Cephalalgia. 2015 (Mar); 35 (3): 211219 ~ 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 2.04.4, 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.  Variation in
epidemiological studies of neck pain is attributable, at
least in part, to differences in sample selection, ascertainment
of symptoms and case definitions.  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.  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.  Neck pain may occur as a premonitory
manifestation or during the headache phase. 
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.  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
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).
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 2565 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 3776 years of age, were identified
from the Danish Civil Registration System. In addition,
300 new individuals aged 2536 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
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. 
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) , 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, 17 days, 814
days, 1530 days, 31100 days, 101179 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.
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, 1530 days, 31100 days, 101179
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. 
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 subjects 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.  Pericranial tenderness
was assessed by palpation of eight pairs of muscle
and tendon insertions.  The tenderness was scored
according to the Total Tenderness Score (TTS) on a
four-point (03) scale, previously proved to be reliable.  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
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. 
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.
Spearmans 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
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%; 1530 days: 13.4%; 31179 days: 11.7%;
>180 days: 7.4%.
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 1.33.6, 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 0.93.1,
p = 0.086).
Prevalence of neck pain in migraine and TTH
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 1.14.9, 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 1.04.7,
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 6.739.2, p<0.001) than in the episodic
headache group (8.9%, OR 1.4, 95% CI 0.82.7,
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 0.421.5, 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: 1.05.9, 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
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.  found
that one-year prevalence of neck pain in a Swedish
population was approximately 73%. In a recent
review , 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 tension-type headache (TTH).
In a large population study from Spain , 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 , 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. 
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.  The relationship between TTH and
neck/shoulder pain has been studied in children. In a
population-based study in adolescents , 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
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.  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  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, 2628]
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.  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 tension-type headache (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
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
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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