When Migraine Isn't Migraine

Note: This article describes a clinical category for educational purposes. We don't diagnose conditions through this website. If you have head pain you're trying to understand, talk to a clinician who can examine you.

One of the most consequential things we've been learning while building 76 Health is how often patients with a migraine diagnosis turn out to have a different condition layered underneath.

Specifically, a condition called cervicogenic headache — head pain that originates from structures in the neck.

It's not rare. The clinical literature suggests a meaningful share of patients diagnosed with migraine have a cervicogenic component contributing to their headaches. For some patients, it's the dominant driver.

The reason it matters is that cervicogenic headache responds to different treatment than migraine. The patients whose headaches have a significant cervicogenic component often don't respond well to standard migraine prophylaxis — but they often do respond to cervical physical therapy and manual therapy.

If you've been treated for migraine for a long time without much response, this is one of the categories worth knowing about.

What cervicogenic headache is

Cervicogenic headache is head pain that originates from structures in the cervical spine — the upper part of the neck. The pain is referred from these structures into the head, often presenting in ways that look similar to migraine.

The clinical literature describes a few features that are common in cervicogenic cases.

The pain is often one-sided — and tends to stay on the same side rather than switching sides between episodes.

The pain often begins in the back of the head or upper neck and radiates forward.

The pain often worsens with specific neck movements or postures — particularly prolonged sitting, looking down, or sustained head positions.

There's often a history of neck injury or neck strain — sometimes years earlier.

The pain can be accompanied by nausea or sensitivity to light, which is part of why it gets confused with migraine.

These features aren't diagnostic by themselves. The diagnosis is made clinically, often with a specific examination including a test called the cervical flexion-rotation test, which can suggest upper-cervical involvement in chronic headache populations.

Why it gets missed

A few things contribute to cervicogenic headache being underrecognized.

First, the overlap with migraine. The presentation can look similar. Patients with primary cervicogenic headache often have some of the same symptoms migraine sufferers have — nausea, light sensitivity, throbbing quality.

Second, the limited time most clinicians have to do a thorough examination. The cervical exam takes time. Most primary care visits don't have it. Most neurology visits don't focus on it.

Third, the way diagnostic workups tend to be structured. Imaging of the brain may be unrevealing. Imaging of the cervical spine may not be ordered unless there's a clear reason. A patient with chronic headache and a normal brain MRI often ends up with a migraine diagnosis by default.

Fourth, the lack of awareness. Many patients have simply never heard of cervicogenic headache. They don't know to ask. And the clinical literature on it is more recent than the broader literature on migraine, which means treatment patterns haven't fully caught up.

What the evidence supports

For patients with cervicogenic headache or a significant cervicogenic component to their head pain, the evidence supports starting with cervical physical therapy and manual therapy.

Multiple controlled trials have shown that manual therapy and targeted cervical exercise reduce headache frequency and intensity for patients with cervicogenic features. The effects tend to be clinically meaningful — not just statistically significant.

This is the same therapeutic approach we'd coordinate for chronic neck pain. The bridge between chronic neck pain and chronic headache, for many patients, turns out to be a single condition presenting in two ways.

In practical terms: if your head pain has a cervicogenic component, the right first step often isn't more migraine medication. It's a cervical physical therapy evaluation, ideally informed by a clinician who knows how to assess cervicogenic involvement.

What this doesn't mean

A few important caveats.

Not all migraine is actually cervicogenic. Most migraine is migraine, and migraine has its own well-established treatment pathways that work.

Some patients have both. Migraine and cervicogenic headache can coexist, and the cervical component may worsen migraine attacks without being the primary driver. In those cases, the cervical work is one piece of a broader plan.

Self-diagnosis isn't appropriate here. The clinical features of cervicogenic headache overlap enough with other conditions that the diagnosis needs to be made by someone who knows how to look for it.

What you can do is raise the question with the clinician treating your headaches. If you have features that suggest a cervical component — neck pain, posture-related triggers, history of neck injury, one-sided pain that begins in the back of the head — those are worth surfacing.

What we've been thinking about

When we started building 76 Health, we underestimated how often cervicogenic headache shows up in the chronic pain and migraine populations we're trying to help.

The patients we've talked to who've been carrying a migraine diagnosis for years — and who haven't responded well to medication — often describe a story that, in retrospect, has cervicogenic features all over it. Neck injury years ago. Pain that's worse when they sit at a desk. Tension that builds across the shoulders before the headache starts.

We don't think every migraine patient has a cervicogenic component. We do think the share of patients who have it but haven't been told about it is significant.

For our migraine work, that's shaped how we think about screening. The intake should surface the cervical features. The plan should include cervical assessment when the features point that direction. The referral pathway should connect to a physical therapist who can actually assess and treat it.

We're still figuring out the right operational version of this. But the principle is consistent.

When a patient has been treated for one condition for years without much progress, it's worth asking whether the diagnosis itself was complete.

Sometimes it is. Sometimes it isn't. The work is to know how to tell the difference.

Sources: General clinical literature on cervicogenic headache, including the cervical flexion-rotation test as a diagnostic indicator for upper-cervical involvement in chronic headache populations.