Specialist article: head
Migraine or neck?Two headaches, one relay station
Throbbing attacks with nausea, or pain that starts in the neck and spreads forwards? Here you will find out how migraine and cervicogenic headache differ, why the neck plays a part in both and what role head balance can play.
Does this sound familiar?
Your head hurts, and your neck is involved too?
What applies to you?
Tap whatever applies to you.
The first two points sound like migraine, the fourth and fifth more like a headache coming from the neck. Often both apply, because the neck and head converge on the same nerve cells in the brainstem. The diagnosis is clarified by a medical examination. What you can influence is the pattern of breathing, swallowing and head balance.
Migraine or neck?When to see a doctor?The key points at a glance
- Migraine is a distinct disorder of the nervous system with attacks lasting 4 to 72 hours. Cervicogenic headache, by contrast, originates from a disorder of the cervical spine or the soft tissues of the neck.
- Neck pain accompanies migraine very often, but that does not make it a neck headache. The neck and head share a relay station in the brainstem, the trigeminocervical complex.
- In cervicogenic and tension-type headache, in our view the constant load on the neck is often a significant factor; in migraine it is one of several that can help determine how easily an attack is triggered. You cannot change your predisposition and hormones, but you can change the pattern of breathing, swallowing and head balance.
Video
Migraine and cervicogenic headache: what the neck has to do with it
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Context
Migraine, tension-type headache, cervicogenic headache: three different pictures
Not all headaches are the same. Three types are particularly common in everyday life, and each calls for its own perspective.
of the world’s population have active migraine according to a review of 357 publications, and 26 % have tension-type headache1
people were living with migraine in 2016 according to the Global Burden of Disease Study2
of the 1,838 adults examined in a Norwegian municipality met the criteria for cervicogenic headache3
According to the same Global Burden analysis, migraine costs a good six times as many healthy years of life worldwide as tension-type headache, most of all in women aged between 15 and 492. The distinction determines which treatment is an option and where training can start.
Migraine
What characterises a migraine
Migraine is more than a severe headache. The International Headache Society describes it by fixed criteria4.
- Duration: Untreated, an attack lasts 4 to 72 hours, and may be shorter in children and adolescents.
- Character: At least two of four features apply. The pain is one-sided, throbbing, moderate to severe, or gets worse with everyday activity such as climbing stairs.
- Accompanying symptoms: Nausea or vomiting, or sensitivity to both light and noise.
- Recurrence: The diagnosis requires at least five such attacks.
Some people experience an aura before the headache, such as flickering zigzags in the visual field, tingling or speech disturbances. The likely basis is thought to be a wave that spreads across the cerebral cortex at 3 to 5 millimetres per minute, known as spreading depolarisation5. During an attack, the trigeminovascular system also becomes active, i.e. the fibres of the trigeminal nerve that supply the meninges and blood vessels.
Migraine is a disorder of the nervous system. The neck still has a say.Predisposition, hormones, sleep and stress play their own role. The question is which factors shift the threshold for an attack and which of them you can influence yourself.
Known triggers include lack of sleep, stress, hormonal fluctuations and certain foods. In our view, the basic pattern with which you breathe, swallow and carry your head also counts. This has not been proven for migraine.
Cervicogenic headache
When the headache starts in the neck
In cervicogenic headache, the neck is not a companion but the starting point. The pain arises in the cervical spine or the soft tissues of the neck and radiates into the head.
The classification requires a finding in the cervical spine or the soft tissues of the neck that can cause headache, and at least two pieces of evidence for the connection4: a temporal link to the neck finding, improvement in parallel with it, restricted mobility with increased pain during certain movements, or freedom from pain after a targeted anaesthetic block in the neck.
More likely migraine
- Attacks lasting hours to days, often symptom-free in between
- Throbbing, the side can change
- Marked nausea and sensitivity to light and noise
- Everyday activity makes the pain worse
More likely cervicogenic
- Starts in the neck or at the back of the head and spreads forwards
- Stays on the same side
- Head movement or pressure on the neck muscles triggers the typical pain
- Restricted mobility of the cervical spine
None of these features is conclusive on its own. Nausea and sensitivity to light can also occur with cervicogenic headache, usually less pronounced than with migraine4.
of those affected in the Norwegian Vågå study felt the pain episodes begin in the neck or at the back of the head. Women were not affected more often than men there3
less rotation in the flexion-rotation test of the upper cervical spine was shown on average by people with cervicogenic headache compared with people with migraine, pooled from 62 studies13
Neck pain
Neck pain in migraine: common, but not proof
Many people with migraine also feel their headache in the neck. The studies bear them out, just not in the way they might think.
of people with migraine had neck pain in clinical studies, compared with 23 % in comparison groups without headache. Pooled from 24 studies7
was the figure in chronic migraine, i.e. headache on 15 or more days a month7
were recorded by 113 people with migraine in a US study. Neck pain accompanied them more often than nausea8
In this study, headache specialists had ruled out cervicogenic headache beforehand8. The neck pain was therefore part of the migraine itself. It is neither a sign of a wrong diagnosis nor proof that the neck triggers the attack. It shows how closely the two regions are interconnected.
Where does your headache usually start?
Anatomy
The trigeminocervical complex: where neck and head converge
Why do you feel neck problems in your head? The answer lies in the upper cervical spinal cord, directly below the brainstem.
The trigeminal nerve, the fifth cranial nerve, supplies the face, forehead, jaw and meninges. Its descending nucleus extends into the upper cervical segments, where fibres from the neck meet the same nerve cells. This region is called the trigeminocervical complex.
This convergence allows pain to be referred between the neck and the face in both directions6. The system then cannot reliably tell where a signal comes from. How the trigeminal nerve supplies the face and the chewing muscles is explained in the article on trigeminal pain. Why ringing in the ears can also respond to the jaw and neck is covered in the article on tinnitus.
in the second cervical segment of rats responded both to stimuli of the meninges and of the greater occipital nerve9
of the recorded cells enlarged their receptive field after stimulation of the meninges, and the response to stimuli from the deep neck muscles increased10
Both experiments on anaesthetised rats come from the Headache Group in London. They show the circuitry, not its magnitude in humans. Stimuli from the neck muscles had a considerably longer after-effect than stimuli from the skin9.
Like a shared telephone exchange
Imagine the neck and face reporting via the same exchange. If the neck keeps ringing without a break, the line is already loaded, and even a small call from the head seems louder. The constant tension does not cause every attack, but in our view it can shift the threshold at which the system raises the alarm.
Head balance
Head forward: what this means for the neck
An adult’s head weighs around four to five kilograms. How much work it makes for the neck depends above all on where it is positioned.
If the head sits over the cervical spine, the system carries it with little muscle work. If it moves forwards, the lever grows and the neck muscles have to counteract constantly.
The kilogram figures in circulation come from a model calculation without measurements on humans. The direction is clear; the numbers are not. You can find more about the chain down into the back in the article Neck and back.
with one-sided migraine and without headache were compared in a Madrid study. The migraine group held their heads further forward and had more active trigger points, especially on the painful side11
with and without migraine were compared in a Brazilian study using X-rays and photographs. It found no difference in head balance12
The findings therefore contradict each other. A review of 62 studies found slightly lower mobility of the cervical spine in migraine, less strength in the neck extensors and more activity in the trapezius and scalene muscles13. Comparative studies cannot clarify whether this is the cause or the consequence of the headaches.
For us, head balance is therefore not a posture grade but the system’s response to its conditions, above all to how free the airway is. If the head has to move forwards so that there is space behind the tongue, the neck becomes a permanent construction site.
Pulling your head back through willpower only lasts as long as you think about it. The balance can be changed via the pattern that produces it.
The triad
Balance from the front: tongue, hyoid bone and neck
The neck holds the head from behind. In our view, its fine balance is also controlled from the front.
Below the lower jaw lies the hyoid bone, a bone without a joint to any other bone. The muscles above it connect it to the lower jaw and the base of the skull, those below it to the breastbone and shoulder blade. Together they form a front chain of reins.
Dr. Klaus Berndsen describes it as the place of fine-tuning: the neck muscles carry the head, and it is balanced via the hyoid muscles. How this chain is tensioned depends on the tongue reference position and the swallowing pattern.
The basic pattern deviates
Mouth breathing, a low-lying tongue or a swallowing pattern with pressing change the tension of the front neck muscles.
The body compensates
The head moves forwards and extends at the upper neck so that the airway stays open. The nervous system stores this as a pattern.
The neck works without a break
The short neck muscles counteract, and their sensors report continuously to the trigeminocervical complex.
The threshold drops
In cervicogenic and tension-type headache, in our view this constant load is often a significant factor. In migraine, it is one of several and can help determine how easily an attack is triggered.
Then there is breathing. In our view, people who breathe through the mouth for a long time often recruit the sternocleidomastoid and scalene muscles as breathing aids. Both pull on the neck and belong to the same chain.
Whether a changed breathing pattern shifts the migraine threshold itself has not been studied. This is an open question, not a finding.
Research
Training for headache: what studies show and what they do not
Does active training change anything? The answer differs depending on the type of headache.
with cervicogenic headache were allocated by lot in Australia. Low-load exercises reduced the frequency and intensity of the headaches, as did manual therapy, over twelve months14
with migraine in Sweden did 40 minutes of endurance training three times a week, practised relaxation or took topiramate. In all groups, the number of attacks fell by just under one per month15
on physiotherapy for headache had a high risk of bias in a Hamburg review. The authors rate the evidence as low16
Active training is therefore well founded for cervicogenic headache. For migraine, exercise is one option among several, according to the Swedish authors above all for people who do not benefit from daily medication or do not want to take it15.
There is no dedicated study on FaceFormer training for migraine. The studies above test other exercises, not the FaceFormer. You can find out which studies exist on FaceFormer therapy and how to interpret them under Studies and science.
The absence of a study does not mean that the connection does not exist. It means that it has not been tested.That is why we promise nothing for migraine. We explain how we see the connection and why we consider the basic functions worth training regardless of the symptom.
Safety
Having headaches checked by a doctor: these warning signs matter
Only a small proportion of headaches are caused by another disease. So that these are not overlooked, there is the SNNOOP10 warning-sign list17.
Sudden and severe
A headache that starts abruptly at full intensity.
With fever
Headache together with fever or other general symptoms.
Neurological deficits
Paralysis, numbness, speech or visual disturbances that are new or different from a familiar aura, or impaired consciousness.
New, changed or worsening
A new, markedly changed or steadily worsening headache, or a first onset after the age of 65.
Coughing, straining, body position
Headache that is triggered by coughing, sneezing or exertion, or that depends on body position.
After an accident or fall
Headache that begins after an injury.
Special circumstances
Pregnancy or the postnatal period, a history of cancer or a weakened immune system.
Painful eye
A painful eye with tearing, redness or a runny nose on the same side.
If any of these signs apply, have yourself examined by a doctor promptly. In the event of an abrupt, extremely severe headache or new deficits such as paralysis or a speech disturbance, call the emergency number 112.
With frequent use, acute headache medication can itself sustain headache. The classification calls this medication-overuse headache4. This is an example of how symptom treatment can prolong the symptom.
a month with headache and regular use of acute medication for more than three months: these are the criteria for medication-overuse headache4
a month with triptans are already enough for this; with paracetamol it is 15 days4
If you take painkillers on many days a month, discuss this with your practice instead of increasing the amount yourself or stopping abruptly. This also applies to prescribed migraine prophylaxis. Training and medication are not mutually exclusive.
Training
Training head balance: the pattern instead of the symptom
FaceFormer therapy is not a remedy for headache. It trains the basic functions of breathing, swallowing and head balance, which in our view are at the start of many chains of complaints.
A pattern does not change through insight, but through precise, frequent repetition. That is why you practise lip closure, nasal breathing, tongue reference position, swallowing and head balance in one sequence. The starting point is the basic exercise: FaceFormer in the oral vestibule, tip of the tongue on the ridge behind the upper front teeth, nasal breathing, bite briefly, swallow.
From around week 6, the head balance rotation is added. You press the lip wedge and slowly turn your head to the side for six seconds until you feel the neck muscles, without pain.
There you bite briefly and swallow once. Then turn back to the centre over six seconds, followed by the other side.
The turn stretches the muscles that keep the head in balance and trains them in interplay with the tongue and the act of swallowing. Look straight ahead.
Later, in module 9, you combine the rotation with calm nasal breathing. How slow breathing engages the parasympathetic nervous system is explained in the article on the vagus nerve.
- From day 1
Basic exercise
A few minutes three times a day with the FaceFormer ZERO; you increase the repetitions weekly.
- From around week 3
Pull exercise and night
The pull exercise is added. At night, you wear the ZERO as soon as you have mastered the basic exercise.
- After a few weeks
Switching to the ONE
During the day, you train with the FaceFormer ONE, the same size and shape as the ZERO, just made of firmer material. At night you stay with the ZERO.
- From around week 6
Head balance rotation
Eight repetitions three times a day, fourteen from week 7, in addition to the basic training.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months until the new sequences run without thinking, followed by maintenance training.
The free FaceFormer app guides you through the basic exercises; you can find all modules on the exercise pages. If you train with a practice, coordinate the rotation with them. Pause during a migraine attack, and only turn your head as far as you can without pain.
Everyday life
Relieving the neck in everyday life
Keep a headache diary
Note the day, duration, location and type of pain, accompanying symptoms, possible triggers and every medication. This helps you recognise patterns and gives your practice a reliable basis.
Screen at eye level
Set up your screen and seat so that your head is balanced over your body. Raise your phone instead of lowering your head.
Lips closed, tongue up
Your lips rest loosely together, the tip of your tongue at the reference point, and you breathe through your nose. Check this several times a day.
Teeth apart
At rest, the teeth do not touch. Clenching and grinding strain the chewing muscles, which report via the trigeminal nerve to the same relay station. More on this in the article TMD and jaw joint.
Move regularly
Endurance exercise is a studied option for migraine. Build up slowly and pay attention to how your head reacts.
Individual users tell us that their attacks have become less frequent or weaker since they started working on their pattern. This is individual experience, not evidence and not a promise. Whether anything changes for you is shown by your headache diary over months.
Questions
Frequently asked
What is the difference between migraine and cervicogenic headache?
Migraine is a distinct disorder of the nervous system with attacks lasting 4 to 72 hours, often throbbing and accompanied by nausea or sensitivity to light. Cervicogenic headache originates from the cervical spine or the soft tissues of the neck, typically starts in the neck and stays on one side.
Can migraine come from the neck?
Neck pain is part of migraine for many people; in clinical studies, in around three out of four of those affected. This does not mean that the neck causes the migraine. The neck and head report to the same relay station in the brainstem. In our view, a neck under constant strain can therefore help shift the threshold for attacks, as one factor among several.
How do I recognise a cervicogenic headache?
Typical signs are onset in the neck or at the back of the head, pain that spreads forwards on the same side, restricted mobility of the cervical spine and pain with certain head movements. None of these features proves it on its own; the diagnosis is made by a medical examination.
Does neck training help with migraine?
For cervicogenic headache, targeted exercises reduced frequency and intensity over twelve months in a large randomised study. For migraine, endurance training performed similarly to relaxation and topiramate. There is no dedicated study on FaceFormer training for migraine.
What role does head balance play in headaches?
If the head sits in front of the plumb line, the neck muscles have to counteract constantly, and their signals arrive where the trigeminal nerve is also connected. In our view, head balance is a response to breathing and swallowing, which is why we train all three together.
When should I see a doctor about headaches?
As soon as a warning sign applies, such as a sudden, severe headache, fever, new neurological deficits, a new or markedly changed headache, headache after an accident, or taking painkillers on many days a month. In the event of sudden, extremely severe pain or paralysis, call the emergency number 112.
Can I train with the FaceFormer if I take migraine medication?
Yes, training and medication are not mutually exclusive. Do not stop prescribed medication on your own initiative; discuss any changes with your practice. Pause the training during an attack.
More articles from the knowledge section
Experiences on this topic
Where to go next
Sources
- Stovner LJ, Hagen K, Linde M, Steiner TJ (2022). The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates. Journal of Headache and Pain 23(1):34. PMID 35410119. Source
- GBD 2016 Headache Collaborators (2018). Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurology 17(11):954-976. PMID 30353868. Source
- Sjaastad O, Bakketeig LS (2008). Prevalence of cervicogenic headache: Vågå study of headache epidemiology. Acta Neurologica Scandinavica 117(3):173-180. PMID 18031563. Source
- Headache Classification Committee of the International Headache Society (2018). The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia 38(1):1-211. Criteria 1.1 Migraine without aura, 8.2 Medication-overuse headache, 11.2.1 Cervicogenic headache. Source
- Lauritzen M (1994). Pathophysiology of the migraine aura. The spreading depression theory. Brain 117(Pt 1):199-210. PMID 7908596. Source
- Biondi DM (2005). Cervicogenic headache: a review of diagnostic and treatment strategies. Journal of the American Osteopathic Association 105(4 Suppl 2):16S-22S. PMID 15928349. Source
- Al-Khazali HM, Younis S, Al-Sayegh Z, Ashina S, Ashina M, Schytz HW (2022). Prevalence of neck pain in migraine: A systematic review and meta-analysis. Cephalalgia 42(7):663-673. PMID 35166137. Source
- Calhoun AH, Ford S, Millen C, Finkel AG, Truong Y, Nie Y (2010). The prevalence of neck pain in migraine. Headache 50(8):1273-1277. PMID 20100298. Source
- Bartsch T, Goadsby PJ (2002). Stimulation of the greater occipital nerve induces increased central excitability of dural afferent input. Brain 125(Pt 7):1496-1509. PMID 12077000. Source
- Bartsch T, Goadsby PJ (2003). Increased responses in trigeminocervical nociceptive neurons to cervical input after stimulation of the dura mater. Brain 126(Pt 8):1801-1813. PMID 12821523. Source
- Fernández-de-Las-Peñas C, Cuadrado ML, Pareja JA (2006). Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Cephalalgia 26(9):1061-1070. PMID 16919056. Source
- Ferracini GN, Dach F, Chaves TC et al. (2016). Cervico-occipital Posture in Women With Migraine: A Case-Control Study. Journal of Orthopaedic and Sports Physical Therapy 46(4):251-257. PMID 26954270. Source
- Anarte-Lazo E, Carvalho GF, Schwarz A, Luedtke K, Falla D (2021). Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis. BMC Musculoskeletal Disorders 22(1):755. PMID 34479514. Source
- Jull G, Trott P, Potter H et al. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 27(17):1835-1843. PMID 12221344. Source
- Varkey E, Cider A, Carlsson J, Linde M (2011). Exercise as migraine prophylaxis: a randomized study using relaxation and topiramate as controls. Cephalalgia 31(14):1428-1438. PMID 21890526. Source
- Luedtke K, Allers A, Schulte LH, May A (2016). Efficacy of interventions used by physiotherapists for patients with headache and migraine: systematic review and meta-analysis. Cephalalgia 36(5):474-492. PMID 26229071. Source
- Do TP, Remmers A, Schytz HW et al. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology 92(3):134-144. PMID 30587518. Source
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FaceFormer ZERO Children’s Set
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FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
