Migraine

Headache

Overview

Migraine is a primary headache disorder characterized by recurrent episodes of moderate to severe unilateral throbbing pain, often accompanied by autonomic and neurological symptoms. It affects approximately 12% of the population and results from complex neurovascular mechanisms involving cortical spreading depression, trigeminal system activation, and neuroinflammatory cascades. Osteopathic management focuses on reducing biomechanical triggers, improving cervical and cranial mobility, and addressing associated musculoskeletal tension.

Pathophysiology

Migraine involves a cascade of neurobiological events beginning with cortical spreading depression—a wave of neuronal and glial depolarization that triggers activation of the trigeminal vascular system. This leads to release of neuropeptides (CGRP, substance P) causing vasodilation, neurogenic inflammation, and sensitization of trigeminal afferents. Secondary mechanisms include dysfunction of pain-modulatory pathways in the brainstem, hormonal influences (estrogen fluctuations), and peripheral sensitization. Cervical myofascial dysfunction and reduced cervical spine mobility often coexist, creating a bidirectional relationship where mechanical dysfunction can trigger or exacerbate migraines through nociceptive input and trigeminal nerve irritation.

Typical Presentation

Site

Usually unilateral (60-70% cases), commonly frontotemporal or periorbital; can be bilateral or diffuse; may alternate sides between episodes

Quality

Throbbing, pulsating, or pressure sensation; described as 'hammer-like' or 'pounding'

Intensity

Moderate to severe (typically 6-10/10), often disabling and preventing normal activity

Aggravating

Physical exertion, bright lights (photophobia), loud sounds (phonophobia), strong odors, menstrual cycle, stress and emotional triggers, skipped meals, caffeine withdrawal, poor sleep, weather changes, neck movement or poor posture

Relieving

Rest in dark, quiet environment; sleep; ice application; some medications (triptans, NSAIDs); neck massage or gentle mobilization; reduction of trigger factors

Associated

Nausea and vomiting (60-70%), photophobia, phonophobia, osmophobia, visual aura (scotomas, fortification spectra in 25-30%), sensory aura (paresthesias), motor symptoms (rare), cervical muscle tension, neck stiffness, shoulder tension, jaw clenching, autonomic symptoms (lacrimation, nasal congestion, facial flushing)

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Cervical Range of Motion Assessment

Procedure

Patient seated. Measure active flexion, extension, side-bending and rotation, comparing sides, and ask whether movement changes the headache.

Positive Finding

Reduced or painful neck movement.

Interpretation

Neck pain and stiffness are common in migraine, often as part of the attack, and do not mean the headache comes from the neck. Migraine is diagnosed from the history. Refer urgently for a new or changed headache with red flags: sudden severe onset, neurological signs, fever or neck stiffness, new headache after 50, headache worse lying down or on straining, or a history of cancer or immune suppression.

Sources

No accuracy study

Palpation of Upper Cervical Joints and Suboccipital Muscles

Procedure

Palpate the upper cervical joints (C0–C3) and suboccipital muscles on both sides, asking about tenderness and headache reproduction.

Positive Finding

Tenderness, or the familiar head pain reproduced.

Interpretation

Upper neck tenderness, and even referred head pain on palpation, is common in migraine and does not by itself mean the headache is cervicogenic. Use it with the history and the flexion-rotation test.

Sources

No accuracy study

Cervical Flexion-Rotation Test (FRT)

Procedure

Patient lying on their back. Fully flex the neck passively, then rotate the head to each side until firm resistance or pain, and compare the range.

Positive Finding

Rotation clearly reduced to one side with a firm end-feel.

Reference: Ogince M, Hall T, Robinson K, Blackmore AM. The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache. Man Ther. 2007;12(3):256-62. Oliveira-Souza AIS, Florencio LL, Carvalho GF, Fernández-De-Las-Peñas C, Dach F, Bevilaqua-Grossi D. Reduced flexion rotation test in women with chronic and episodic migraine. Braz J Phys Ther. 2019;23(5):387-394.

Interpretation

Usually normal or only mildly reduced in migraine. In one study, rotation was much less restricted in migraine than in cervicogenic headache (Hall 2010), so a clearly positive test suggests an added cervical component. In Ogince 2007 (23 people with cervicogenic headache, 12 with migraine with aura, 23 without headache), the test was positive in 91% with cervicogenic headache and negative in 90% of the others. But a later study of 55 women with migraine (Oliveira-Souza 2019) found rotation on this test was reduced compared with women without headache (by about 8° in episodic and 13–15° in chronic migraine), and a positive test was nearly three times as common. A positive test does not rule migraine out; it suggests the upper neck may also be involved.

Sources

No accuracy study

Occipital Nerve Palpation and Percussion

Procedure

Palpate and gently tap over the greater occipital nerve, a little below and to the side of the external occipital protuberance, and over the lesser occipital nerve behind the ear, comparing sides.

Positive Finding

Tenderness, or shooting or tingling pain spreading over the scalp.

Interpretation

Scalp tenderness and pain from light touch (allodynia) are common during and after migraine attacks. Brief electric shooting pains in the nerve's area suggest occipital neuralgia instead.

Sources

No accuracy study

Temporomandibular Joint (TMJ) Palpation and Functional Assessment

Procedure

Palpate the TMJ in front of the ear at rest and during opening, and the masseter and temporalis. Measure mouth opening and note clicks, deviation or pain.

Positive Finding

Familiar pain in the jaw joint or jaw muscles, limited opening, or deviation.

Interpretation

Jaw disorders (TMD) often coexist with migraine and can aggravate headache, so finding them adds a treatable target. They do not explain the migraine itself.

Sources

No accuracy study

Pericranial Muscle Palpation (Temporal, Masseter, Frontal, Posterior Cervical)

Procedure

Palpate the temporalis, masseter, frontalis, sternocleidomastoid, trapezius and posterior neck muscles on both sides with steady pressure.

Positive Finding

Increased tenderness, sometimes reproducing head pain.

Interpretation

Increased pericranial tenderness occurs in both migraine and tension-type headache and does not separate them.

Sources

⚠ Red Flags

  • •Sudden onset 'thunderclap' headache (subarachnoid hemorrhage risk)
  • •First severe migraine in patient over 50 years old (new-onset late-life migraine)
  • •Change in migraine pattern, frequency, or characteristics
  • •Headache with fever, neck stiffness, and confusion (meningitis)
  • •Progressive neurological deficits or focal signs not typical of patient's usual aura
  • •Migraine with prolonged aura (>60 minutes) or motor weakness (stroke risk)
  • •Head injury preceding migraine onset
  • •Immunocompromised patient with new headache
  • •Papilledema or signs of increased intracranial pressure
  • •Migraine resistant to standard treatments or acute medication overuse headache (>10 days/month)

⚡ Yellow Flags

  • •High frequency migraine (≥4 days/month) or chronic migraine (≥15 days/month)
  • •Significant psychological distress, anxiety, or depression associated with migraine
  • •Catastrophizing about migraine or health anxiety
  • •Belief that migraine is unmanageable or untreatable
  • •Work or social avoidance due to migraine fear
  • •Medication overuse (opioids, combination analgesics, triptans) indicating poor pain coping
  • •Recent major life stressor or trauma
  • •Sleep disturbance unrelated to migraine episodes
  • •Maladaptive coping strategies (excessive caffeine, substance use)
  • •Limited social support or understanding of condition
  • •Somatization tendency or multiple unexplained symptoms

Osteopathic Techniques

Evidence for manual therapy in migraine is mixed. One review found joint mobilisation did not change outcomes, while osteopathic treatment added to medication helped in chronic migraine. Treat it as a supplement to medical care.

Safety: Before treating the neck, screen for vascular causes of headache and neck pain, such as artery dissection. Suboccipital release is not used with an acute neck fracture, suspected neurovascular compromise or a new focal neurological deficit.

Region

Cervical spine (C2–C4)

Technique

Articulation, cervical
Contested
Evidence is conflicting across studies
A review found joint mobilisation did not help migraine. A trial of a full osteopathic treatment beat sham in chronic migraine.

Rationale

Gentle neck mobilisation as an add-on to medical care. Evidence is mixed.

How it's done & evidence

How it's done

Rhythmic, low-velocity movement of a restricted cervical segment within its passive range, with no thrust. Usually done with the patient supine and the head supported; the amplitude can vary.

Evidence in Migraine

A 2022 meta-analysis found manual joint mobilisation did not change migraine outcomes (low to very low certainty). In contrast, a 2015 three-arm trial (105 patients) found osteopathic treatment beat sham and usual care for disability, migraine days and medication use, and a 2023 review found osteopathic treatment plus medication helped in chronic migraine.

Region

Suboccipital muscles (below the occipital ridge)

Technique

Suboccipital release
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials of suboccipital release on its own in migraine. A reference chapter lists migraine as an indication.

Rationale

Gentle sustained hold under the base of the skull, as an add-on to medical care. Untested on its own in migraine.

How it's done, cautions & evidence

How it's done

Patient lies supine and flat. Sitting at the head of the table, cup the head in both hands, find the occipital ridge and slide just below it onto the suboccipital muscles. Curl the fingertips up into the muscles and hold for 3–5 minutes or until the tension releases, then re-check symptoms.

Cautions

Do not use with an acute neck fracture, suspected neurovascular compromise or a focal neurological deficit. The commonest reactions are a passing headache, tiredness or nausea; worse pain or nerve compression are rarer risks.

Evidence in Migraine

Searched 24 Oct 2026: no trials of suboccipital release on its own in migraine. StatPearls lists migraine as an indication. Whole osteopathic treatment helped chronic migraine in a 2015 trial, which is indirect evidence.

Region

Lower cervical spine and cervicothoracic junction

Technique

Muscle energy, cervical (C2–C7)
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials of MET on its own in migraine. Only indirect evidence from whole osteopathic treatment.

Rationale

Low-force and patient-powered, for neck stiffness between attacks. Untested on its own in migraine.

How it's done, cautions & evidence

How it's done

The neck is positioned against the restricted barrier. The patient gently pushes back toward neutral for 3–5 seconds against equal resistance, relaxes, and the neck is taken to the new barrier. Repeat 3–5 times, then re-check.

Cautions

Do not use with fracture, dislocation, infection or muscle tear. Take care with cervical instability (check for it in rheumatoid arthritis and Down syndrome), other rheumatological disease, and recent heart attack or surgery. Use the least force needed, especially in older patients.

Evidence in Migraine

Searched 24 Oct 2026: no trials of cervical MET on its own in migraine. A 2015 trial of whole osteopathic treatment in chronic migraine is indirect evidence only.

Rehabilitation Exercises

Cervical Active Range of Motion Sequence (Flexion, Extension, Lateral Flexion, Rotation)

Range of MotionBeginner

Suboccipital Muscle Stretch (Neck Flexion with Gentle Overpressure)

StretchingBeginner

Upper Trapezius Stretch (Cervical Lateral Flexion with Shoulder Depression)

StretchingBeginner

Deep Cervical Flexor Activation (Isometric Neck Flexion Against Resistance)

StrengtheningBeginner

Chin Tucks (Craniocervical Flexion Exercise for Posture Correction)

PosturalBeginner

Levator Scapulae Stretch (Cervical Rotation and Lateral Flexion Combined)

StretchingIntermediate

Cervical Isometric Stabilization (Resisted Neck Movements in All Planes)

StrengtheningIntermediate

Scapular Stabilization Series (Prone Y-T-W Raises and Scapular Retraction)

StrengtheningIntermediate

Cervical Proprioceptive Training (Head Position Sense with Eyes Closed)

BalanceIntermediate

Thoracic Mobilization on Foam Roller (Prone Extension Over Roller)

PosturalIntermediate

Progressive Cervical Resistance Training (Rubber Band Resistance Exercises)

StrengtheningAdvanced

Graded Aerobic Exercise Program (Walking, Swimming, or Cycling at Moderate Intensity)

CardiovascularIntermediate

Referral Criteria

  • •Any red flag presentation—refer urgently to emergency department or neurology
  • •Migraine with aura lasting >60 minutes or with motor symptoms—refer to neurology for stroke risk assessment
  • •Chronic migraine (≥15 days/month) or medication overuse headache—refer to neurologist for preventive medication management and specialized headache care
  • •First migraine or significant change in migraine pattern—refer to neurologist for imaging and differential diagnosis
  • •Migraine resistant to standard osteopathic and conservative management after 4-6 weeks—refer to neurologist for advanced pharmacological intervention
  • •Significant psychological distress, anxiety, or depression accompanying migraine—refer to psychologist or psychiatrist for mental health assessment and cognitive behavioral therapy
  • •Suspected cervical myelopathy or radiculopathy with migraine—refer to neurologist or neurosurgeon for imaging and specialized evaluation
  • •Migraine precipitated by head trauma with progressive symptoms—refer to neurologist and consider imaging
  • •Temporomandibular dysfunction significantly contributing to migraine pattern—refer to dentist or TMJ specialist for occlusal assessment
  • •Suspicion of secondary headache disorder (vascular, infectious, structural)—refer appropriately based on clinical findings