This symposium aims to provide a deeper understanding of:  the mechanisms of migraine associated neck pain  the clinical criteria to differentially diagnose migraine related neck pain  indications for local neck treatment for migraine associated neck pain and outcome expectations Migraine is a severe and disabling brain disorder1 causing significant societal and personal burdens.2 Up to 70-80% of persons report significant neck pain with their migraine.3 Many persons seek local treatments for their neck thinking it might be the cause, or at the least, to assist both the neck pain and migraine. Nevertheless, recent trials and systematic reviews reveal only weak evidence for neck treatments as effective adjunct treatments for migraine.4-7 This realises the need for better understanding about (i) the origins of neck pain in migraine, (ii) the nature and frequency of presentation of cervical musculoskeletal dysfunction (iii) examination for differential diagnosis and (iv) and future approaches to management. Neck pain associated with migraine has two predominant mechanisms. Neck pain may reflect pain hypersensitivity and be part of the migraine symptom complex without any neck dysfunction).8-11 Conversely, local nociception from cervical musculoskeletal dysfunction may be causing or contributing to the neck pain.10,12,13 These mechanisms are driven by the trigeminocervical nucleus which receives afferent input from both the trigeminal and upper cervical nerves, which creates this potential for head pain to be referred to the neck and neck pain to be referred to the head.14 In recent years, there has been a body of research by physiotherapists investigating cervical musculoskeletal dysfunction and other physical impairments in migraine.10,15-18 Two systematic reviews appraising the evidence for cervical musculoskeletal dysfunction in migraine compared to healthy controls19,20 concluded that overall, differences in cervical impairments were minor which does not support a strong case for a frequent cervical musculoskeletal cause of neck pain in migraine. Cross-sectional studies may suffer wash-out effects if the neck pain of some migraineurs has a neurobiological origin. A subsequent study used a cluster analysis to classify patients based on outcomes of a combination of neck function tests and determined that about 40% of the migraine cohort had neck dysfunction which aligned with participants with non-specific neck pain while the neck function of the remainder aligned with the healthy controls.10 This evidence indicates the strength of identifying a combination of cervical musculoskeletal dysfunction to identify a local cause or contributor to neck pain, noting the evidence of the importance of the presence of upper cervical joint signs.10,21 The clinical examination of the patient with migraine and associated neck pain aims to determine the indications for neck related treatment. Care must be taken in the clinical reasoning process. Clinicians often seek a confirming relationship between the neck pain and headache, but the evidence indicates that this relationship is not helpful in determining if the migraineur’s neck pain is related to local dysfunction.22 Additionally, migraineurs often have pain hypersensitivity23 24 whether or not they have local neck dysfunction.8,10,24,25 It has been shown that as a consequence, musculoskeletal tests might elicit pain even when musculoskeletal dysfunction is absent.10 Hence provocation of symptoms alone cannot reliably be interpreted as musculoskeletal dysfunction. Knowledge of the true value of interventions to the neck as an adjunct treatment for migraine requires further research. For both the clinical setting and when designing future clinical trials, current research informs on the need for; selection of appropriate patients,10 a clear knowledge of treatment aims e.g. acute/abortive or preventative treatment, consideration of patient preferences26 and an evidence informed management program. The evidence indicates that the program must recognise neurobiological as well as musculoskeletal aspects of migraine. Multimodal treatment is indicated, including pain education, manual therapy, specific therapeutic exercise and self-management programs.27,28 It is vital that research continues so that the indications and outcomes of local interventions to the neck for persons with migraine and neck pain are known and supported by high quality evidence.

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