity to sound was reported by 98% of patients and sensitivity to light
was present in 86% of the patients. 86% of the patients had nausea, 34% had
vomiting, 76% had vertigo, 46% had tinnitus, and 96% had an aggravation of
pain during physical activity. 40% of the patients reported neck spasms. While
89.1% of the patients reported that their headache and neck pain started and
ended concurrently, only 10.9% of them had neck pain starting at different
times in comparison to migraine headache (30 min before headache, 2 h
before or later than headache and 12 h later than headache). Neck pain was
localized on the left side in 26% of the patients and 22% had bilateral neck
pain. Neck massage appeared to alleviate the pain in 78% of the patients .9
1. Bragatto MM, Bevilaqua-Grossi D, Benatto MT, Lodovichi SS, Pinheiro CF, Carvalho GF, et al. Is
the presence of neck pain associated with more severe clinical presentation in patients with migraine? A
cross-sectional study. Cephalalgia. 2019;39(12):1500-8.
2. Liang Z, Thomas L, Jull G, Minto J, Zareie H, Treleaven J. Neck pain associated with migraine does
not necessarily reflect cervical musculoskeletal dysfunction. Headache: The Journal of Head and Face
Pain. 2021;61(6):882-94.
3. Al-Khazali HM, Younis S, Al-Sayegh Z, Ashina S, Ashina M, Schytz HW. Prevalence of neck pain in
migraine: A systematic review and meta-analysis. Cephalalgia. 2022;42(7):663-73.
4. Florencio LL, Chaves TC, Carvalho GF, Gonçalves MC, Casimiro EC, Dach F, et al. Neck pain
disability is related to the frequency of migraine attacks: A cross‐sectional study. Headache: The Journal
of Head and Face Pain. 2014;54(7):1203-10.
5. Hvedstrup J, Kolding LT, Ashina M, Schytz HW. Increased neck muscle stiffness in migraine
patients with ictal neck pain: a shear wave elastography study. Cephalalgia. 2020;40(6):565-74.
6. Pradhan S, Choudhury SS. Clinical characterization of neck pain in migraine. Neurology India.
2018;66(2):377.
7. Xavier NdS, Benatto MT, Florencio LL, Fernández-de-Las-Peñas C, Dach F, Bevilaqua-Grossi D.
Are there gender differences in neck pain and musculoskeletal disorders of the cervical spine associated
with migraine? Pain Medicine. 2021;22(12):3021-9.
8. Krøll LS, Hammarlund CS, Linde M, Gard G, Jensen RH. The effects of aerobic exercise for
persons with migraine and co-existing tension-type headache and neck pain. A randomized, controlled,
clinical trial. Cephalalgia. 2018;38(12):1805-16.
9. Özer G, Benlier N. Neck pain: is it part of a migraine attack or a trigger before a migraine attack?
Acta neurologica Belgica. 2020;120:289-93.