Migraine or your neck? How to tell the difference, and why it's often both
Two people describe the same headache. It sits on one side, it reaches behind the eye, and the neck feels stiff and sore every time it comes. One of them has migraine. The other has a headache coming from the top of the neck. From the description alone, nobody can reliably tell them apart, and that includes the person living with it.
The difference still matters, because the two belong to different people. Migraine is a neurological condition, and its management sits with your doctor or neurologist. A neck-driven headache is a mechanical problem that a hands-on examination can find, and it responds to treatment aimed at the neck. Plenty of people carry some of each. This article is about working out which share is which.
None of what follows applies if any of these are present. Get medical assessment promptly, and treat the first one as an emergency:
- A sudden, severe headache that peaks within seconds or a minute: call emergency services
- Headache with fever, a stiff neck, or a rash
- Weakness, numbness, slurred speech, drooping on one side of the face, confusion, or a change in vision
- An aura that is new for you, lasts longer than an hour, or comes with weakness on one side
- Headache after a head injury, a fall, or a car accident
- A new or clearly changed headache pattern after age 50, or alongside unexplained weight loss
Why the two get mixed up so often
They share wiring. The nerves from the top three segments of the neck feed into the same brainstem relay as the trigeminal nerve, which supplies the forehead, the temple and the area behind the eye. Irritation arriving from the neck can be felt in the face, and a migraine running through the same relay can be felt in the neck. The signal travels both ways. (Our guide to cervicogenic headache covers the mechanism in detail.)
That two-way traffic shows up clearly in the research. In a three-month electronic diary study published in Neurology, a stiff neck was one of the three most common warning signs before a migraine, reported in 50% of the attacks that came with a warning. A 2022 meta-analysis found neck pain in 77% of migraine patients seen in clinics. A sore neck before or during the headache does not, on its own, mean the neck started it.
It cuts the other way too. Nausea and sensitivity to light and sound can turn up with a neck-driven headache as well, usually less strongly than in migraine. Feeling sick does not rule the neck out.
How each one is actually diagnosed
The two diagnoses rest on different kinds of evidence. If you take one idea from this article, take this one.
Under the International Classification of Headache Disorders (ICHD-3), migraine without aura needs at least five attacks lasting 4 to 72 hours, with at least two of: one-sided, pulsating, moderate or severe, and made worse by routine activity such as stairs. Plus nausea or vomiting, or sensitivity to both light and sound. No examination finding and no scan is required. A good description is the diagnosis.
Cervicogenic headache needs a neck disorder known to be able to produce headache, plus at least two signs of a link: the headache began alongside the neck problem; it improves as the neck improves; the neck has lost range of motion and provoking it makes the headache worse; or numbing a neck structure or its nerve switches the headache off.
Notice the asymmetry. You can describe your way to a migraine diagnosis. You cannot describe your way to a neck diagnosis, because the evidence it needs lives in the neck itself, and someone has to examine it. That is why so many people with a neck component get labelled migraine or "tension" by default: the description fits, and nobody checks the other option.
The clues that lean one way or the other
Your own history can still tilt the odds. These are the questions worth asking yourself, and which way each answer leans:
- Where does it start? At the back of the head or upper neck, then travelling forward to the temple or eye, leans neck. Starting at the temple, behind the eye, or everywhere at once leans migraine.
- Does it ever swap sides? Always the same side leans neck. Switching sides between attacks leans migraine.
- Can you bring it on mechanically? A headache provoked by holding your head in one position, turning it, or pressing at the base of the skull leans neck.
- What do you need during it? Lying still in a dark, quiet room, feeling sick, leans migraine. Carrying on with a dull ache that builds through the day leans neck.
- Attacks or background? Attacks with a clear start and finish lean migraine. A grumble that is there most days and flares with long desk hours leans neck.
- Does your neck turn equally both ways? Sitting tall, turn slowly right, then left. A clear difference between sides, in someone with one-sided headaches, leans neck.
Two honest caveats. The international classification treats several of these (same side, provoked by pressure or movement, travelling back to front) as features that lean towards the neck, and is explicit that none of them is unique to it. And if your answers split down the middle, that is not a failed quiz. It is often the answer.
Why one sign never settles it
The sign people find most convincing is pressing a sore spot at the base of the skull and feeling their usual headache. It is a real finding. It is also less specific than it feels.
In a study in Headache, researchers applied sustained pressure to the top two segments of the neck between attacks. It reproduced the usual head pain in 19 of 20 people with migraine without aura, and in every person with tension-type headache. It also produced head pain in 8 of 14 people who did not get headaches at all. The neck can send pain into the head in most people. Finding that yours does tells you the pathway is live, not which headache you have.
What did separate the groups was a combination. In a blinded study from the University of Queensland, three findings together (restricted neck movement, a painful upper neck joint on hands-on examination, and poor control of the deep neck flexors on a specific test) identified cervicogenic headache with 100% sensitivity and 94% specificity, and those impairments were not found in the migraine group. It was a small study, 73 people with a single headache type, and the authors called for more work to confirm it. A follow-up in 108 people with two or more headache types found the same pattern in 36 of them, while single measures, such as how far the neck bends back, were no help on their own.
The practical takeaway: the neck question is answerable, but by an examination that looks for a pattern. Not by a symptom checklist, a single sore spot, or a scan.
When it's both
This is the common case, not the exception. In the population-based Akershus study, 42% of people with cervicogenic headache also had migraine. Each one blurs the other, and treating only one leaves the other running.
The neck can also act as a trigger in someone with migraine, even when it is not the source. In a 2020 study in Cephalalgia, a standard endurance test of the neck muscles was followed by a migraine-like headache in 42% of people with migraine, on average about sixteen hours later, and in none of the people without headaches. That cuts two ways: an irritable, overloaded neck is worth taking off the list of inputs, and neck exercise for a migraine sufferer has to be dosed carefully rather than pushed.
And the honest boundary: treating the neck is not a migraine treatment. A randomised trial gave people with migraine eight weeks of neck-specific strengthening, and it did no better than a sham treatment on migraine frequency or intensity. General exercise is a different story. A meta-analysis found moderate-quality evidence that regular aerobic exercise reduces migraine days, though modestly: by an average of 0.6 days a month. Worth doing alongside medical care, not instead of it.
So the realistic goal when you have both is to find the neck share and work on that: fewer and milder headache days from the part the neck contributes, while the migraine itself stays with your doctor.
What to do this week
- Keep a two-week headache diary. Columns: which side, where it started, attack or background, nausea or light sensitivity, what you were doing in the two hours before, and every tablet you took. It separates the two patterns better than memory does, and it is exactly what your doctor will want to see.
- If your attacks fit the migraine description above, take that diary to your doctor or a neurologist. Migraine has effective medical treatments. Mention how many days a month you take painkillers, because frequent use can keep headaches going on its own (our cervicogenic headache guide explains the thresholds).
- If the neck questions leaned your way, get the neck examined by someone who will test how it moves and how the upper joints respond, not just look at a scan. Our Headache Map shows the four common starting points, and the Source Test walks you through three physical checks you can do at home.
If your headaches start at the back, stay on one side, and nobody has ever examined the neck underneath them, that is worth one short call. If the pain tends to sit behind one eye, our article on headache behind one eye covers the other candidates for that spot, including cluster headache.
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.
Migraine, neck, or both?
If your headaches start at the back of your head, stay on one side, and nobody has ever examined the neck underneath them, that is worth one short call. We'll tell you honestly whether there is a neck share worth working on, and if there isn't, who you should see instead.
Not ready for a call? See where yours starts (four patterns, one of them is probably yours) or run the Source Test for three physical checks.