The Mindful Migraine

OK, so this is one of the last posts from the notes that I took during the Migraine World Summit that took place at the beginning of 2024.  This summary is of the presentation by Dr Rashmi Singh, a professor of neurology at the Mayo Clinic in Arizona.

It was agreed that many people with migraine have neck pain; it is a very common symptom.  Sometimes it is part of their migraine and sometimes it is a separate problem. Dr Singh noted it is important to ‘tease out’ the cause and effects of neck pain.

Neck issues can be raised as a symptom of what comes up as part of a migraine, but it can also be the first symptom they experience as a clue that one is on the way, and sometimes it appears in between migraine attacks. 

Dr Singh said it is important to remember that there are other conditions that generate pain problems in the neck, so it is not necessarily ALWAYS migraine related. 

If it IS part of migraine, she said to think of it as a ‘referred pain’ – migraine is a problem of pain processing, and the migraine-brain gives and receives inputs to and from the neck that say ‘pain’.

When she talks to her patients about it, she talks about the variety of symptoms and then focuses on the neck, it needs to be a holistic approach.

[Disclaimer – remember, I’m not a healthcare worker – please see a doctor for more information that is specific to your personal situation.]

There is also a thing called ‘occipital neuralgia’ which is a headache disorder that occurs when the nerves at the top of your spine (that run into your scalp) become inflamed.  It can be related to migraine but also problems in the neck itself.  It tends to be in a very specific location, and creates sharp, shooting pain, as well as tenderness over the spinal or skull ‘notches’.  One potential treatment is physical therapy or else a nerve block.

‘Cervicogenic headache’ is similar, but instead of staying at the skull-spine location, it moves from the soft tissues of the neck up and over one side of your head.  It can look like arthritis, and lead to structural problems that can then cause headaches.

Dr Singh spoke about ‘TMD’ (which means temporomandibular disorders) – which in simple terms, are the conditions which relate to the jaw joints, its muscles and ligaments.  You might be a tooth-grinder, or feel clicking when you move your jaw, or clicking when you eat, and this can then create referred pain, including migraine.

There is so much interaction between pain in one area of the head and neck, which can influence pain in other parts of your head and neck.  Overlapping symptoms can make accurate diagnosis difficult.  People often have other neck issues that are separate to, and predate, their migraine conditions.

Clinical examination can see if there is jaw clicking, neck mobility, or head tenderness.  She also asks how long symptoms persists.  So, for example, if neck pain persists, independent of episodic migraines, then there might be neck problems.  Or, conversely, if migraine medication removes pain in the head, and the neck, simultaneously, then the neck pain is probably a symptom.

First, she takes a careful history, then undertakes a careful physical examination, then decide what’s the right test to take (if needed), and then decides if migraine treatment is enough, or do we need to employ the help of other specialists.  Additional steps of diagnosis might include imaging, xrays, and/or an MRI.

Tests to be sure the migraine is not a structural issue, might include ear tests, eye tests, dental checks, allergy tests, all designed to eliminate other conditions; we don’t want to miss anything that’s going on, and there can be other issues that are happening that require other testing.

Dr Singh was asked could jaw pain be a trigger or the result of migraine?  Dr Singh said she would ask if it’s a predictable migraine symptom.  If the soreness is infrequent and only happens with migraine, then it’s probably part of migraine.  But if the jaw-pain is frequent and not tied to migraines, then maybe there is a separate problem.  That said… the separate problem can still be contributing to the migraines.  Dr Singh noted an interdisciplinary approach can be helpful.  Patients can think about their migraine treatment plan and what is helpful, then keep communicating with a doctor to discuss ‘next steps’.  The patient needs to communicate what’s getting better and what’s getting ‘left over’ when they take their migraine medication.  Conversely, if the neck pain is going away but not their jaw, then again, pivot in that direction for advice.

[You can download my trigger-tracker-diary here if you like.]

There are other issues for why a person’s neck might be sore, including degenerative causes, such as arthritis, that become more prevalent with age. 

Treatment options include everything from neuromodulation devices, medicine, injections, all the way through to surgery.  Preventative migraine medications should be helpful, but there might be additional neck pain meds.

Non-pharmalogical approaches (depending on the needs of the patient) might include; physical therapy, relaxation therapy can help, or a nightguard / splint for teeth, perhaps jaw exercises. 

When asked if chiropractic treatment was an option, Dr Singh raised a concern that rapid neck movement / manipulation has a rare risk of causing stroke, so she would caution against that… “rare is rare, but not zero” she said – risk is still present, so massage or physical therapy would be safer.

In terms of neck surgery, she said that as a neurologist she would not recommend it, because it doesn’t always eliminate the pain, especially if there are other issues at play: it has big risks with no guarantee of return.  (There is a jaw surgery which she didn’t discuss, but was less concerned about because it was not associated with someone’s spinal chord.)

She said the best thing to do to avoid neck pain for migraines (or in general) was to stay as active as possible and move towards a healthy lifestyle.

In a similar way that I came up with the anacronym SWANEY, she had a different one:

SEEDS = Sleep / exercise / eat (well) / (keep a) diary / (reduce) stress

She concluded her interview by recognizing that the word ‘exercise’ can be intimidating when we are in pain or fearful of pain, but reminded listeners that it can it be low impact – yes absolutely “give yourself grace in those moments of pain” she said – or as her colleague says, “plan for more opportunities”. We know our limitations, so try for 10 minutes every day, knowing that might not be possible, but it still makes it easier to hit the goal.

She closed by noting that from a self-care perspective, you want to minimize the impact of migraine on your life and empower yourself to live life better.

Sounds good to me.

Take care, carefully, Linda x