Cervical Musculoskeletal Impairments in Migraine and Tension-Type Headache

Neck pain is a common complaint among patients with migraine and tension-type headache (TTH), often leading them to seek cervical treatment. However, the drivers of neck pain in these primary headache disorders are complex, involving headache pathophysiology, local musculoskeletal (MSK) dysfunction, or peripheral sensitivity.

An article published in Musculoskeletal Science and Practice synthesizes findings from a systematic review of 77 studies to update evidence on cervical MSK impairments in migraine and TTH, explore pain during MSK testing, and examine relationships between MSK impairments, active trigger points (ATrPs), and tenderness.

Key Findings:

1. Cervical MSK Impairments:
   • Migraine: Meta-analyses revealed very low certainty evidence for increased forward head posture (FHP) in standing, reduced cervical range of motion (ROM), reduced flexion rotation test (FRT) performance, and decreased cervical flexor and extensor strength and endurance. However, the clinical relevance of these findings is questionable due to small effect sizes and heterogeneity.
   • TTH: Only reduced cervical extensor strength was identified, with very low certainty of evidence.
   • Other Findings: Reduced movement accuracy, deep cervical flexor activation during the craniocervical flexion test (CCFT), and increased positive joint signs were observed in migraine, while TTH showed reductions in ROM, movement accuracy, and muscle dimensions.
2. Pain During MSK Testing:
   • Pain during testing was reported in approximately one-third of studies, with moderate pain intensity (around 5/10 on the VAS) commonly noted. Pain during testing may reflect either cervical MSK dysfunction or peripheral sensitization, but the relationship between pain and MSK impairments remains unclear.
   • In migraine, pain during testing was associated with reduced cervical endurance, particularly in flexor muscles, suggesting that pain may inhibit performance.
3. ATrPs and Tenderness:
   • ATrPs and tenderness were common in both migraine and TTH, particularly in chronic or mixed headache cases. However, only a few studies explored the relationship between ATrPs, tenderness, and cervical MSK impairments, with limited evidence suggesting a potential link between tenderness and reduced muscle performance in TTH.

Clinical Implications:

• Assessment: Therapists should consider whether neck pain during MSK testing reflects true cervical MSK dysfunction or cervical hypersensitivity. A comprehensive assessment, including a series of tests for articular, neuromuscular, and sensorimotor function, may help differentiate between these causes.
• Pain Management: Pain during testing can significantly impact performance, particularly in endurance and strength tests. Clinicians should record pain intensity during specific tests to better interpret results and tailor interventions.
• Treatment Prioritization: Understanding the primary driver of neck pain (MSK dysfunction vs. hypersensitivity) is crucial for prioritizing treatment. For example, treatments targeting cervical MSK insufficiencies may be more appropriate for patients with true dysfunction, while those with hypersensitivity may benefit from interventions addressing central or peripheral sensitization.
• Future Research: Longitudinal studies are needed to better understand the drivers of neck pain in migraine and TTH. Additionally, incorporating quantitative sensory testing may help clarify the role of cervical hypersensitivity in MSK impairments.

Conclusion:

This review highlights the complexity of neck pain in migraine and TTH, emphasizing the need for careful interpretation of cervical MSK test outcomes. While some cervical MSK impairments were identified, the clinical relevance of these findings is uncertain due to heterogeneity and small effect sizes. Pain during testing, ATrPs, and tenderness are common but poorly understood in relation to MSK impairments. Therapists should adopt a comprehensive assessment approach to differentiate between cervical MSK dysfunction and hypersensitivity, ensuring targeted and effective treatment strategies. Further research is needed to explore the bidirectional relationships between pain, ATrPs, tenderness, and cervical MSK function in primary headache disorders.