Prevalence of Neck Pain in Migraine and Tension-type Headache:
A Population Study

This section is compiled by Frank M. Painter, D.C.
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FROM:   Cephalalgia. 2015 (Mar);   35 (3):   211–219 ~ FULL TEXT

Sait Ashina, Lars Bendtsen, Ann C Lyngberg, Richard B Lipton, Nazrin Hajiyeva and Rigmor Jensen

Department of Pain Medicine and Palliative Care,
Mount Sinai Beth Israel,
Icahn School of Medicine at Mount Sinai, NY, USA

BACKGROUND:   We assessed the prevalence of neck pain in the population in relation to headache.

METHODS:   In a cross-sectional study, a total of 797 individuals completed a headache interview and provided self-reported data on neck pain. We identified migraine, tension-type headache (TTH) or both migraine and TTH (M+TTH) groups. Pericranial tenderness was recorded in 496 individuals. A total tenderness score (TTS) was calculated as the sum of local scores with a maximum score of 48.

RESULTS:   The one-year prevalence of neck pain was 68.4% and higher in those with vs. without primary headache (85.7% vs. 56.7%; adjusted OR 3.0, 95% CI 2.0–4.4, p<0.001). Adjusting for age, gender, education and poor self-rated health, in comparison with those without headaches, the prevalence of neck pain (56.7%) was significantly higher in those with M+TTH (89.3%), pure TTH (88.4%) and pure migraine (76.2%) (p<0.05 for all three group comparisons). Individuals with neck pain had higher TTS than individuals without neck pain (15.1±10.5 vs. 8.4±8.0, p<0.001).

CONCLUSIONS:   Neck pain is highly prevalent in the general population and even more prevalent in individuals with primary headaches. Prevalence is highest in coexistent M+TTH, followed by pure TTH and migraine. Myofascial tenderness is significantly increased in individuals with neck pain.

KEYWORDS:   Neck pain, migraine, tension-type headache, prevalence, population, tenderness

From the FULL TEXT Article:


Neck pain and primary headaches are highly prevalent in the population. [1, 2] Estimated global one-year period prevalence is about 10% for migraine and about 38% for tension-type headache (TTH). [3, 4] One-year prevalence of neck pain ranges from 4.8% to 79.5% in population-based studies. [1] Variation in epidemiological studies of neck pain is attributable, at least in part, to differences in sample selection, ascertainment of symptoms and case definitions. [1] Neck pain can arise from many local structures, including muscles, ligaments, facet joints and visceral structures of the neck, through direct compression of upper cervical roots or it can be referred. [5] Thus, the differential diagnosis for neck pain includes various conditions such as spinal disease, whiplash-associated disorder, fibromyalgia, myofascial pain, rheumatic disease, direct trauma and neoplasms.

Neck pain is common in people with primary headaches, both in population-based studies and in the clinic. [6–10] Neck pain may occur as a premonitory manifestation or during the headache phase. [11] A better understanding of neck pain in primary headache is important. First, it will help facilitate more accurate diagnosis. Second, neck pain may influence the treatment response and result in increased disability in headache suffers. [12] Finally, neck pain may play a role in the pathophysiology of both migraine and TTH. [13, 14] It may arise because of convergent input from the first division of the trigeminal nerve and the upper cervical roots to the trigeminal cervical complex. [13]

The aim of our study was to assess the prevalence of self-reported neck pain in individuals with common primary headaches including migraine, TTH and coexistent migraine and TTH in a general population sample using the clear diagnostic criteria of the International Classification of Headache Disorders (ICHD).


      Study population

This study is a part of a Danish population-based study conducted at the Research Center for Prevention and Health and the Danish Headache Center, University of Copenhagen, Glostrup Hospital. The methods of the study are described in detail elsewhere. [2, 15, 16] In brief, 1,000 residents from the county of Copenhagen, aged 25–65 years, were randomly selected from the Danish Civil Registration System in 1989. In 2001, a combined cross-sectional and follow-up study designed to replicate the 1989 study was conducted. Regardless of the participation status in 1989, individuals from the 1989 study, now 37–76 years of age, were identified from the Danish Civil Registration System. In addition, 300 new individuals aged 25–36 years were selected to participate in the 2001 study. These new individuals were selected by the same research criteria as in 1989. Thus, a total of 1,300 individuals were selected to participate in the cross-sectional study conducted in 2001. All individuals were invited to participate in a headache interview and a clinical examination. The invitation letter stated that the purpose of the study was to obtain knowledge about headache in the general population. If no response was obtained, the telephone headache interview was attempted by a physician (Ann C Lyngberg) and in this case no clinical examination was performed. A self-administered questionnaire in Danish obtained information on several variables of interest. The follow-up study in 2001 used the same procedure, questions and wordings as the original 1989 study to optimize data comparability on the two testing occasions.

The study sample was representative of the Danish population with respect to age, gender and employment status with the exception of self-employment, such as fishing and farming, that was underrepresented. [16] The study was approved by the ethics committee for Copenhagen County and by the Danish Data Protection Agency. Informed consent was obtained from individuals before participation.

      Headache interview and case definitions

The headache interviews were designed to assess the clinical features specified in the first edition of the International Classification of Headache Disorders (ICHD-1) [17], with an emphasis on migraine and TTH. Individuals were asked about the number of days with TTH and migraine in the past year with seven answer categories: “0 days,” “1–7 days,” “8–14 days,” “15–30 days,” “31–100 days,” “101–179 days,” and “180 days or more.” The interviewer in 2001 had no knowledge of the headache diagnoses from 1989. The telephone interviews were conducted with the same diagnostic criteria (ICHD-1), interviewer, data collection period, interview questions and sequence as the face-to-face interviews, including all interview questions necessary for diagnosing primary headaches.

ICHD-1 criteria for migraine and TTH used in the headache interview are fundamentally the same in the third edition of the ICHD (ICHD-3 beta) so no differences in classifications would be expected at the first digit level. For the analyses, migraine and TTH diagnoses were therefore given according to ICHD-3 beta with the exception of Criteria E as neurological examination was not conducted in those individuals who were interviewed by telephone (18). Headache categories were the following: pure frequent episodic TTH (ETTH), pure chronic TTH (CTTH), episodic migraine ± ETTH and episodic migraine coexistent with CTTH (chronic coexistent headache). Individuals with a chronic migraine diagnosis could not be identified with the headache frequency response categories in the questionnaire. The no headache group included individuals who had either no primary headache or with infrequent ETTH. To study the relationship of primary headaches to neck pain, we also categorized participants with headache into three alternative groupings:

(1)   any primary headache (migraine and/or TTH) vs. no primary headache,

(2)   pure migraine, pure TTH, coexistent headache (migraine and TTH) vs. no primary headache; and

(3)   episodic headache (<15 any headache days per month), chronic headache (≥15 any headache days per month) vs. no primary headache.

      Neck pain

Presence of neck pain was assessed by the self-administered questionnaire. Individuals were asked if they ever experienced neck-shoulder pain. Frequency of neck pain in the past year (one-year prevalence) was assessed by self-report. Response options were: 0 days, one to seven days, eight to 14 days, 15–30 days, 31–100 days, 101–179 days, and 180 or more days. For the analysis individuals were also categorized as with (one or more days per year) and without one-year prevalence of neck pain. Neck pain in our questionnaire referred to the pain in the back of the neck or the posterior neck region.

      Demographics, comorbidities and symptoms

The self-administered questionnaire obtained information about socio-demographic factors, education, selfrated health, daily headache-related disability, and impact of headache on daily activities (household work, work, social activities and family life). For the assessment of self-rated health, the participant was asked how he or she would say his or her overall health was. The response categories were excellent, very good, good, less well, and bad. The last two categories were coded as poor self-rated health. Daily disability was assessed by asking the participant if he or she felt disabled in their life because of headache (migraine and TTH). The questionnaire also assessed previous and current self-reported history of pain and psychiatric conditions and symptoms: low back pain, spine disease, rheumatic disease, fibromyalgia, depression and anxiety disorder. An eventual relation of neck and low back trauma to headache was assessed with two questions for each type of headache:

(1)   Did your headache start in relation to a back or neck injury (no later than one month)?;

(2)   Was your headache aggravated by a back or neck injury?

Individuals answering “yes” to any of these two questions were coded as having eventual relation of neck and low back trauma to their headache. The questionnaire with the studied variables has been used in previous population studies and found to be applicable. [16]

      Quantitative sensory testing (QST)

The individuals who participated in the general and neurological examination were included in the QST study. Local tenderness was examined by a specially trained nurse using standardized methods. The participants were examined sitting in a comfortable dental chair with a headrest. The subject’s headache history was not available to the nurse. The palpometer was used to train the examiner to exert a palpation pressure of moderate intensity (140 U). The palpometer has previously been described in detail. [19]   Pericranial tenderness was assessed by palpation of eight pairs of muscle and tendon insertions. [19] The tenderness was scored according to the Total Tenderness Score (TTS) on a four-point (0–3) scale, previously proved to be reliable. [19] TTS was calculated by summation of the scores from the eight right- and left-sided locations with a maximum possible score of 48. A local tenderness score for each of the eight pericranial locations was calculated by summing both sides and then dividing by two.

Pressure pain thresholds (PPTs) were assessed by an electronic pressure algometer (Somedic AB, Stockholm, Sweden) with a circular stimulation probe (0.5 cm2), and a pressure loading rate of 0.68 N/s was used. [20]   PPTs were measured at the dorsum of the second (index) finger and at the anterior part of the temporal muscle, 2 cm behind the lateral orbital margin and 2 cm above the orbito-temporal line, at the non-dominant side. The PPT was defined as the pressure at which the sensation changed from pressure alone to a combination of pressure and pain. Measurements were performed alternately in the temporal region and in the finger at intervals of approximately 60 seconds. A mean value of three measurements at each location was used to determine the individual PPT.


Data from individuals were summarized using frequency counts with percentages and descriptive statistics such as means and standard deviations (SD). Cross-sectional analysis included the chi square test for comparison of frequencies. A logistic regression model was used for analyses of ordered categorical variables, and multivariate logistic regression was used when adjustment for covariates were made. Odds ratios (OR) with confidence intervals (CI) were calculated. For continuous variables, we used the Shapiro-Wilk test to determine whether the data were normally distributed. For results that were not normally distributed, Mann-Whitney test was used to test recordings for paired observations. Multiple regression analysis controlling for the effect of covariates on comparison of continuous variables was performed. Spearman’s test was used for calculation of correlation coefficients, r. Individuals with missing data were excluded from the analyses. Only one subject reported a history of fibromyalgia, and therefore this condition was not included in the analysis. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 20.0 (Armonk, NY). Two-tailed p values were calculated. Five percent was accepted as the level of significance.



Of a total potentially eligible sample of 1,300, 848 (65.2%) participated in the study. Altogether, 555 individuals participated in the face-to-face interview and 293 in the telephone interview. Participants did not differ from non-participants in gender (p = 0.59). The mean age of participants was slightly lower than the mean age of non-participants, 49.1 ± 13.9 vs. 52.9 ± 15.2 (p<0.001). Complete data were available on 797 of 848 participants (94.0%). All 797 participants provided complete data on variables of interests such as demographic data (age, gender and education), selfreported health, neck pain and other pain-related and psychiatric comorbidities/symptoms. Individuals who provided data and were included in the analysis did not differ from individuals excluded for missing data in terms of age (p = 0.39), gender (p = 0.91) and presence of migraine and/or TTH (p = 0.22). Of 797 individuals, 496 (62.2%) also participated in the QST study. QTS study participants did not differ from non-participants in gender (p = 0.19) but the mean age of participants was higher compared to the mean age of non-participants, 50.7 ± 13.7 vs. 46.5 ± 13.8 (p<0.001).

      Prevalence, demographics and comorbidities of neck pain

In our sample of 797 individuals, 609 (76.4%) reported a lifetime prevalence of neck-shoulder pain. One-year period prevalence of neck pain in our sample was 68.4% (545 individuals). Reported days of neck pain per year varied widely as follows: no neck pain: 31.6%; one to seven days: 23.1%; eight to 14 days: 12.8%; 15–30 days: 13.4%; 31–179 days: 11.7%; >180 days: 7.4%.

Table 1

Individuals with neck pain over the past year were younger (47.2 ± 13.2 vs. 53.4 ± 14.2, p<0.001) and more likely to be female (Table 1). The relationship of neck pain to sociodemographic characteristics, headache diagnosis and lifetime prevalence of self-reported psychiatric diagnoses and pain comorbidities in individuals with and without neck pain in the past year is presented in Table 1. One-year prevalence of neck pain was associated with poor self-rated health (OR 2.1, 95% CI 1.3–3.6, p = 0.003). Poor self-rated health was also associated with spine disease (p<0.001), rheumatic disease (p<0.001) depression (p<0.001), and anxiety disorder (p<0.001). The report of poor self-rated health was high in individuals with low back pain but not statistically significant from individuals without low back pain (OR 1.7, 95% CI 0.9–3.1, p = 0.086).

      Prevalence of neck pain in migraine and TTH

Table 2

Out of 797, a total number of 321 (40.3%) individuals met criteria for a primary headache (migraine and/or TTH) over the past year. In total, 183 (23.0%) individuals had migraine while 241 (30.2%) had TTH. No individuals had headache that fulfilled ICHD criteria for chronic migraine. Individuals with any primary headache were more likely to have neck pain compared to individuals with no headache (Table 2). Neck pain was most common in those with both migraine and TTH (89%), similarly more prevalent in pure TTH (88%) and slightly less prevalent in migraine (76%). In logistic models examining headache type as a predictor of neck pain, after adjusting for age, gender, education and poor self-rated health, the relative odds of neck pain in individuals with pure TTH or migraine and TTH were about four times higher than in individuals free of primary headache. Those with pure migraine were 1.8 times more likely to have neck pain than those without primary headache but this finding just missed statistical significance. Neck pain was more common in individuals with TTH (88.4%) than those with migraine (76.2%); (OR 2.4, 95% CI 1.1–4.9, p = 0.02) but when adjusted for age, gender, education and poor self-rated health, the statistical significance was lost (OR 2.1, 95% CI 1.0–4.7, p = 0.066). There was a significant correlation between number of days with TTH per year and number of days with neck pain per year, r = 0.43, p<0.001. Furthermore, there was a significant correlation between number of days with migraine per year and number of days with neck pain per year, r = 0.33, p<0.001. The number of individuals with 180 or more days with neck pain in the past year was higher in the chronic headache group (47.5%; OR 16.3, 95% CI 6.7–39.2, p<0.001) than in the episodic headache group (8.9%, OR 1.4, 95% CI 0.8–2.7, p = 0.24) compared to individuals with no headache (3.2%; reference) after adjusting for age, gender, education and poor self-rated health.

In 17 individuals (5.3%) headache was related to neck and lower back trauma. In individuals with migraine and/or TTH, history of neck and low back trauma was associated with neck pain in the past year but the association did not reach statistical significance (OR 2.8, 95% CI 0.4–21.5, p = 0.31). A total of 45 (14.0%) individuals with migraine and/or TTH reported daily disability due to headache. The selfreported daily headache-related disability was associated with the presence of neck pain during the past year but the association did not reach statistical significance when adjusted for age, gender and education (OR 2.4, 95% CI: 1.0–5.9, p = 0.06). Neck pain was not associated with impact of TTH on at least of one type of daily activities (p = 0.89). Neck pain was not associated with impact of migraine on at least one type of daily activities (p = 0.17).

      Tenderness by manual palpation

Figure 1

Tenderness was significantly increased at all examined pericranial locations in individuals with neck pain in the past year compared to individuals with no neck pain (Figure 1). Individuals with neck pain had increased TTS compared to individuals with no neck pain (15.1 ± 10.5 vs. 8.4 ± 8.0, p<0.001). The difference remained significant when adjusted for presence of primary headache, age and gender (F = 21.2, p<0.001).


Mean PPT in temporal muscle was lower in individuals with neck pain in the past year than in individuals with no neck pain (231.3 ± 103.5 vs. 249.2 ± 101.5, p = 0.046). However, when controlled for the effects of presence of primary headache, age and gender, the difference did not reach statistical significance (F = 16.5, p = 0.82). In the index finger, mean PPT in individuals with neck pain in the past year did not significantly differ from mean PPT in individuals without neck pain in the past year (291.6 ± 143.2 vs.314.7 ± 136.9, p = 0.06).


In this population study, the prevalence of self-reported lifetime neck-shoulder pain (76.4%) and the one-year period prevalence of neck pain (68.4%) were high. Neck pain was more common in women than in men. Just a few previous population studies have demonstrated high prevalence of neck pain similar to our findings. [1, 21, 22] Ektor-Anderson et al. [21] found that one-year prevalence of neck pain in a Swedish population was approximately 73%. In a recent review [1], using data from 28 studies with low or moderate risk of bias, mean one-year prevalence was estimated to be 25.8% (range: 4.8%–79.5%). The large variation can be explained by methodological variations among studies including differences in sample demographics and in neck pain case definitions. Like our study, others have reported that women and younger age groups are at increased risk for neck pain. [1, 22]

Our findings confirm previous studies in adults showing higher frequencies of muscle pain in the neck/shoulder region in individuals with primary headache. To our knowledge, none of the previous population-based studies used strict ICHD criteria to define headache cases or analyzed the group with coexistent migraine and TTH. In a large population study from Spain [8], individuals with self-reported migraine in the past year were approximately 2.3 times more likely to have neck pain lasting at least six months compared to individuals without headache. In another large population study from the United States [7], 38% of individuals with severe headache or migraine assessed by self-report had neck pain in the past three months vs. 11% of individuals without severe headache or migraine. Hagen et al. [9] demonstrated that individuals with neck pain were more likely to have migraine and non-migrainous headache compared with individuals with musculoskeletal pain in other areas. In contrast to our findings, the authors did not demonstrate a difference between prevalence of neck pain between individuals with migraine and non-migrainous headache. [9] The relationship between TTH and neck/shoulder pain has been studied in children. In a population-based study in adolescents [23], neck/shoulder pain was more prevalent in those with migraine or coexistent migraine followed by TTH than individuals with no headache. In contrast, in our population we demonstrate a much higher prevalence of neck pain in coexistent headache and in pure THH compared to pure migraine.

We also found a correlation between the frequency of neck pain and frequency of migraine and TTH, though the correlation was stronger for TTH. Interestingly, the association of neck pain with episodic headache was stronger than with chronic headache in our study. In contrast to our study, previous population-based studies found that higher headache frequency had a higher association with neck/shoulder pain. [9] Our finding could be explained by the relatively small sample size. However, we also found that the proportion of individuals with 180 or more days with neck pain in the past year was higher in the chronic headache group than in the episodic headache group.

Correlation between neck-shoulder muscle tenderness and non-specific neck-shoulder pain was reported in highly selected subjects, office workers and sewing machine operators. [24, 25] Individuals with neck pain in our study had higher total and local tenderness scores and lower pain thresholds compared to individuals with no neck pain. When adjusted for age, gender and comorbid primary headache, results remained significant only for TTS. The tenderness was increased throughout the pericranial region and was more pronounced at neck muscle insertions and the trapezius muscle. Levoska [26] found a higher number of tender points in female office employees with neckshoulder symptoms compared to those with no or occasional neck-shoulder symptoms, with suboccipital and trapezius muscles tender in most cases in both groups.

Increased pain sensitivity in individuals with neck pain has been previously reported in experimental studies but not in population studies. [24, 26–28] The PPT of trapezius and levator muscles were lower in female office employees with disturbing neck-shoulder symptoms compared to individuals with no or occasional neck-shoulder symptoms. [26] PPTs have been reported lower in the neck area but not in the tibialis anterior muscle in subjects with neck pain compared to controls. [27, 28] In our study, both cephalic (temporalis muscle) and extracephalic (index finger) pain thresholds were lower in individuals with neck pain than in individuals with no neck pain. However, when adjusted for presence of migraine and/or TTH, the difference lost statistical significance in both regions. The magnitude of PPT decrease was greater in the cephalic region compared to the extracephalic region. The presence of higher degrees of local and total tenderness in individuals with neck pain probably indicates peripheral nociceptor sensitization. Peripheral sensitization may lead to segmental sensitization of second-order neurons in the trigemino- cervical nucleus and subsequently to the development of increased pain sensitivity at cephalic (trigeminal and cervical) regions. [13, 29] Our results indicate that neck pain does not induce central sensitization as frequent headache does, since the statistical significance for the difference in pain thresholds between individuals with and without neck pain disappears when controlling for a primary headache variable.

There are several methodological limitations in the current study. One of the limitations is a relatively low response rate: A total of 65.2% of individuals participated in the headache interview. In addition, only 62.2% of these individuals participated in the QST study. As in most previous epidemiological studies in headache, we did not use a daily headache diary. This could account for no chronic migraine cases in our study as well as prevalence rates of CTTH, ETTH, etc. Future studies on prevalence of migraine and TTH should be based on use of headache diaries. With our data we cannot assess whether neck pain prevalence will still be high in primary headache sufferers in a headache-free period. In addition, we do not know if neck pain is a trigger, premonitory symptom or a consequence of headache due to central sensitization. Does the neck pain predict chronification of migraine and TTH? A prospective and longitudinal study would be needed to answer these questions. The advantage of the present study is a large population-based sample of well-characterized individuals with primary headaches. The detailed interviews were conducted by physicians blinded to the initial diagnosis of migraine or TTH.

In conclusion, we demonstrated that neck pain is highly prevalent in the general population and is more prevalent in individuals with migraine and TTH. Prevalence of neck pain was highest in coexistent headache and pure TTH followed by migraine. Finally, we showed that myofascial pericranial tenderness is significantly increased in individuals with neck pain compared to individuals without neck pain, indicating a possible shared pathophysiological mechanism with primary headache.

Clinical implications
  • Neck pain is highly prevalent in the general population and is more prevalent in individuals
    with migraine and tension-type headache.

  • Neck pain has the highest prevalence in coexistent migraine and tension-type headache.

  • Myofascial pericranial tenderness is significantly increased in individuals with neck pain
    compared to individuals without neck pain.

  • Neck pain may have a shared pathophysiological mechanism with primary headaches.

  • Neck pain may result in increased disability in headache sufferers and treatment may also
    be directed to the neck.


This work was supported by grants from the East Denmark Health Science Research Forum, the Danish Medical Association Research Fund, the Danish Health Insurance Foundation, the Danish Hospital Foundation for Medical Research, the Danish Headache Society, the Cool Sorption Foundation, GlaxoSmithKline A/S, Merck Sharp Dohme A/ S, Pfizer A/S, Lundbeck Pharma A/S and H. Lundbeck A/S. The funding sources have not been involved in conducting the study.

Conflict of interest

Sait Ashina has received honoraria for lecturing from Allergan, Nautilus Neurosciences and Neurogesx and served as a consultant for Depomed. Lars Bendtsen has received honoraria for lectures from MSD, Allergan and Pfizer and serves on the scientific advisory board for Berlin-Chemie. Richard Lipton receives research support from the National Institutes of Health (NIH) (PO1 AG03949 (program director), RO1AG025119 (investigator), RO1AG022374-06A2 (investigator), RO1AG034119 (investigator), RO1AG12101 (investigator), K23AG030857 (mentor), K23NS05140901A1 (mentor), and K23NS47256 (mentor)), the National Headache Foundation, and the Migraine Research Fund; serves on the editorial board of Neurology; has reviewed for the National Institute on Aging (NIA) and National Institute of Neurological Disorders and Stroke (NINDS); holds stock options in eNeura Therapeutics; and serves as consultant, advisory board member, or has received honoraria from Allergan, American Headache Society, Autonomic Technologies, Boston Scientific, Bristol Myers Squibb, Cognimed, Colucid, Eli Lilly, eNeura Therapeutics, GlaxoSmithKline, MAP, Merck, Nautilus Neuroscience, Novartis, NuPathe, Pfizer, and Vedanta. R. Jensen has received honoraria for lectures and patient leaflets from MSD, Berlin-Chemie Menarini, ATI and Pfizer, and serves on medical advisory boards for LindeGas, ATI and ElectroCore. Ann C Lyngberg and Nazrin Hajiyeva have nothing to declare.


We thank Nurse Vibeke Thomsen for skillful assistance in conducting the clinical examination.


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  29. Bendtsen L.
    Central sensitization in tension-type headache — possible pathophysiological mechanisms.
    Cephalalgia 2000; 20: 486–508.

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