Can physiotherapy help migraines? An honest answer, graded by the evidence
If you live with migraine, sooner or later someone suggests physio: a friend whose headaches eased after a few sessions, a clinic that talks about the root cause, a video of someone cracking a neck. It deserves a straighter answer than it usually gets.
Here it is. Physiotherapy does not treat migraine itself; that belongs with your doctor or neurologist. What a physiotherapist can do is narrower and still worth having: treat a neck that is genuinely adding to your headaches, and help you build an exercise habit that has evidence behind it. Below, each option is graded plainly: good, modest, weak, or not shown.
- Physiotherapy does not treat migraine itself. Diagnosis and treatment, including preventive medicines that work, sit with your doctor or neurologist.
- Regular aerobic exercise has the best evidence of anything a physio offers, and the benefit is modest: about 0.6 fewer migraine days a month.
- Spinal manipulation did no better than a convincing sham in the most rigorous trial, and neck-focused manual therapy has not beaten usual care on migraine days.
- Most people with migraine also get neck pain. When the neck is genuinely involved on examination, treating it aims for fewer and milder headache days from the share the neck contributes.
- Always alongside medical care, never instead of it.
Some headaches that feel like migraine are not. Get medical assessment promptly if any of these apply, and treat the first one as an emergency:
- A sudden, severe "thunderclap" headache that peaks within seconds or a minute: call emergency services
- An aura that is new for you, lasts longer than an hour, or comes with weakness on one side of the body
- Weakness, numbness, slurred speech, drooping on one side of the face, confusion, loss of vision, or a seizure
- Headache with fever, a stiff neck, or a rash
- Your first severe headache after age 50, or a clear change in your usual pattern at any age
- A new, severe headache during pregnancy or in the weeks after giving birth
- Headache after a head injury, or new neck pain with a headache unlike your usual ones
- Headache that is worse lying down, or brought on by coughing, straining or exertion
Migraine belongs with your doctor, and that is good news
Migraine is diagnosed from the pattern of the attacks, not from a scan or a neck examination (our article on migraine versus a neck headache covers how the two are told apart). Once it is diagnosed, there is real treatment: medicines to stop an attack, and preventive medicines to make attacks less frequent. For the newest preventives, antibodies against a migraine signalling molecule called CGRP, the European Headache Federation found moderate to high quality evidence and recommends them as effective and safe long term.
So if your migraine has never been properly assessed, or nobody has discussed prevention with you, start there. A physiotherapist should not diagnose migraine, judge your medication, or tell you to stop it.
Physiotherapy comes in through the neck. In a population study of 797 adults, 76.2% of people with migraine alone had had neck pain in the past year, against 56.7% of people with no headaches; with migraine and tension-type headache together, it was 89.3%. Some of that neck pain is part of the attack itself. Some is a genuine neck problem adding input to an already sensitive system. Telling the two apart is most of the job.
What the evidence shows, graded
The grades are mine, based on each study's size, design and the authors' quality ratings. No physiotherapy option earns "good".
A meta-analysis found moderate-quality evidence that regular aerobic exercise reduces migraine days, by an average of 0.6 days a month. In a trial of 91 adults, 40 minutes of exercise three times a week cut attacks about as much as the preventive drug topiramate or a relaxation programme, with every group improving by less than one attack a month. Small, but real.
A 2025 review of 50 trials in 6,024 adults found that cognitive behavioural therapy (CBT), relaxation training and mindfulness may each reduce attack frequency, though the strength of evidence was low. A Danish guideline review found no clear effect from psychological treatment. Promising, not proven.
In a trial of 50 women with migraine and neck pain, all on medication, eight sessions of manual therapy and stretching gave an extra 18% fall in headache frequency that was not statistically significant, though pain intensity improved. A 2026 primary care trial in 67 people with migraine and neck pain found no difference in migraine days against usual GP care over a year. Neck strengthening did no better than a disconnected ultrasound machine on headache frequency in a third trial.
In the most rigorous test, a three-armed trial of 104 people, real chiropractic manipulation and a sham (a push on the shoulder blade or buttock) reduced migraine days by about the same amount, and the authors concluded the effect was probably placebo. A 2024 meta-analysis of six trials found no effect on intensity or duration; an earlier one that found a small benefit called it preliminary.
A review of six trials in chronic tension-type headache judged physiotherapy and massage effective, though none of the trials used a placebo comparison. If part of your headache burden is tension-type or comes from the neck, that share is a more realistic target than the migraine.
Across headache types, a meta-analysis of physiotherapy found results pointing the right way, but 19 of the 26 trials it assessed had a high risk of bias in more than one area, and the authors rated the evidence low. The Danish review found manual mobilisation did not change migraine outcomes, yet still made a weak recommendation to consider these treatments as a supplement to standard care, given the lack of serious side effects. A recent three-arm trial of 75 people found that combining manual therapy, neck exercise and education did better over time than manual therapy or education alone, but with no sham or untreated group it cannot show that any of it beats placebo.
Where the neck fits
The nerves from the top three segments of the neck feed into the same brainstem relay as the trigeminal nerve, the main pain nerve of the head and face. That is why an irritable neck can add to a migraine-prone system, and why a migraine can be felt in the neck (our guide to cervicogenic headache explains the mechanism).
Two things follow. First, the neck can act as a trigger. In a 2020 study, a standard endurance test of the neck muscles was followed by a migraine-like headache in 42% of people with migraine, on average about 16 hours later, and in none of the people without headaches. Neck exercise for someone with migraine has to be dosed with care, not pushed.
Second, overlap is common: many people with migraine also have tension-type headache or a headache that genuinely comes from the neck, and those shares are what physiotherapy can realistically reduce.
Check one thing before any of this: if you take painkillers or triptans on many days a month, frequent use can keep headaches going by itself, and no neck treatment will out-work that. Raise it with your doctor rather than stopping on your own (the thresholds are in our cervicogenic headache guide).
What a physio should and should not promise you
A good physiotherapist will:
- Examine the neck before treating it, and tell you plainly whether it is involved.
- Name the target: fewer and milder headache days from the share the neck contributes, tracked in a diary, with a set point to review it.
- Work alongside your doctor, and leave medication decisions to your prescriber.
- Dose neck exercise carefully, and build general exercise up gradually.
- Refer you on when the neck examines normally or a red flag appears.
Be wary of anyone who:
- Promises your migraines will go away permanently, or blames them on vertebrae being out of place.
- Treats without examining, or books open-ended sessions with no review.
- Tells you to cut down or stop your medication.
- Makes manipulation the main event, when the best trial found it did no better than a sham.
Who is a good candidate, and who isn't
- Migraine plus a neck that is involved on examination: lost movement, painful upper neck joints, your usual head pain reproduced.
- Frequent headache days with a neck pattern: starting at the back, staying on one side, building with desk hours.
- Migraine mixed with tension-type or neck-driven headache.
- People who want a non-drug add-on alongside medical care, especially if preventive medicines do not suit them.
- Migraine with a neck that examines normally. The neck share may simply be zero.
- Anyone hoping physio will replace their doctor or neurologist.
- Headaches with a red flag, until a doctor has seen them.
- Near-daily headaches with frequent painkiller use, until your doctor has addressed that.
- Anyone expecting the attacks to stop altogether.
Assessment is available online by video and in person in Beirut. If the examination finds no neck share, the useful outcome is to be told so.
What to do this week
- Keep a two-week headache diary. Headache days, how bad each one was, where it started, and every dose of medication. It is the yardstick any treatment should be judged against, and your doctor will want to see it.
- Start aerobic exercise you can repeat, such as brisk walking or cycling, and build up gradually towards the three 40-minute sessions a week used in the trial above.
- Check whether your neck is part of it. The Headache Map shows the four common starting points, and the Source Test walks you through three physical checks at home.
If you have migraine, your headaches start at the back and stay on one side, and nobody has examined the neck underneath them, that is worth one short call. Weighing up who to see? Compare physio, osteopath or chiropractor for headaches.
Frequently asked questions
This article is general information, not a diagnosis. Headaches have many causes and a proper assessment is individual. If you are on regular headache medication, speak to your prescriber before changing anything.
Is your neck part of it?
If you have migraine and your headaches also start at the back of your head, stay on one side, or come with a neck that never quite settles, that is worth one short call. We'll tell you honestly whether there is a neck share worth working on alongside your doctor's care, and if there isn't, who you should see instead.
Not ready for a call? Take the Headache Check (six lines, one minute), see where yours starts (four patterns, one of them is probably yours) or run the Source Test for three physical checks.