There are many causes of head pain and migraines, everything from sinus migraines, tension head pain, bunch headaches, classic headaches, and others. But second, one of the major causes of head pain, and unfortunately it is also one of the most missed causes of headaches, is referred pain from the neck or the neck area of spine.

Explanation of Referred Pain

Referred pain is another form, a pinched wine. In a pinched nerve, you might feel pain emit along the route of the nerve. In a referral pain pattern such as from the neck into the head, the pain doesn’t refer along the course of a nerve root; rather, the pain is referred in a different way. In this type of referred pain, the brain isn’t sure where the pain is originating from, and so it feels it in a different place from its actual source.

Heart Attack Pain Example

You’ve probably heard that if someone is having a heart attack, then that may present with pain in the jaw or pain in the left arm. your jaw; it’s coming from a lack of blood flow to your heart leading to death of cardiac tissue. You could use a numbing medicine like lidocaine, and you could block your left arm or your jaw, but it would still hurt in the arm or jaw just the same.

Nerve Signal Explanation

And this is because what’s actually happening is that the nerves going to your brain from a specific body part, say the heart, run with other nerves and enter your brain together, so that the same wire carrying pain signals from the heart may be running with signals from your left arm. The brain sees that there is pain from that bundle of fibers and decides the pain is coming from the arm. Well, it’s the same basic function with your head and neck, where the pathologic structure that’s inflamed is in your neck, but those fibers run with sensory fibers from your head and enter your brain, and when the brain sees that bundle of fibers, it decides the problem is actually in the head.

Common Cervical Spine Sources of Head Pain

So in the neck, there are three most common aspects that refer pain into the head. The most common, by far, are the little facet joints in the back of the cervical spine. These facet joints, particularly the C2-3 and 3-4, but also the atlanto-axial joint, are like any other mobile synovial joint in your body, like your knees, hips, fingers, shoulders, and these facet joints can become arthritic and they can become painful, just like those other joints. The cervical facet joints, when inflamed, often refer pain into the suboccipital region and sometimes into the top of the head and even sometimes behind the eye or both eyes if the pain is bilateral.

Myofascial Pain from Repetitive Stress

And finally, sometimes people have myofascial pain from chronic repetitive stresses, such as a bad computer setup at work or spending too much time staring at the phone in your hand. And yes, I think that most of us are guilty of that to one degree or another. The muscles in the trapezius right over here and the paraspinals tighten up, and those muscles can then refer pain into the head as well.

How to know Head pain  Come from the Neck

Well, first of all, with any recurring or severe headache, you want to first rule out serious medical causes such as a tumor or serious vascular problem. These are very uncommon, but they need to be ruled out.

Two Basic Presentations of Neck-Related Headaches

Now, with that stipulation, there are two basic presentations of necks causing headaches. In one instance, a person has neck pain and headaches. The neck pain may refer directly into the head or may feel separate from the headaches, but you’re having both. Now, in these instances, to me, the obvious answer is to treat the neck. For example, I often see patients who have neck pain and headaches, and the patient will often ask me if I think that headaches are coming from their neck, in which case can we get them better, right? So almost always, my answer is, I don’t know, but the way that we’re going to go about finding out is we’re going to get your neck all better, and when we do that, if the headaches are still there, then it’s not coming from your neck. Now, if the headaches are much better or if they’re gone, then that’s our answer, and often it does turn out that the neck and headaches are related, but then again sometimes it doesn’t, right? And you just have to sometimes go through it to find out. So what I would say to anyone with neck pain and headaches is get the neck pain all better and then see if the headaches have improved, and that’s how you’re going to find your answer.

Headaches Without Neck Pain and Migraine Misdiagnosis

The more tricky situation is in someone with headaches and no neck pain. Now, I have seen scores of patients at this point who have been diagnosed with migraines and who have lived for years or decades with their migraines, and then they come to see me, and we evaluate the neck and we ultimately get these patients better by treating their neck. I can easily remember more than a few patients who have been on chronic migraine pain meds who were able to stop all of them after we recognized that the neck was really the cause of their pain, and we got the neck better. That’s not because I’m doing anything particularly special as a doctor other than I have an expertise in spine, and so I’m aware of this connection that’s sometimes missed.

Neurology Blind Spot and Migraine Medication Effects

I don’t know why, it seems that this is an under-recognized connection in primarily the neurology community, but honestly, I do think it is. I have lots of friends who are neurologists, and they’re very smart, they’re very well-intentioned doctors, and they’re very good doctors. I think this is one blind spot in their training and growing up in the system, for whatever reason. I do think one of the things that obscures this problem is that when you give someone who has cervicogenic headaches—that is, headaches that are, you know, coming from their neck—when you give that person a migraine medication, a lot of times it makes that pain better, at least to a point, and so this seems to reinforce the idea that they found the right diagnosis, because otherwise why would the migraine medication be making the pain better? When really it’s just blunting whatever pain is there that’s actually being referred from the neck.

Migraines and Other Headaches Are Real

Now, importantly, sometimes, indeed often, a migraine is just a migraine, right? For every patient that I’ve been able to help by addressing their neck, I’ve had another one who I’ve tried to help but it turned out that the neck was not involved at all. And migraines and sinus headaches and tension headaches are all very real in their own rights, and they can be very difficult things to deal with. So clearly, you know, to be crystal clear, the neck is not a silver bullet for all things headache related, but—and here’s the thing—if you don’t consider the neck as a potential cause, then you don’t have the chance to address it, and you will miss helping a lot of people who could otherwise have been helped.

No final Diagnostic Test for Neck-Related Head pain

Unfortunately, also, there’s no single diagnostic test that will prove or disprove the neck as being involved with a person’s headaches. An MRI may show facet joint arthritis or degenerative disc disease, but these findings are present in so many people with no symptoms that their presence is consistent with, but it’s certainly not diagnostic of these problems.

Conservative Treatments to Try First

Treating your neck: so what’s one to do? Well, I think at a minimum you could start with trying therapeutic exercises for the neck to see if that helps the headaches. To that end, you could start with our video on exercises for neck pain. You could also start with physical therapy where the therapist, in addition to showing you the exercises that you could be doing, the therapist can also offer passive modalities such as soft tissue mobilization, ultrasound, and electrical stimulation to help with the pain or to see if that’s what’s causing the pain. These are all very conservative measures to try.

Advanced Treatments When Conservative Measures Fail

If this isn’t helpful but the index of suspicion for the cervical spine being involved is high or if the migraines or headaches are so poorly managed that it’s worth ruling out every other potential cause, then doing something like injecting the facet joints under fluoroscopic guidance may be an appropriate option.

Research and Treatment Success

Now, it just so happened that I was at a spine conference at this time, and I was presenting a paper, and while I was there, I listened to another paper about a study in which a series of patients had presented with basically similar classical migraine symptoms, including nausea and vomiting, that had resolved after the neck was treated. Now, this was very surprising to me at the time, and I still wasn’t completely convinced, but I took that information and I talked to my patient, and we agreed that given how much her life was bothered by her migraines, even though it was a low chance of being the diagnosis, it was worth a try to treat her neck as if that was the problem to see if that would help her migraines. So we went ahead and we did that, and sure enough, when we got her in with physical therapy and I did some trigger point injections into her trapezius that were particularly tight, the migraines got almost all better, and within a couple of months, she was off all of her migraine medications.

Personal Reflection on Neck and Migraine Connection

This was as close to a home run as I could have imagined for her. Personally, I think what was happening for her was that her neck would get tight and that would trigger a more classical migraine for her in the same way that chocolate triggers migraines in other people. Either way, for me, what it did is it reinforced the importance of at least considering the neck as a contributing factor when treating migraines, recognizing that the neck is not always or maybe even is not usually going to be involved, but there will be some people for whom it’s going to make a real difference.