Headache and Migraine: Symptoms, Assessment and Management

Headache is one of the most common neurological complaints and may arise from a primary headache disorder or from another medical condition. Migraine is a disabling neurological disorder characterized by recurrent attacks, often with nausea and sensitivity to light or sound. Correct classification matters because management differs between migraine, tension-type headache, cluster headache and secondary causes (World Health Organization [WHO], 2025; Headache Classification Committee of the International Headache Society [IHS], 2018).

A headache should not be judged by pain intensity alone. Attack pattern, associated symptoms, medication use, functional impact and warning signs help guide appropriate care. Physiotherapy may support selected patients, particularly when neck pain, movement impairment, stress or deconditioning coexist, but it does not replace medical assessment or migraine-specific treatment (Ashina et al., 2021).

What Are Headache and Migraine?

Headache is pain in the head or upper neck and is a symptom rather than a single diagnosis. Primary headache disorders include migraine, tension-type headache and cluster headache; secondary headache results from another condition, such as infection, trauma, vascular disease or medication overuse. Migraine commonly produces moderate-to-severe, often pulsating pain, frequently worsened by routine activity and accompanied by nausea and/or light and sound sensitivity. Some people experience aura—reversible visual, sensory or speech symptoms—before or during an attack (IHS, 2018).

Migraine may occur with or without aura and may be episodic or chronic. Chronic migraine is generally defined by headache on 15 or more days per month for over three months, with migraine features on at least eight days. Diagnosis is clinical; imaging is considered when the history or examination suggests a secondary cause, not routinely for every typical migraine (IHS, 2018; NICE, 2025).

How Common Is It? Prevalence and Epidemiology

Headache disorders affect people of all ages and create substantial personal, educational and economic burden. WHO estimates that headache disorders affected about 40% of the global population in 2021, while Global Burden of Disease analyses identify migraine as a major contributor to years lived with disability. Migraine is more prevalent in females, especially during reproductive years, although it occurs in all sexes and age groups (WHO, 2025; GBD 2023 Headache Collaborators, 2025).

Table 1. Selected epidemiological and classification points for headache disorders.

Prevalence estimates differ by survey methods, diagnostic criteria and population. These values describe population burden and do not predict an individual’s diagnosis or attack frequency.

Causes and Risk Factors

Migraine is a complex neurological disorder involving altered sensory processing and activation of trigeminovascular pathways. It is not simply a blood-vessel problem or a consequence of poor posture. Genetic susceptibility interacts with hormonal, environmental and behavioural factors. Triggers vary between individuals and do not necessarily cause an attack every time (Ashina et al., 2021).

• Family history: migraine commonly clusters in families, reflecting a heritable susceptibility.
• Hormonal changes: menstruation and changes in oestrogen may influence attacks in some individuals.
• Sleep and routine: irregular sleep, missed meals, dehydration and changes in caffeine intake may contribute to attacks.
• Sensory and environmental factors: bright light, strong odours, noise, weather changes or visually demanding tasks may be reported triggers.
• Stress and musculoskeletal symptoms: stress and neck discomfort may coexist with migraine; neither alone proves the headache is cervicogenic.

Frequent use of acute headache medication can contribute to medication-overuse headache. A headache diary helps identify personal patterns without encouraging unnecessary restriction of everyday activities (WHO, 2025; NICE, 2025).

Clinical Features and Pain Location

Symptoms differ by headache type. Migraine pain is often unilateral but can be bilateral; it may be pulsating and aggravated by ordinary movement. Tension-type headache is commonly pressing or tightening, mild to moderate and not worsened by routine activity. Cluster headache causes severe, usually unilateral orbital or temporal pain with same-sided tearing, red eye, nasal symptoms or restlessness (IHS, 2018).

• Migraine: moderate or severe pain, nausea or vomiting, light/sound sensitivity, activity limitation, and sometimes aura.
• Tension-type headache: pressure or tightness, usually without vomiting and with limited nausea or sensory sensitivity.
• Cluster headache: very severe attacks around one eye, often recurring in bouts with tearing, nasal congestion or eyelid changes.
• Associated neck pain: may occur during migraine and should be assessed, but does not by itself establish a neck-generated headache.

Urgent warning: sudden “thunderclap” headache reaching maximum intensity within seconds, new weakness or confusion, fever with neck stiffness, seizure, new vision loss, headache after significant head injury, or a new severe headache during pregnancy/postpartum requires urgent medical assessment. New headache with cancer, immune suppression or progressive neurological symptoms also warrants prompt review (NICE, 2025).

Diagnosis and Assessment

Assessment begins with a detailed history and neurological examination. The clinician identifies the headache pattern, screens for secondary causes and determines whether the presentation meets accepted diagnostic criteria. Routine imaging is not necessary for a typical stable primary headache with a normal examination, but investigations may be required when red flags are present (IHS, 2018; NICE, 2025).

• History and headache diary: record frequency, duration, location, quality, severity, associated symptoms, menstrual relationship, possible triggers, medication use and impact on work or sleep.
• Neurological and general examination: assess mental status, cranial nerves, strength, sensation, gait, vital signs and other findings guided by the presentation.
• Red-flag screening: ask about abrupt onset, fever, trauma, pregnancy/postpartum status, cancer, immune suppression, new onset at older age and progressive change.
• Differential diagnosis: consider migraine, tension-type or cluster headache, medication-overuse headache, sinus or eye disorders, cervical causes and potentially serious secondary conditions.
• Functional assessment: use a validated measure such as HIT-6 or MIDAS when appropriate and document the effects on activity and participation.

A diagnosis should be based on the full clinical pattern rather than a single symptom, posture finding or response to manual therapy. Suspected secondary headache must be referred for medical investigation.

Treatment and Physiotherapy Management

Management is individualized according to headache type, frequency, disability, comorbidities and patient preference. Migraine care may include acute medication, preventive medication when indicated, education and behavioural strategies. Medication selection and dosing belong to a qualified prescriber. Overuse of acute medication should be identified early because it can perpetuate headache (Ailani et al., 2021; NICE, 2025).

• Education and pacing: explain the diagnosis, establish realistic goals and plan activity around symptoms without prolonged unnecessary rest.
• Lifestyle regularity: encourage consistent sleep, regular meals, hydration and a stable caffeine routine; address individual triggers identified in the diary.
• Exercise: graded aerobic activity may support general health and may help some people with migraine prevention. Start at a tolerable level and progress gradually.
• Neck and shoulder rehabilitation: when relevant impairments coexist, use individualized mobility, endurance, strengthening and movement-control exercises without assuming that all migraine originates in the neck.
• Manual therapy: may be considered as an adjunct for selected musculoskeletal symptoms, but evidence is limited and it should not be presented as a cure for migraine. Avoid forceful techniques when contraindications or red flags are present.
• Medical management: acute and preventive treatments should follow current guidance and consider contraindications, pregnancy, other conditions and medication-overuse risk.

Physiotherapy should complement, not replace, evidence-based headache care. Reassess headache days, disability, exercise tolerance, medication use and patient-defined goals. Worsening symptoms or new neurological signs require medical reassessment (Ashina et al., 2021; NICE, 2025).

Structural Assessment and Management (SDM)-Informed Approach

A structural assessment framework can organize examination of cervical and thoracic movement, muscle function, posture, sensory symptoms and functional limitations when these are relevant. It should be treated as a clinical reasoning aid—not as proof that a structural abnormality causes migraine or that a particular SDM treatment is effective. Headache-specific evidence for SDM has not been established by the references cited here.

How a structured assessment can guide care

• History and red-flag screening: classify the headache pattern and identify symptoms requiring urgent or routine medical referral.
• Musculoskeletal examination: assess neck movement, tenderness, strength and functional tasks where symptoms suggest a relevant cervical component.
• Differential diagnosis: distinguish migraine and other primary headaches from cervicogenic headache and secondary causes.

How management is adjusted

• Diagnosis-led plan: match interventions to the headache diagnosis, impairments, preferences and measurable goals.
• Avoid overclaiming: do not interpret posture, muscle tightness or temporary pain relief as proof of migraine cause or cure.
• Co-management and monitoring: coordinate with a physician or headache specialist when attacks are frequent, disabling, atypical or poorly controlled.

Daily Tips and Self-Management

Self-management is most useful when it supports, rather than replaces, a clear diagnosis and treatment plan.

• Keep a diary: record headache days, symptoms, possible triggers and medicines used.
• Maintain routines: aim for regular sleep, meals, hydration and appropriate physical activity.
• Use a planned response: follow the clinician’s advice on acute treatment and seek review if medication is needed frequently.
• Adapt activity: during an attack, reduce sensory load if helpful; resume usual activity gradually as symptoms settle.
• Avoid self-treatment risks: do not ignore red flags or rely on repeated painkillers without reviewing frequency and safety with a clinician.

Other Conditions and When to Get Help

Headache can be associated with eye disease, infection, vascular disorders, head injury, medication overuse and cervical conditions. Seek medical review for a new, persistent or changing headache, recurrent attacks that affect daily life, or increasing reliance on acute medication. Sudden severe onset, focal neurological deficit, confusion, seizure, fever with neck stiffness or acute visual loss requires emergency assessment (NICE, 2025; WHO, 2025).

Headache Care: Choosing an Appropriate Service

Final Takeaway

Headache is a symptom with multiple possible causes, while migraine is a common and disabling neurological disorder. Accurate diagnosis depends on the attack pattern, associated features, examination and screening for secondary causes. Management may combine appropriate acute or preventive medical treatment, regular routines, graded exercise and targeted physiotherapy when musculoskeletal impairments are relevant. SDM-style assessment can organize clinical reasoning but should not replace established headache criteria or be presented as a proven migraine-specific treatment. Recognizing red flags and arranging timely medical care are essential for safety (WHO, 2025; IHS, 2018; NICE, 2025).