|  17 min read

Understanding the Role of Physiotherapy in Migraine Management

Tension type headache guide

This blog post is largely derived from our podcast interview with Dr. Kerstin Luedke and complemented with scientific evidence. It is by no means a complete overview of the scientific literature on migraines but aims to provide important information to the reaeder. Enjoy reading!

Migraine is a complex neurological disorder characterized by recurrent headaches, often accompanied by nausea, vomiting, and sensitivity to light and sound. For many sufferers, migraines can significantly impair their quality of life and daily functioning. Traditional treatment approaches have primarily focused on pharmacological interventions; however, the role of physiotherapy and manual therapy in migraine management is increasingly being recognized. In this blog post, we explore the latest insights and research findings on the contributions of physiotherapy to migraine management, based on an in-depth discussion with Dr. Kerstin Luedtke, a leading expert in the field.

What is Migraine? A Definition and Subcategories

Migraine is a neurological disorder characterized by recurring headache episodes that meet specific diagnostic criteria. Professor Kerstin emphasized that migraines are not simply headaches caused by neck dysfunction or stress but rather involve distinct neurological changes that affect both the head and the broader nervous system.

To be classified as a migraine, certain clinical features must be present, namely the following:

  1. A history of at least five headache attacks fulfilling criteria 2 and 4 (see below)
  2. Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated)
  3. Headache has at least two of the following four characteristics:
    • unilateral location
    • pulsating quality
    • moderate or severe pain intensity
    • aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
  4. During headache at least one of the following:
    • nausea and/or vomiting
    • photophobia and phonophobia

These criteria are outlined in international classification systems and serve to differentiate migraine from other headache types.

Blog featured images

Subtypes of Migraine

Migraines can also be classified into subtypes, including:

  • Migraine without aura: The most common form, characterized by the typical symptoms without any preceding neurological symptoms.
  • Migraine with aura: Involves neurological symptoms such as visual disturbances, sensory changes, or motor weakness preceding the headache phase.
  • Chronic migraine: Defined as experiencing 15 or more headache days per month, with at least eight days meeting the criteria for migraine.
  • Vestibular migraine: Characterized by episodes of vertigo and balance disturbances, which may occur with or without headache.

A full list of migraine subtypes and associated symptoms can be found in the The International Classification of Headache Disorders’ website.

Pathophysiology of Migraine

Migraines represent a state of hypersensitivity and dysregulation within the central nervous system, involving intricate dysfunctions across multiple brain regions and systems. The interplay between the hypothalamus, cerebellum, trigeminal system, and other neural circuits underpins the diverse symptoms experienced during attacks, including pain, sensory sensitivity, and systemic effects. Far from being simply severe headaches, migraines are a complex neurological condition with a wide-reaching impact.

The Role of the Hypothalamus

Often described as the “migraine generator”, the hypothalamus is crucial in initiating and orchestrating migraine attacks, particularly during the prodromal phase, the period before pain onset. Research indicates increased activity in the hypothalamus during this phase, correlating with symptoms such as yawning, fatigue, mood changes, and food cravings. These early signs suggest that the hypothalamus acts as a central control hub, setting the stage for the cascade of events leading to a migraine.

Recent MRI studies have shown that the hypothalamus exhibits heightened activation in response to visual, auditory, and painful stimuli. This research indicates that the hypothalamus plays a significant role in processing various sensory inputs, contributing to the overall migraine experience.

Cerebellar Involvement

The cerebellum, traditionally associated with balance and motor coordination, also shows heightened activity in migraine sufferers. This overactivation contributes to symptoms such as dizziness, nausea, and balance disturbances. Exposure to motion, like in virtual reality environments, can exacerbate these effects, highlighting the cerebellum’s sensitivity in migraine patients.

Sensitization of the Trigeminal System

The trigeminal system is key in transmitting sensory signals from the head and face and becomes overly responsive during a migraine. This heightened sensitivity results in the characteristic throbbing pain of migraines. The trigeminal system interacts with inputs from other areas, such as the musculoskeletal system, potentially intensifying the headache when issues like neck tension are present.

Vestibular Dysfunction

Vestibular symptoms, including vertigo and unsteadiness, are prevalent in some migraine sufferers. Vestibular migraine is characterized by prominent balance disturbances, but even those without this subtype often experience subtle postural instability and swaying. Changes in brain function and structure contribute to these symptoms, underscoring the widespread effects of migraine on the nervous system.

Common Symptoms

Migraine symptoms can vary significantly among individuals but generally follow a specific pattern:

  1. Prodrome Phase: This initial phase can occur hours or even days before the headache itself. During this time, individuals may experience subtle changes that serve as warnings. Common symptoms include:
  • Mood Changes: Increased irritability or a sense of euphoria.
  • Fatigue: A feeling of tiredness or low energy.
  • Food Cravings: An intense desire for specific foods, often sweets or carbohydrates.
  • Yawning: Frequent yawning can signal the onset of an attack.
  1. Aura Phase (if present): If the condition is accompanied by auras, these most commonly manifest as visual disturbances, and less commonly as neurological or motor symptoms. Auras may also manifest without being followed by a headache attack. Symptoms include:
    • Seeing spots, bright dots, flashes of lights, zig-zags
    • Disrupted speech (aphasia)
    • Tingling down the limbs or face
    • Muscle weakness
  2. Headache Attack Phase: The hallmark of a migraine, this phase is characterized by intense and often debilitating pain. Key features include:
    • Location: The headache is typically unilateral, affecting one side of the head but can spread to both sides.
    • Quality of Pain: The pain is often described as throbbing or pulsating and can range from moderate to severe intensity.
    • Associated Symptoms: Many individuals experience nausea and vomiting, along with significant sensitivity to light (photophobia) and sound (phonophobia). This can make it challenging to function normally during an attack, as everyday sounds and lights become overwhelming.
  3. Postdrome Phase: Following the headache, individuals may experience a recovery period that can last for hours or days. Symptoms during this phase can include:
    • Fatigue: A lingering feeling of exhaustion.
    • Mood Changes: A sense of relief or, conversely, a low mood or irritability.
    • Cognitive Difficulties: Problems with concentration or memory.

Prevalence, Risk Factors and Triggers

Migraine affects a significant portion of the population, with estimates suggesting that around 15% of adults experience migraines. The prevalence varies by gender, with women being three times more likely to suffer from migraines than men. This figure is uncertain, however, as it is unclear whether men are less likely to seek medical help in case of migraines. Various risk factors and triggers contribute to the likelihood of experiencing migraines, including:

  • Stress: While individuals with migraines typically do not experience more stress than those without migraines, stress appears to be a significant factor in triggering migraine attacks, particularly during periods that follow increased stress levels. Many migraine sufferers report experiencing what they call “weekend headaches”.
  • Weather: Many individuals with migraines frequently claim that changes in weather conditions trigger their migraine episodes; however, research has not yet been able to confirm this.
  • Genetics: A family history of migraines increases the risk.
  • Other environmental factors: Exposure to bright lights, and strong smells can precipitate attacks.

Migraines typically begin during puberty, with individuals experiencing their first episodes in their teenage years and it commonly accompanies them throughout their productive years. This timing poses a significant challenge, as migraines are predominantly experienced when individuals are often focused on careers, work, and raising children. After reaching this peak, many people experience a gradual decline in the frequency of migraines as they age, especially women, who may notice a reduction in migraine occurrences around menopause.

Diagnosis

Red flags

When diagnosing migraines, healthcare providers must remain vigilant for “red flags” that suggest a more serious underlying condition rather than a primary headache disorder. These warning signs include:

  • Thunderclap headaches: Sudden, severe headaches that reach maximum intensity within seconds and could indicate conditions like a subarachnoid hemorrhage.
  • Headaches that progressively worsen over time: This pattern may suggest a mass effect, such as a brain tumor or other structural abnormalities.
  • New or first-time headaches in individuals over the age of 50: These headaches warrant careful investigation as they may indicate temporal arteritis or other serious conditions.
  • Headaches associated with systemic symptoms: Fever, weight loss, or other signs of systemic illness can point to infections or systemic diseases.
  • Neurological symptoms: Persistent confusion, focal deficits, or seizures alongside a headache require urgent evaluation.

To ensure thorough assessment, the SNOOP criteria is often applied. This acronym highlights key areas to investigate during a headache evaluation:

  • S: Systemic symptoms (e.g., fever, weight loss) or Secondary risk factors (e.g., cancer, HIV).
  • N: Neurological symptoms or signs (e.g., focal deficits, altered consciousness).
  • O: Onset that is sudden or abrupt (e.g., thunderclap headache).
  • O: Older age at headache onset (typically over 50 years).
  • P: Pattern change or progressive headache, especially if different from a patient’s usual presentation.

Assessment

Physiotherapists are integral to the assessment and management of headache disorders by addressing musculoskeletal factors that may contribute to a patient’s symptoms. Comprehensive physiotherapy assessments focus on evaluating neck mobility, posture, muscle strength, and the presence of trigger points. These elements are closely associated with tension-type headaches and can exacerbate migraines, emphasizing the importance of their identification and management.

To streamline and enhance this process, a standardized test battery (Leudke et al., 2016) has been developed. This battery allows physiotherapists to systematically evaluate physical and functional impairments related to headache disorders. While highly effective in identifying musculoskeletal dysfunctions, this tool is not designed to differentiate between distinct headache types, such as migraines, tension-type headaches, or cluster headaches. The limitation lies in the overlap of physical symptoms—neck dysfunction, muscle tension, and postural issues are common across different headache disorders. For example, trigger points and neck pain are prevalent in both tension-type headaches and migraines, rendering the test battery insufficient as a standalone diagnostic tool.

To address this gap, the International Headache Society (IHS) classification criteria provide a reliable framework for identifying headache types. These criteria guide physiotherapists in combining the findings of the test battery with broader diagnostic guidelines, enabling informed decisions about whether to proceed with treatment or refer the patient for further medical evaluation. This approach ensures that individuals with primary headaches, suitable for physiotherapy, receive targeted care while those presenting with red flags or complex conditions are directed to appropriate medical specialists.

For diagnosing migraines specifically, healthcare providers often rely on a detailed medical history and physical examination, supplemented by the International Classification of Headache Disorders (ICHD) criteria. In cases of atypical or sudden presentations, imaging studies, such as MRI or CT scans, may be employed to exclude other potential causes of the headache. 

Differential Diagnosis

Research has revealed that over 90% of patients with migraines exhibit detectable musculoskeletal dysfunctions. This significant finding raises numerous questions regarding the relationship between these dysfunctions and migraine attacks. Are these musculoskeletal issues a causative factor in migraines, a contributing factor, or merely a consequence of repeated headache episodes? Understanding this relationship is complex and extends beyond the simple evaluation of cervical function.

While studies have highlighted the prevalence of musculoskeletal dysfunctions among migraine patients, they have not effectively differentiated between migraine and cervicogenic headaches. Although it was hoped that specific tests could clarify these distinctions, such as the flexion-rotation test assessing the C1/C2 joint in rotation, these tests often yield positive results for both types of headaches, indicating a lack of clear differentiation.

However, it is essential to consider the role of specific maneuvers in the assessment of headache types. For example, if certain head positions or movements—such as extension or lateral flexion—provoke the typical headache pattern, this could suggest a cervicogenic headache rather than a migraine. Nonetheless, it is worth noting that referred pain to the head can also occur in migraine patients, complicating the diagnostic process.

Another crucial aspect of differentiating headaches lies in understanding tension-type headaches (TTH). Despite their name, the muscle tension associated with TTH is not a causative factor; rather, it is a symptom that emerges from the underlying headache disorder. TTH is classified as a primary headache, originating in the brain itself. While physiotherapists can help alleviate neck tension, it is important to recognize that this muscle tightness is not the root cause of the headache.

Given these complexities, physiotherapists should rely on the International Headache Society (IHS) classification criteria, which primarily focus on patient history and symptomatology. Assessing musculoskeletal factors is still valuable, as it informs treatment decisions and helps determine whether physiotherapy is appropriate for the patient. Understanding the nuances of different headache types allows physiotherapists to provide tailored interventions that address specific symptoms and improve patient outcomes.

Mpti

Treatment

Physiotherapy and manual therapy have demonstrated to be effective for treating headaches. However, it is essential to understand their role within the broader context of migraine management. While physiotherapy may not provide a cure for migraines, it can certainly contribute to alleviating associated symptoms and improving patient outcomes.

It is important to recognise that migraines are not solely a neck issue, and therefore, physiotherapy alone cannot be expected to resolve them. Patients must be educated about this limitation to set realistic expectations. Effective acute pain management, such as the use of triptans or other medications, remains crucial for migraine sufferers and it would be unethical to restrict them from such medications. Some patients may respond better to specific treatments, and preventive medications—like antidepressants or anti-epileptics—can be beneficial for those experiencing more frequent or severe attacks.

For physiotherapists, the focus should be on treating any existing musculoskeletal dysfunctions, particularly in the neck. Research indicates that individuals with neck issues often experience a higher frequency of migraine attacks and greater disability. By addressing these dysfunctions, physiotherapists can help minimize additional nociception, which could worsen quality of life.

Recent studies have shown promising results regarding the impact of physiotherapy interventions. For instance, adding educational components to manual therapy has been linked to a reduction in headache days. Furthermore, comparisons of manual therapy with guideline-based aerobic exercise revealed both approaches led to a similar reduction in headache frequency.

Generally, the following treatment approach and recommendations is a good starting point when treating patients with migraines:

Adherence to Guidelines: Treatment should align with established guidelines that emphasize a multi-faceted approach to managing migraines.

Aerobic Exercise: Engaging in aerobic exercise is beneficial for migraine sufferers, even if the effect sizes are modest. It’s essential to educate patients about the timing of exercise, advising them to avoid physical activity during the 48 hours leading up to a migraine attack, while encouraging regular aerobic activity during symptom-free periods. Research suggests that higher intensity exercise provides better outcomes than mild-intensity exercise.

Relaxation Techniques: Incorporating relaxation strategies into daily routines can be helpful. Activities perceived as relaxing—such as walking in nature, spending quality time with loved ones, or simply taking a moment to unwind—can significantly impact stress levels and overall well-being.

Hydration: Emphasizing proper hydration is important, not only for its physiological benefits but also as a mindful practice that allows individuals to take breaks from their daily stressors.

Education: Providing education on the neurophysiology of migraines can empower patients. Understanding their condition can demystify symptoms, reduce anxiety, and reassure them that migraines are not indicative of more serious health issues.

Symptom Tracking: Encouraging patients to maintain a headache diary can be an effective way to monitor symptoms and evaluate the impact of various interventions over time.

Promoting Stability: Helping patients establish stable routines can help manage migraines effectively. This includes maintaining regular meal and sleep schedules to stabilize blood sugar and rest. It’s also beneficial to gradually reduce stress rather than allowing it to peak and then drop sharply; for example, managing work tasks, like answering emails, during weekends can help maintain a more consistent stress level throughout the week. 

The treatment of migraines increasingly emphasizes a holistic perspective, recognizing that physical, psychological, and lifestyle factors all play significant roles in migraine management. This broader approach reflects the evolving practice of physiotherapy in addressing complex health conditions.

Take this course now!

Participate in this course with headache expert and manual therapist René Castien exclusively on the Physiotutors Website!

Future Directions in Migraine Research

Despite advancements in understanding migraines, significant gaps remain in the research landscape. One of the key areas that requires further exploration is the role of the musculoskeletal system in migraine management. Although there is growing recognition of its importance, current clinical guidelines, particularly in Germany, have not yet incorporated physiotherapy, manual therapy, or exercise as viable treatment options. Advocates in the field are hopeful that future revisions will address this oversight.

Additionally, the investigation into learning mechanisms related to migraines presents an intriguing avenue for research. While it is essential to clarify that individuals do not simply “learn” to have migraines, there is a possibility that pain behaviors can be influenced by observational experiences. For example, children may mimic behaviors observed in parents who experience migraines, which could impact their own pain perception and management strategies.

Another promising area of study involves the dynamics of nocebo and placebo effects within migraine treatment. Early findings suggest that these psychological factors may play a more nuanced role than previously understood, highlighting the complexity of pain management.

Finally, a pressing need exists for comprehensive RCTs focusing on the effectiveness of physiotherapy for migraine patients. Such studies could provide valuable insights and potentially demonstrate the efficacy of physiotherapeutic approaches, ultimately contributing to more holistic and effective migraine management strategies.

References

Carvalho, G. F., Becnel, A. R., Miske, C., Szikszay, T. M., Adamczyk, W. M., & Luedtke, K. (2022). Postural control impairment in patients with headaches—A systematic review and meta‐analysis. Headache: The Journal of Head and Face Pain, 62(3), 241-270.

Carvalho, G. F., Mehnert, J., Basedau, H., Luedtke, K., & May, A. (2021). Brain processing of visual self-motion stimuli in patients with migraine: an fMRI study. Neurology, 97(10), e996-e1006.

Luedtke, K., Adamczyk, W., Mehrtens, K., Moeller, I., Rosenbaum, L., Schaefer, A., … & Wollesen, B. (2018). Upper cervical two-point discrimination thresholds in migraine patients and headache-free controls. The Journal of Headache and Pain, 19, 1-7.

Luedtke, K., Boissonnault, W., Caspersen, N., Castien, R., Chaibi, A., Falla, D., … & May, A. (2016). International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Manual therapy, 23, 17-24.

Luedtke, K., Starke, W., & May, A. (2018). Musculoskeletal dysfunction in migraine patients. Cephalalgia, 38(5), 865-875.

Luedtke, K., Starke, W., Korn, K. V., Szikszay, T. M., Schwarz, A., & May, A. (2020). Neck treatment compared to aerobic exercise in migraine: a preference-based clinical trial. Cephalalgia Reports, 3, 2515816320930681.

Mehnert, J., & May, A. (2019). Functional and structural alterations in the migraine cerebellum. Journal of Cerebral Blood Flow & Metabolism, 39(4), 730-739.

Meise, R., Carvalho, G. F., Thiel, C., & Luedtke, K. (2023). Additional effects of pain neuroscience education combined with physiotherapy on the headache frequency of adult patients with migraine: a randomized controlled trial. Cephalalgia, 43(2), 03331024221144781.

Olesen, J. (2016). From ICHD-3 beta to ICHD-3. Cephalalgia, 36(5), 401-402.

Schulte, L. H., & May, A. (2016). The migraine generator revisited: continuous scanning of the migraine cycle over 30 days and three spontaneous attacks. Brain, 139(7), 1987-1993.

Stovner, L. J., Hagen, K., Linde, M., & Steiner, T. J. (2022). The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates. The journal of headache and pain, 23(1), 34.

Woldeamanuel, Y. W., & Oliveira, A. B. (2022). What is the efficacy of aerobic exercise versus strength training in the treatment of migraine? A systematic review and network meta-analysis of clinical trials. The Journal of Headache and Pain, 23(1), 134.

Back
Download our FREE app