What’s the source of your headaches? It could be your neck.

There’s a saying: pain begets pain. It is used in the context of physical pain, and also when someone inflicts their own psychological pain on others. On the physiological front, mounting research is providing more evidence that neck pain often leads to headaches.

A recent study published in The Journal of Headache and Pain is the first to provide an objective marker for muscle involvement.

Researchers used magnetic resonance imaging (MRI) to investigate myofascial (muscle and surrounding connective tissue) involvement in tension-type headaches and migraines among 50 people. Besides finding a link between neck pain and the presence of both types of headaches, the MRI scans revealed subtle changes in the trapezius muscle, which extends from the mid-back into the neck and shoulders, that may stem from inflammation among those with these headache disorders.

“We also found significant associations between those muscular changes and the number of days an individual suffered from headache over the 30 days prior to imaging as well as neck pain,” says study coauthor Nico Sollmann, a radiologist affiliated with the University Hospital Ulm and Technical University of Munich in Germany. These “findings may provide objective evidence for the interrelationship between the neck area and the brain in headache disorders.”

Mark Green, a professor of neurology at the Mount Sinai Icahn School of Medicine in New York City, questions some of the findings. “You can’t assume it’s inflammation from an MRI—the muscle could be strained or contracted,” he says. What he doesn’t dispute is the link between neck pain and tension headaches or migraine.

Sollmann’s research isn’t the first to link neck pain and headache. Another study in Neurology found that neck pain is highly prevalent before, during, and after the onset of migraine pain.

“Sometimes people think neck pain is a trigger but it’s also a sign that nervous system activity that goes on with a migraine attack has started,” says Neurology study coauthor Dawn C. Buse, clinical professor of neurology at the Albert Einstein College of Medicine in New York. “It can be a sign to start treating migraine.”

The connections between neck muscles, the brain, and pain 

Whether neck pain actually causes headache or whether the two pain conditions simply coexist isn’t entirely understood. But this much is clear: “People with migraine more frequently have neck pain even when they don’t have a migraine attack,” says Jessica Ailani, a professor of clinical neurology and director of the Headache Center at Medstar Georgetown University Hospital in Washington, D.C.

As far as the underlying cause goes, the trigeminal nerve, also known as the fifth cranial nerve,  is the common denominator for many headaches; it connects to the brainstem and descends to the upper cervical spine, transmitting pain, touch, and temperature signals to various parts of the face and head.

With neck pain, “the upper cervical nerves activate the trigeminal nerve and can trigger a migraine,” notes Green, president of the World Headache Society. “Seventy-five percent of people with migraine have neck pain.”

There also may be a pain sensitization phenomenon at work. Simply put, with long-lasting pain, a person’s nervous system stays in a chronically activated state, lowering their threshold for experiencing pain and making them hypersensitive to pain. A study in the Scandinavian Journal of Pain found that people who have neck pain and chronic migraine—defined as 15 or more headache days per month—or tension-type headaches tend to have greater pericranial (deep scalp) tenderness than those with episodic headaches; one theory is that this may be due to pain sensitization.

“When you’re having more pain in one region, you’re more likely to have more pain in another because all pain resides in the brain,” Ailani explains. “The brain becomes over-sensitized and pain becomes amplified. It also can be harder for the brain to shut off pain signals.”

Moreover, people with migraine or tension-type headaches often have myofascial trigger points that when manually palpated can trigger episodes of head pain. Research suggests that active myofascial trigger points in the scalps of people with tension-type headaches are correlated with lower pain pressure thresholds, which suggests a sensitization effect.

Who’s susceptible and why

Based on these mechanisms, anyone who has neck pain is potentially at risk for developing a tension-type headache or a migraine attack (if they’re prone to these).

In addition, people who are at higher risk for this painful one-two punch include those with bad spondylosis (degeneration of bones and disks in the neck), poor posture, or sports injuries.

“The combination of neck pain, headache and increased pain sensitivity can also be seen in patients with acute neck pain after a whiplash injury,” says Brian Grosberg, a neurologist and director of the Hartford HealthCare Headache Center.

In some cases, neck pain that’s accompanied by head pain “can be a red flag if someone has chills, a fever, coordination or balance problems, difficulty walking, radiating pain, or tingling in the arms or legs,” Buse says. In these instances, the neck pain could suggest a tumor or meningitis, she notes.

If these worrisome symptoms aren’t present and neck pain accompanies someone’s tension-type headaches or migraine attacks, the challenge is to treat both forms of pain so they don’t continue to trigger each other. “We want people to be aggressive about treating their neck pain so this problem doesn’t get worse,” Green says.

Magnetic stimulation and other treatments

Right now, there isn’t a single treatment that’s guaranteed to help both forms of pain. Various non-pharmacological therapies—including massage, acupuncture, stretching exercises, or the application of heat or ice (whichever feels better)—can improve neck pain, Ailani says. Improving your ergonomic set-up at work and switching to a more supportive pillow for sleep may help, too.

Research has found that myofascial release—which involves applying pressure to hyperirritable spots in neck muscles—and stretching techniques are also effective in improving migraine pain intensity and cervical range of motion.

Sollmann’s team has recently used repetitive peripheral magnetic stimulation (rPMS) to non-invasively stimulate the neck muscles and alleviate neck pain. With rPMS, a special device is used to deliver a rapidly pulsed, magnetic stimulation to peripheral nerves to reduce pain. “In the context of repeated rPMS applications, we have observed that headache can be reduced,” Sollmann adds.

On the medication front, over-the-counter medications such as acetaminophen or ibuprofen can be taken for flare-ups of neck pain, tension-type headaches and/or migraine attacks.

“Don’t overuse these medications because over time, they will make the pain worse,” Green warns. (When this happens, these are often called medication-overuse headaches or rebound headaches.)

For frequent or chronic headaches, along with neck pain, certain antidepressants—such as amitriptyline, mirtazapine, and duloxetine—and some anti-seizure drugs (such as gabapentin) may be used in an off-label capacity to prevent attacks, Ailani says.

Other migraine treatments include classes of drugs called triptans, gepants, or ditans, and a variety of preventive agents in the gepants, beta blocker, tricyclic antidepressant, and monoclonal antibody classes, are also available, Grosberg says.

Botox injections are sometimes used for chronic migraine, with the goal of reducing headache intensity and the number of headache days per month. In a study in a 2023 issue of the journal Toxins, researchers examined the effects of Botox injections among 116 people with chronic migraine and varying levels of neck disability: The Botox treatments had the greatest improvement in reducing the number of monthly headache days and disability from migraine among those with severe neck disability at the three-month follow-up, but a drop in headache intensity was similar among all the participants.  

“If headaches are frequent, it’s best to do something preventive,” Green says. This way you can potentially break the cycle of recurring pains in the neck and the head.

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