Migraine Explained: Causes, Symptoms, and How We Can Help

If you've read our previous blog comparing cervicogenic headache, migraine, and TMD, you'll know how much overlap exists between these conditions. This blog focuses specifically on migraine itself: what's actually happening in the brain, the four phases of an attack, and what genuinely helps, including where manual therapy and exercise fit in.

What Headache Do I Have? Cervicogenic, Migraine, or TMD?

Migraine Is More Than "Just a Bad Headache"

Migraine is one of the most misunderstood health conditions around, often dismissed as simply a severe headache. In reality, migraine is a complex neurological condition, and headache is just one part of a much larger process happening in the brain. Research has identified migraine as the leading cause of years lived with disability in people aged 15 to 49, reflecting just how significant its impact can be on daily life, work, and relationships. ¹

Understanding what is actually happening during a migraine attack, and recognising its different phases, can make a genuine difference to how you manage it, and to working out which triggers and treatments are most relevant to you.

What Is Actually Happening in the Brain During a Migraine?

Migraine has a genetic component, meaning some people are simply more biologically susceptible to it than others. ² At its core, current research describes migraine as involving inherited alterations in brain excitability, changes in blood vessels within the brain, and recurrent activation of a specific pain pathway known as the trigeminovascular system. ³

The trigeminovascular system, in simple terms, is the connection between the trigeminal nerve (the large nerve responsible for sensation in the face and head) and the blood vessels covering the brain (the meninges). When this system becomes activated and sensitised, it produces the throbbing head pain characteristic of migraine, alongside inflammation in the surrounding tissue. ³

Cortical spreading depression is another key piece of the puzzle, particularly relevant to migraine with aura. This is a slow-moving wave of electrical activity that spreads across the surface of the brain, followed by a temporary period of reduced activity. ⁴ Research has found that this wave can directly activate the trigeminovascular system, helping explain why aura and headache so often occur together, even though they were once thought to be separate, unrelated processes. ⁵

A chemical called calcitonin gene-related peptide (CGRP) plays a particularly important role in this process. Research has shown that CGRP levels rise significantly during a migraine attack and fall again once the pain resolves, and CGRP is now understood to contribute directly to the dilation of blood vessels, inflammation, and pain signalling involved in migraine. ⁶ This discovery has been genuinely significant in modern medicine, leading to a newer class of migraine medications that specifically target CGRP.

In short, migraine is not simply "a headache that won't go away." It is a distinct neurological event involving changes in brain excitability, nerve sensitisation, and inflammatory chemical signalling, all of which explain why migraine can feel so much more intense and disabling than other types of headache.

The Four Phases of a Migraine Attack

One of the most useful things to understand about migraine is that the headache itself is often just one part of a longer process. Research describes migraine attacks as typically progressing through up to four distinct phases, although not everyone experiences all four, and the boundaries between them are not always clear-cut. ⁷

1. Prodrome (Premonitory Phase)

This is the earliest phase, occurring in around 80% of people with migraine, and can begin anywhere from two hours to two days before the headache itself starts. ⁷ ⁸ Many people don't realise this phase is part of the migraine at all.

Common prodrome symptoms include:

• Fatigue or excessive yawning

• Irritability or mood changes

• Neck stiffness

• Food cravings (Typically chocolate / sweet foods / salty snacks / caffeinated drinks)

• Difficulty concentrating

• Increased sensitivity to light, sound, or smell

  
  

Recognising your own prodrome symptoms can be genuinely useful, as some people find that early intervention, whether through medication, rest, or hydration, during this phase can reduce the severity of the headache that follows.

2. Aura

Aura affects around a quarter of people with migraine and, when it occurs, typically develops gradually over 5 to 20 minutes before or alongside the headache. ⁹ Aura is a temporary, fully reversible neurological disturbance.

Common aura symptoms include:

• Visual disturbances such as flashing lights, zigzag lines, or blind spots

• Tingling or numbness, often starting in the hand and spreading up the arm or to the face

• Difficulty finding words or speaking clearly

• In rare cases, temporary weakness on one side of the body

It's worth noting that aura does not occur in the majority of people with migraine, so its absence does not rule migraine out.

3. Headache

This is the phase most people associate with migraine: typically a moderate to severe, throbbing or pulsating pain, usually on one side of the head, though it can switch sides or become bilateral. The headache phase is often accompanied by nausea, sensitivity to light and sound, and can be made worse by routine physical activity. Without treatment, this phase can last anywhere from a few hours to several days.

4. Postdrome

Often called the "migraine hangover," the postdrome occurs in around 80% of people with migraine and can last from several hours up to two days after the headache pain has resolved. ⁸

Common postdrome symptoms include:

• Exhaustion

• Difficulty concentrating, sometimes described as brain fog

• Dizziness

• Mood changes, including either low mood or, less commonly, euphoria

• Lingering, milder head pain triggered by sudden movement

  
  

Understanding the postdrome matters because many people push themselves back into normal activity too soon, not realising this final phase is still part of the migraine process and genuinely requires some recovery time.

Common Triggers

Migraine triggers are genuinely individual, and what provokes an attack in one person may have no effect on another. Common categories include:

• Hormonal changes, particularly around menstruation, which is one of the most consistently reported triggers in women

• Sleep disruption, both too little and too much sleep

• Dietary factors, including caffeine, alcohol, and skipped meals, though specific food triggers vary considerably between individuals

• Stress, both during periods of high stress and, for some people, during the relaxation that follows a stressful period

• Sensory stimuli, such as bright or flickering lights, strong smells, or loud noise

• Weather changes, including changes in barometric pressure

• Dehydration

• Neck tension and posture, which can act as a genuine trigger or amplifier of migraine in people who are migraine-prone, even though it is not the underlying cause

Keeping a simple migraine diary, tracking what you ate, how you slept, your stress levels, and where you were in your hormonal cycle if relevant, alongside when attacks occur, can be a genuinely useful tool for identifying your personal pattern of triggers.

What to Look Out For

The vast majority of migraine, even when severe, is not dangerous. However, certain features require urgent medical assessment to rule out a more serious underlying cause:

• A sudden, severe "thunderclap" headache reaching maximum intensity within seconds to minutes, unlike any previous headache

• A new headache pattern in someone over 50 with no previous history of migraine

• Headache following significant head trauma

• Headache with fever, neck stiffness, confusion, or a non-blanching rash

• New or worsening neurological symptoms that don't resolve, including weakness, numbness, vision loss, or difficulty speaking

• Aura symptoms lasting longer than an hour, or occurring for the first time over the age of 50

• Headache that wakes you from sleep and is significantly worse first thing in the morning, accompanied by vomiting

• Unexplained weight loss alongside persistent headache

If you experience any of these, please seek prompt medical attention.

How We Can Help

Migraine is a neurological condition, and appropriate medical management, whether through preventive medication, acute treatment, or both, should remain the foundation of your care, ideally guided by your GP or a neurologist. That said, manual therapy can play a genuinely useful supporting role, particularly where neck tension and dysfunction are contributing to or amplifying your attacks.

Research has found that musculoskeletal impairment in the neck is common in people with migraine, and addressing this component can meaningfully reduce overall headache burden, even though it does not treat the underlying neurological mechanism itself. ¹⁰ Research comparing manual therapy plus usual care against usual care alone, in people with migraine and coexisting neck pain, found that manual therapy provided a useful adjunctive benefit, supporting its use alongside, rather than instead of, standard migraine management. ¹¹

A three-armed trial combining manual therapy, neck muscle exercise, and pain education found that all approaches led to improvement over time, with the combined multimodal approach showing the most consistent benefit at longer-term follow up. ¹² Separate research comparing connective tissue massage with manual lymphatic drainage in migraine patients found that manual lymphatic drainage had a stronger effect on overall pain relief and wellbeing, whilst connective tissue massage was particularly effective for reducing the coexisting neck pain and disability that so commonly accompanies migraine. ¹³

Manual therapy and massage: Gentle soft tissue work targeting the neck and shoulder muscles, alongside connective tissue massage techniques, can help reduce the neck-related component that frequently accompanies and can trigger migraine attacks.

Medical acupuncture: Used alongside standard migraine management, acupuncture can help address coexisting muscle tension and pain sensitivity, supporting overall symptom management.

Exercise for Migraine

• Gentle neck mobility and deep neck flexor exercises: chin tucks, performed lying down or sitting upright by gently nodding the chin in a small "yes" motion, can help address coexisting neck dysfunction, which research has shown to be common in people with migraine. ¹⁰

• Regular aerobic activity: research into physical activity and migraine has found a clear relationship between activity levels and improvements in pain, function, and quality of life, making gentle, consistent exercise a genuinely useful part of overall migraine management. ¹⁴ Activity should generally be introduced gradually, as sudden, intense exercise can act as a trigger for some people.

• Postural and shoulder release work: a simple doorway chest stretch and an upper trapezius stretch (gently tilting one ear toward the same shoulder) can help reduce the secondary muscular tension that frequently builds up around migraine episodes.

• Thoracic mobility: as discussed in our neck pain and stiffness blog, restoring thoracic rotation reduces the compensatory load placed on the neck, which can help lower the frequency of neck-related migraine triggers over time.

• Sleep and hydration habits: not exercises in the traditional sense, but genuinely important "lifestyle exercises," given how consistently sleep disruption and dehydration are reported as migraine triggers.

It is important to be clear that manual therapy and exercise are a supportive, adjunctive approach for migraine, not a replacement for appropriate medical management. We would always encourage ongoing communication with your GP or neurologist regarding your migraine treatment plan, particularly around medication and trigger management.

Living With Migraine: Practical Day-to-Day Tips

• Consistency matters: regular sleep, meal, and hydration patterns reduce the likelihood of several of the most common migraine triggers occurring at once.

• Track your pattern: a simple migraine diary noting triggers, prodrome symptoms, and timing can help you and your GP identify personal patterns and assess whether preventive treatment might be appropriate.

• Manage neck tension proactively: given the close relationship between neck dysfunction and migraine, regular movement breaks, good workstation posture, and the exercises above can help reduce one of the more modifiable contributing factors.

• Recognise the postdrome: build in some recovery time after an attack rather than immediately returning to full activity, since postdrome symptoms are a genuine part of the migraine process.

• Manage light and sound sensitivity during an attack: a dark, quiet space, alongside whatever acute treatment your GP has recommended, remains one of the most effective ways to manage the headache phase itself.

What to Expect at Your First Appointment

At your first appointment, we will take a thorough history of your headaches, including whether they show features more consistent with migraine, cervicogenic headache, or TMD, as covered in our previous headache comparison blog. We will assess your neck and thoracic spine for any contributing musculoskeletal factors, and explain clearly how manual therapy and exercise might support your overall migraine management. We will always encourage and support ongoing communication with your GP or neurologist regarding the neurological and medical aspects of your care.

Frequently Asked Questions

Can manual therapy cure my migraine? No, and we want to be upfront about that. Migraine is a neurological condition, and manual therapy is a supportive, adjunctive approach, most useful where neck dysfunction is contributing to or amplifying your attacks, not a replacement for appropriate medical management.

Why does my neck always hurt before a migraine starts? Neck stiffness is a recognised prodrome symptom for many people, appearing hours before the headache phase begins. It can also act as a genuine trigger or amplifier in people who are migraine-prone, which is why addressing neck tension can be a useful part of overall management.

Should I exercise during a migraine attack? Generally, no. Routine physical activity often worsens the headache phase. Gentle activity introduced consistently between attacks, rather than during one, is where the evidence supports the most benefit.

How is migraine different from cervicogenic headache or TMD? We cover this in detail in our previous blog comparing the three conditions, but in short, migraine is a primary neurological headache disorder, whereas cervicogenic headache and TMD related headache are secondary headaches driven by a musculoskeletal problem in the neck or jaw. The three can also coexist.

Think neck tension might be playing a role in your migraines? Get in touch using the contact form and we will assess whether manual therapy could be a useful part of your overall management plan.

BOOK YOUR APPOINTMENT HERE

References

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2. Migraine With Aura. StatPearls Publishing. Updated 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK554611/

3. Noseda R, Burstein R. Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, cortical spreading depression, sensitization, and modulation of pain. PubMed. Available at: https://pubmed.ncbi.nlm.nih.gov/23891892/

4. Molecular and Cellular Neurobiology of Spreading Depolarization/Depression and Migraine: A Narrative Review. International Journal of Molecular Sciences. 2024;25(20):11163. Available at: https://www.mdpi.com/1422-0067/25/20/11163

5. Moskowitz MA. Rethinking migraine with aura: Why cortical spreading depolarization (depression), not aura, causes headaches. Cephalalgia. 2025. Available at: https://journals.sagepub.com/doi/10.1177/03331024251370629

6. Pathophysiology of Migraine. Science of Migraine. Available at: https://www.scienceofmigraine.com/pathophysiology/phases-of-migraine

7. Migraine Headaches. Healio Clinical Guidance. Available at: https://www.healio.com/clinical-guidance/headaches/migraine-headaches-assessment-and-treatment

8. Migraine Headache. StatPearls Publishing. Updated 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK560787/

9. Migraine With Aura. StatPearls Publishing. Updated 2024. Available at: https://www.ncbi.nlm.nih.gov/books/NBK554611/

10. Pensri C, Liang Z, Treleaven J, et al. Cervical musculoskeletal impairments in migraine and tension-type headache and relationship to pain related factors. Musculoskeletal Science and Practice. 2025;76:103251.

11. Effectiveness of manual therapy as a prophylactic treatment for migraine: a randomized controlled trial. Archives of Physiotherapy. Available at: https://www.archivesofphysiotherapy.com/index.php/aop/article/view/3799

12. Effects of combining manual therapies, neck muscle exercises, and therapeutic education pain neuroscience in patients with migraine. Musculoskeletal Science and Practice. Available at: https://www.sciencedirect.com/science/article/abs/pii/S2468781225001080

13. Comparison of the efficacy of connective tissue massage and manual lymphatic drainage in patients with migraine: a randomized controlled trial. Journal of Oral and Facial Pain and Headache. 2025;39(3):121-132.

14. Sağlı Diren G, Kaya Ciddi P, Ergezen G, Şahin M. Effect of physical activity level on pain, functionality, and quality of life in migraine patients. The Journal of the Turkish Society of Algology. 2023;35:212.