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General physical impairments in
migraine patients beyond cervical
function
Roy La Touche 1,2,3, Teresa García-Pastor 4,7, Álvaro Reina-Varona 1,2,
Alba Paris-Alemany 2,3,5 & Mónica Grande-Alonso 6
Previous research has focused on the possibility of cervical dysfunction in migraine patients, similar to
what is observed in patients with tension-type headaches. However, there is no evidence concerning
the physical function of other body regions, even though lower levels of physical activity have
been reported among migraine patients. The aim of this study was to compare cervical and extra-
cervical range of motion, muscular strength, and endurance, as well as overall levels of physical
activity, between patients with chronic migraine (CM) and asymptomatic participants. The secondary
objective included the analysis of associations between CM-related disability and various physical
and psychological variables. A total of 90 participants were included in this cross-sectional study:
30 asymptomatic participants (AG) and 60 patients with CM. Cervical and lumbar range of motion,
strength and endurance, as well as handgrip strength were measured. Headache-related disability,
kinesiophobia, pain behaviors, physical activity level and headache frequency were assessed through
a self-report. Lower values were found in CM vs AG for cervical and lumbar ranges of motion (p < 0.05;
eect sizes ranging from 0.57 to 1.44). Also, for neck extension strength (p = 0.013; d = − 0.66),
lumbar strength (p < 0.001; d = − 1.91) and handgrip strength (p < 0.001; d = − 0.98), neck endurance
(p < 0.001; d = − 1.81) and lumbar endurance (p < 0.001; d = − 2.11). Signicant dierences were
found for physical activity levels (p = 0.01; d = − 0.85) and kinesiophobia (p < 0.001; d = − 0.93)
between CM and AG. Headache-related disability was strongly associated with headache frequency,
activity avoidance, and rest, which together explained 41% of the variance. The main ndings of this
study suggest that patients with CM have a generalized tness decit and not specically cervical
dysfunction. These ndings support the hypothesis that migraine patients have not only neck-related
issues but also general body conditions.
Keywords Chronic migraine, Cervical region, Physical activity, Physical function, Migraine related disability
Migraine is a complex and multifactorial neurological disorder1 that can present as episodic or chronic,
depending on the frequency of the signs and symptoms2.
Epidemiologically, migraine is one of the most disabling disorders worldwide3. e prevalence of CM is
estimated to be between 1% and 2.2% of the general population4,5, and it has been reported that 3.1% of patients
with EM might progress to CM6.
Patients with migraine might experience neck discomfort and stiness during the various phases of the
migraine attack7. Recent evidence based on a meta-analytical analysis indicates that neck pain is a highly
prevalent symptom in patients with CM8 and has been reported as an even more prevalent symptom than
nausea9. ese and other ndings suggest that factors associated with cervical disability should be considered in
the prevention and treatment of migraine and suggest the need for further research10.
One of the most extensively studied aspects of the cervical region has been range of motion decits. e
results of these studies conrm that patients with CM and EM present decreased cervical range of motion
1Departamento de Fisioterapia, Centro Superior de Estudios Universitarios (CSEU) La Salle, Universidad Autónoma
de Madrid, Madrid, Spain. 2Motion in Brains Research Group, Centro Superior de Estudios Universitarios (CSEU) La
Salle, Universidad Autónoma de Madrid, Madrid, Spain. 3Instituto de Dolor Craneofacial y Neuromusculoesquelético
(INDCRAN), Madrid, Spain. 4Facultad HM de Ciencias de la Salud, Universidad Camilo José Cela, Madrid, Spain.
5Departamento de Radiología, Rehabilitación y Fisioterapia, Facultad de Enfermería, Fisioterapia y Podología,
Universidad Complutense de Madrid, Plaza Ramón y Cajal, s/n, Ciudad Universitaria, 28040 Madrid, Spain.
6Departamento de Cirugía, Ciencias Médicas y Sociales, Facultad de Medicina, Universidad de Alcalá, Alcalá de
Henares, Spain. 7 Instituto de Investigación Sanitaria HM Hospitales, Madrid, Spain. email: albaparis@gmail.com
OPEN
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compared with the asymptomatic population11,12. e data obtained for neck range of motion in patients with
migraine were 59.3° extension, 44.5° le lateral exion and 60.8° right rotation11, also reduced exion rotation
test mobility and reduced velocity of neck movements12. It has also been observed that limitations in range of
motion were related to migraine frequency and disability12.
Another cervical function characteristic found to be altered in patients with migraine is the strength and
endurance of the cervical musculature13–15. e exor endurance was found to be a 25% reduced compared to
controls13. Regarding strength, a reduction of 4.4N/kg was observed in cervical extension force in patients with
migraine compared to asymptomatic participants14. is strength decit has been associated with cutaneous
allodynia15 and migraine frequency14. Also, signicantly greater coactivation of antagonist muscles (splenius
capitis muscle) was found among EM and CM compared to controls14.
Although the ndings on cervical function disorders in migraine are important, these studies have a
signicant limitation in the assessment of strength and range of motion was evaluated only in the cervical
region, which questions the specicity of the results, especially considering that recent evidence reports that
patients with migraine have lower levels of physical activity than the asymptomatic population16. Indeed, lower
cardiovascular tness levels had higher long-term risk of developing migraine17. ese ndings support our
hypothesis that decits in physical variables such as strength and range of motion occur at a general level and
not only in the cervical region.
In patients with migraine, avoidance of physical activity has been reported as a behavioral response driven by
cognitive factors, such as fear of exacerbating headaches18. is avoidance is further inuenced by anxiety18 and
fear of movement12,19, both of which are closely linked to a reduction in physical activity and limited movement
of the cervical region and head.
ese ndings suggest two hypotheses: (1) Migraine patients exhibit general, not localized, functional
decits in strength and range of motion, linked to reduced physical activity; and (2) Migraine-related disability
correlates with functional decits, low physical activity, and psychological factors. is study aims to provide a
comprehensive understanding of migraine patients, potentially inuencing treatment strategies. Unlike previous
cervical-focused research, it employs a thorough evaluation of overall physical condition. e primary objective
is to compare cervical region strength and range of motion with other areas in CM patients and asymptomatic
participants. Secondary goals involve analyzing CM disability’s association with physical/psychological factors
and comparing physical activity levels between CM patients and asymptomatic individuals.
Materials and methods
Study design
is cross-sectional study employed purposive sampling, adhering to STROBE guidelines20. Participants
received comprehensive information and provided voluntary informed consent. Ethical principles following the
Declaration of Helsinki were upheld21, with approval from the Centro Superior de Estudios Universitarios La
Salle ethics committee (CSEULS-PI-034/2019).
Participants
e participants included in the study were required to meet the proposed inclusion criteria. Male and female
adult patients aged between 18 and 65years were recruited and were required to have a good command of the
Spanish language. Participants in the CM group were recruited from a clinic specializing in treating patients
with temporomandibular disorders, headaches, and craniofacial pain (Madrid, Spain). e patients had to have a
previous medical diagnosis and meet the CM criteria of the International Classication for Headache Disorders22,
which are as follows: (a) headache frequency ≥ 15days per month; (b) migraine symptom frequency ≥ 8d ays;
(c) chronicity ≥ 3months; and (d) a history of migraine starting before the age of 50years. e following cases
were excluded: (a) previous cervical and cranial trauma; (b) infectious or tumor diseases; and (c) recent surgical
procedures (in the previous 12months).
e control group consisted of asymptomatic individuals with no history of head and neck pain for at least
one year and who did not require any medical treatment or physiotherapy. Participants in this group were
intentionally age- and gender-matched with those in the CM group to achieve similar groups. e control group
was recruited through social networking from a university population.
Procedure
Aer giving their consent to participate in the study, all participants were given a set of questionnaires, which
included a socio-demographic assessment and were asked to complete a series of self-reports: Head Impact
Test (HIT-6)23, International Physical Activity Questionnaire (IPAQ)24, Tampa scale of Kinesiophobia (TSK-
11)25, Pain Catastrophism Scale (PCS)26, chronic pain self-ecacy scale (CPSS)27, Pain Behaviors Questionnaire
(PBQ)28.
Aer the participants had completed the self-report measured, the following physical measured were
assessed: cervical range of motion, lumbar range of motion, cervical exor muscle endurance, maximal isometric
contraction of the cervical exor and extensor muscles was assessed during cervical exion and extension
movements, maximal lumbar isometric contraction and handgrip dynamometry. e assessor was a physical
therapist blinded to the participants’ condition. All patients’ assessments were done during the interictal periods.
Physical measures
Cervical range of motion
Cervical range of motion (CROM) was measured in degrees using a cervical range-of-motion device referred
to as a CROM (Performance Attainment Associates, Lindstrom, MN)29, which consists of three independent
inclinometers, one for each plane of motion, attached to a plastic frame similar to a pair of glasses. e cervical
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ranges of motion measured were (1) exion–extension, (3) right-le lateral exion, (5) right-le rotation. CROM
was measured with participants seated in a chair with a backrest, maintaining a 90-degree angle at both the hips
and knees, and feet at on the oor to ensure a standardized and stable position. Each movement was performed
three times, and the average value was used for analysis. e CROM has proven to be a valid and reliable tool for
measuring the range of motion of the cervical region30.
Lumbar range of movement
Lumbar exion range of motion was assessed in degrees using a digital inclinometer based on the iHandy mobile
application. To perform the measurement, the assessor holds the mobile device over the participants’ sacrum
and applies light pressure while the participants perform a lumbar exion movement. Each movement was
repeated three times, and the average value was used for analysis. is measurement has been shown to have
good intra-rater and inter-rater reliability, with an intra-class correlation coecient ≥ 0.8631.
Endurance of the cervical musculature
e endurance of the cervical musculature was measured with a test that primarily assesses the endurance of the
neck exor muscles, which has good reliability32. Participants were placed in the supine position. e examiner
raised the participants’ head 2.5cm above the couch and instructed the participants to hold this position for as
long as possible. e examiner then let go of the participants’ head, leaving it suspended, held in place only by
the participants’ muscle exertion. e test was nished when the participant could no longer maintain the head
in the required position, and the endurance was recorded in seconds. e test was performed two times, and the
average value was used for analysis.
Endurance of the lumbar musculature
Endurance of the lumbar musculature was assessed using the Ito test. Participants lay prone with a 10-cm pillow
beneath their lower abdomen to reduce lumbar lordosis. With arms parallel to the body axis, they raised their
upper body to a 15° angle, maintaining a neutral cervical spine position, and both feet on the couch. e test
continued until fatigue, with termination upon a > 10° decrease in trunk angle. Endurance was measured in
seconds. Two brief practice attempts (5s) ensured correct execution. e test was performed twice, and the best
result was used for analysis. e Ito test is a valid and reliable measure of lumbar extensor muscle strength33.
Cervical strength
Maximal isometric contraction (MIC) of cervical exion and extension was assessed using a calibrated
handheld digital dynamometer (MicroFET 2 dynamometer, Hoggan Health Industries, Salt Lake City, UT).
e dynamometer, with a cushioned pad, was placed on the area to be assessed. For exion MIC, participants
were supine, with the pad on their forehead, performing maximal craniocervical exion. For extension MIC,
participants were prone, with the pad on the occipital area, resisting the assessor’s opposing force. Each
movement was tested three times, with each attempt lasting 5s, and a 60-s rest between attempts. e MIC was
measured in kilograms of force (kgf), ensuring consistent reliability34.
Lumbar strength
e extension MIC of the lumbar region was measured using a foot dynamometer (Takei TM 5420, Takei
Scientic Instruments CO., Niigata City, Japan). is device has been validated and can be used to determine leg
and back strength in held positions, provided that the measurement protocol is standardized (r, 0.91; p < 0.001)35.
For the measurement, participants let their arms hang down to hold the dynamometer’s bar with both hands,
palms facing the body. e dynamometer chain was adjusted so that the knees were exed to approximately
110°. e evaluator took 3 measurements, each in kgf, and the mean was used in the data analysis.
Handgrip strength
Isometric handgrip strength was measured using a JAMAR hydraulic handgrip dynamometer (Sammons
Preston, Rolyon, Bolingbrook, IL), following the procedure recommended by Roberts et al. Participants sat
upright with feet at on the oor, elbows exed at 90°, and wrists and forearms in a neutral position36. Grip
strength was recorded three times on the dominant hand, in kgf, with a 30-s interval between measurements.
is test demonstrates excellent reliability across various populations and conditions37–39.
Psychological and disability measures
Headache-related disability
Disability was assessed using the Spanish HIT-6, comprising 6 items to measure headache-related disability in
CM patients23. e questionnaire exhibits acceptable psychometric properties and validation for CM patients40.
Scores range from 36 to 78 points, categorized into four severity levels: little or no impact (36–49), some impact
(50–55), substantial impact (56–59), and severe impact (60–78).
Pain behaviors
e PBQ assesses pain-related behaviors, initially validated in headache patients41,42. e Spanish version,
validated in patients with migraine and tension-type headache, exhibits strong psychometric properties,
comprising 19 items across six factors: avoidance behaviors (5 items), active non-verbal complaint (4 items),
passive non-verbal complaint (3 items), verbal complaint (3 items), rest (2 items), and medication (2 items)28.
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Fear of movement
We assessed fear of movement using the Spanish TSK-11, with good psychometric properties (Cronbach’s α,
0.81)25. It has 2 subscales: one for fear of physical activity and another for fear of harm. Each of 11 items was
scored 1–4 (1 = “strongly disagree”, 2 = “disagree”, 3 = “agree”, 4 = “strongly agree”), yielding scores from 11 to 44.
Physical activity level
e IPAQ assessed participants’ physical activity, categorizing them into three levels (high, moderate, low/
sedentary) and estimating activity in METs. IPAQ’s psychometric properties are accepted; it has a reliability of
about 0.77 (95% CI 0.67–0.84)43.
Pain intensity
Self-reported pain intensity was assessed using the numerical pain scale (NPS) (0–10/10). A score of 0 indicates
“no pain”, while a score of 10 indicates “maximum possible pain intensity”44.
Sample size
e sample size was estimated with G*Power 3.1.7 (G*Power of the University of Düsseldorf, Germany)45. A pilot
study was conducted with 16 patients with CM and 16 asymptomatic participants to determine dierences using
Student’s t-test and eect size to compare cervical muscle endurance variables and the handgrip dynamometry
pressure. e study employed an alpha error level of 0.05, a statistical power of 80% (1-B error) and an eect size
d (0.68 and 0.81). e estimated total sample size was 56 for the cervical muscle endurance variable and 40 for the
handgrip dynamometry variable; ultimately, the larger sample size (28 patients with CM and 28 asymptomatic
participants) was chosen. An additional 5% of the sample was included to allow for possible withdrawals that
may occur during the physical evaluation. For these comparisons, the sample was nally 60 participants.
e sample calculation required for the multiple regression analysis was performed taking into account the
use of 8 predictor variables, an alpha error level of 0.05, a statistical power of 99% (1-B error), an R2 of 0.2 and
an eect size f2 of 0.25, resulting in a total sample estimate of 65 patients with CM. e procedures followed for
this estimation are based on the guidelines outlined by Faul et al. (2009) for calculating sample sizes in studies
involving correlation and regression analyses46.
Statistical analysis
All analyses were performed using SPSS statistical soware, version 27.0 (SPSS Inc., Chicago, IL). Statistical
analyses were performed at a 95% condence level; P-values < 0.05 were considered statistically signicant. To
compare descriptive statistics, physical variables and self-reports scores between the CM group and asymptomatic
participants t-test for independent samples was used and the chi-square test was used to compare categorical
variables. Eect sizes (Cohen’s d) were calculated for the outcome variables. According to Cohen’s method, the
eect size was classied as small (0.20–0.49), moderate (0.50–0.79) or large (≥ 0.8)47.
An analysis of covariance (ANCOVA) was used, it included “physical activity level” as a covariate for between-
group comparisons of physical measures and kinesiophobia. For this analysis the eect size was estimated with
partial eta squared (ηp2).
e relationship between headache-related disability and physical and psychological variables in the CM
group was examined using Pearson’s correlation coecients. A Pearson correlation coecient > 0.60 indicated a
strong correlation, a coecient between 0.30 and 0.60 indicated a moderate correlation, and a coecient < 0.30
indicated a low or very low correlation48.
A stepwise multiple linear regression analysis was used to estimate the strength of the association between
headache-related disability (criterion variable) and psychological, behavioral, and physical variables (predictor
variables). Only variables that obtained moderate correlations in the correlation analysis were included in the
regression model. We assessed multicollinearity in the models using the Variance Ination Factor (VIF). A
VIF near 1 implies minimal multicollinearity; values between 1 and 5 suggest moderate correlation among
predictors; and a VIF over 10 indicates signicant multicollinearity.
In the development of our multiple linear regression model, we have performed comprehensive diagnostic
analyses to verify its robustness and adherence to key assumptions.
e model’s evaluation began with an investigation into the homogeneity of variance, which is crucial for the
reliability of the regression estimates. A graphical approach was employed, plotting residuals against tted values
to visually inspect the data. is plot revealed a random dispersion of residuals with no apparent patterns or
funnels, leading us to conrm that the variance of the residuals is consistent across all levels of the independent
variables, thereby satisfying the homogeneity criterion.
Another critical assumption, the independence of observations, was rigorously tested using the Durbin-
Watson statistic. is test is instrumental in detecting any autocorrelation in the residuals that could compromise
the integrity of the regression analysis. A value of the statistic proximate to 2.0 was indicative of the absence of
autocorrelation, thereby upholding the model’s assumption of independent observations.
Moreover, the normality of the residuals’ distribution was scrutinized using Q-Q plots. ese plots provided
a visual assessment by comparing the distribution of the residuals to a perfectly normal distribution. e
alignment of the residuals along a straight line on the Q-Q plots suggested that the distribution of the residuals
aligns well with the assumption of normality.
Lastly, the linearity assumption was substantiated by examining scatter plots of observed versus predicted
values and normal P-P plots of standardized residuals. ese assessments disclosed a clear linear trajectory,
thereby reinforcing our condence in the linearity of the relationship modeled.
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Results
e total study sample consisted of 95 participants (30 asymptomatic participants and 65 patients with CM) who
met the inclusion criteria. Statistically signicant dierences were found only in body mass index (which was
higher in the CM group) and in the level of physical activity measured in METS (p = 0.01) (the control group
were more active). ere were statistically signicant dierences in the subclassication according to the level of
physical activity (Fig.1). e statistics for the sociodemographic variables are presented in Table 1. All statistics
followed a normal distribution except for those representing physical activity.
Comparative analysis
In the comparative analysis, there were statistically signicant dierences in the variables of range of motion,
endurance and MIC for measurements in the cervical region and in other body segments (p < 0.05), and the
eect sizes of these comparisons were moderate-high in magnitude (Table 2), with the endurance-related
variables having the largest dierences (Fig.2).
With respect to the kinesiophobia variable (TSK-11) and the avoidance subscale, there were statistically
signicant dierences with a large eect size (TSK-11; p < 0.001; d = 0.93; Activity Avoidance, p = 0.001;
d = 0.86); as well as for the harm subscale although the eect size was moderate (p = 0.030; d = 0.57).
When adjusting with the physical activity covariate, only statistically signicant results where obtained for
the maximal isometric cervical exion strength (F = 8.05; p = 0.006; ηp2 = 0.12), maximal isometric cervical
extension strength (F = 9.00; p = 0.004; ηp2 = 0.14) and handgrip strength (F = 7.29; p = 0.009; ηp2 = 0.113).
Correlation analysis
Table 3 shows the Pearson correlation analysis. e highest correlations were between disability (HIT-6) and
frequency of headaches (HIT-6) (r = 0.51; p < 0.001); and between disability and the avoidance behaviors
subscale of the PBQ (r = 0.50; p < 0.001).
Fig. 1. Physical activity subclassication. e graph shows the subclassication of the physical activity levels of
both study groups.
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Measures CM group
(n = 30) Asymptomatic
group (n = 30) Dierence of means (95%
CI) t-student; p-value; Eect size (d)Covariate: physical activity
F; p-value; Eta Squared (ηp2)
ROM
Cervical exion–extension (°) 99.36 ± 15.72 107.33 ± 11.76 − 7.96 (− 15.14 to − 0.78) t = − 2.22; p = 0.030; d = − 0.57 F = 2.94; p = 0.091; ηp2 = 0.05
Cervical rotation (°) 113.22 ± 22.99 129.1 ± 20.17 − 15.3 (− 26.47 to − 4.12) t = − 2.74; p = 0.008; d = − 0.71 F = 0.11; p = 0.739; ηp2 = 0.002
Cervical lateral exion (°) 71.43 ± 18.79 83.16 ± 10.56 − 11.73 (− 19.61 to − 3.85) t = − 2.98; p = 0.004; d = − 0.77 F = 0.63; p = 0.429; ηp2 = 0.11
Lumbar exion (°) 36.04 ± 8.3 46.36 ± 5.71 − 10.32 (− 14.03 to − 6.63) t = − 5.60; p < 0.001; d = − 1.44 F = 1.64; p = 0.205; ηp2 = 0.03
Muscular endurance
Cervical endurance (s) 22.53 ± 7.81 36.3 ± 7.41 − 13.76 (− 17.7 to − 9.83) t = − 7.01; p < 0.001; d = 1.81 F = 0.03; p = 0.864; ηp2 = 0.001
Lumbar endurance (s) 57.81 ± 27.44 155.58 ± 59.62 − 97.77 (− 121.76 to − 73.78) t = − 8.15; p < 0.001; d = − 2.11 F = 0.28; p = 0.596; ηp2 = 0.005
Muscular strength
Cervical extension (Kgf) 21.16 ± 5.72 25.1 ± 6.18 − 3.93 (− 7.01 to − 0.85) t = − 2.55; p = 0.013; d = − 0.66 F = 8.05; p = 0.006; ηp2 = 0.12
Cervical exion (Kgf ) 12.56 ± 4.02 16 ± 4.85 − 3.43 (− 5.73 to − 1.13) t = − 2.98; p = 0.004; d = − 0.77 F = 9.00; p = 0.004; ηp2 = 0.14
Handgrip (Kgf) 33.88 ± 6.71 40.14 ± 5.94 − 6.25 (− 9.53 to − 2.98) t = − 3.82; p < 0.001; d = − 0.98 F = 7.29; p = 0.009; ηp2 = 0.113
Lumbar extension (Kgf) 43.78 ± 13.42 75.71 ± 19.34 − 31.92 (− 40.55 to − 23.31) t = − 7.42; p < 0.001; d = − 1.91 F = 0.98; p = 0.362; ηp2 = 0.02
Kinesiophobia (TSK-11) 27.63 ± 7.08 21.7 ± 5.52 5.93 (2.65 to 9.21) t = 3.61; p < 0.001; d = 0.93 F = 0.03; p = 0.859; ηp2 = 0.001
Harm_subscale 10.36 ± 3.51 8.66 ± 2.29 1.7 (0.16 to 3.23) t = 2.22; p = 0.030; d = 0.57 F = 0.004; p < 0.952; ηp2 = 0.00
Activity Avoidance_subscale 17 ± 4.71 13.33 ± 3.69 3.66 (1.48 to 5.85) t = 3.35; p = 0.001; d = 0.86 F = 0.03; p < 0.867; ηp2 = 0.00
Tab le 2. Comparative analysis between the CM group and the asymptomatic group. Values are presented as
mean ± standard deviation. CI coecient interval, CM Chronic Migraine, ROM Range of motion, TSK Tamp a
Scale of Kinesiophobia.
Measures CM group
(n = 30)
Asymptomatic
group
(n = 30) p-value t-test (independent samples) or chi-square test
Age (years) 46.8 ± 12.5 43 ± 14.4 p = 0.281
BMI (kg/m2)25.9 ± 4.7 23.8 ± 1.6 p = 0.028
Gender
Women 19 (63) 22 (73) p = 0.405
Men 11 (34) 8 (24)
Marital status
Married 12 (40) 18 (60) p = 0.052
Single 7 (23) 10 (34)
Divorced 5 (17) 1 (3)
Widow 1 (3) 1 (3)
No answer 5 (17) 0
Educational level
Primary education 3 (10) 2 (7) p = 0.299
Secondary education 14 (47) 9 (38)
College education 13 (43) 19 (63)
Employment status
Unemployed 7 (23) 2 (6) p = 0.057
Sick leave 7 (23) 2 (6)
Active 13 (44) 17 (57)
Student 2 (7) 5 (17)
No answer 1 (3) 4 (13)
IPAQ (Mets) 1554.4 ± 2472.4 3848.4 ± 4183.6 p = 0.001
Tab le 1. Descriptive statistics for sociodemographic data. Values are presented as mean ± SD or number (%);
CM chronic migraine, BMI Body Mass Index, IPAQ physical activity questionnaire.
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e physical variables with the highest correlations with disability were the cervical exor endurance test
(r = 0.31; p = 0.016) and handgrip strength (r = 0.32; p = 0.012), and the correlations were negative in magnitude
(Table 3).
Regression analysis
Table 4 presents the linear regression model for the disability criterion variable (HIT-6). e model found that
headache frequency, avoidance behaviors (PBQ/Avoidance behaviors subscale), and rest (PBQ/Rest subscale)
were associated with headache-related disability, together explaining 41% of the variance. Six variables were
excluded from the model (pain intensity, fear of movement, harm subscale, verbal complaint subscale, cervical
endurance and handgrip strength) due to their lack of signicant correlation with the disability outcome or
minimal contribution to explaining the variance. e results of the variance ination factor indicates that there
is very little multicollinearity in the model.
Discussion
is study aimed to compare cervical and overall physical variables in patients with CM and asymptomatic
participants. Findings revealed that CM patients exhibited lower strength, endurance, and range of motion in
all assessed regions. To our knowledge, this is the rst study to evaluate these physical variables in the cervical
region and in other regions. is represents a novel exploration, as previous research mainly focused on cervical
neurophysiological mechanisms in migraine11–14. Our results introduce alternative hypotheses regarding the
observed physical decits in migraine patients.
e reduced physical tness variables may be linked to the lower physical activity levels observed in these
patients, aligning with our initial hypothesis. Existing studies consistently show that migraine patients exhibit
lower physical activity levels compared to asymptomatic participants16,49–53. Although the relationship between
physical activity levels and decits in tness-related variables seems relatively clear, the results are not at all
Fig. 2. Dierences in endurance tests. e graphs represent the comparison of the endurance tests between the
two groups.
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clear when this relationship is established with respect to variables related to migraine worsening. Bond et al.
found that patients with migraine had lower physical activity levels, but this has not been related, for example,
to migraine frequency53, with recent ndings contradicting those results16. Importantly, physical activity or
physical exercise was not found to cause migraine exacerbations53, as recently suggested in other studies54.
Bond et al. reported that the analyzed migraine population had a higher body mass index than the
asymptomatic participants53, a nding consistent with our results. A number of consistent results from the
scientic literature suggest that obesity might be related to the prevalence, frequency and disability of migraine
in both pediatric and adult populations55.
Variable criteria: headache-related disability
Overall model
R2 = 0.44; Adjusted R2 = 0.41; F = 14.695; p < 0.001
Regression coecient (B) Standardized co ecient (β) p-value VIF
Predictor variables
Headache frequency 0.7 0.38 0.001 1.12
Pain behaviour_Avoidance behaviors subscale 0.9 0.29 0.012 1.26
Pain behaviour _Rest_subscale 1 0.24 0.029 1.15
Excluded variables
Pain intensity – 0.25 0.256 1.30
Harm subscale (TSK-11) – 0.09 0.612 1.19
Pain behaviour_verbal complaint_subscale – 0.05 0.654 1.29
C_Endurance – 0.05 0.574 1.25
Handgrip strength – 0.17 0.093 1.11
Tab le 4. Regression model for headache-related disability in chronic migraine group (n = 65). VIF Variance
Ination Factor, TSK Tampa scale of kinesiophobia, C. Endurance Cervical Endurance.
N = 60
Headache-
related disability
56.4 ± 7
Measures Mean ± SD rp-value
Headache frequency 20.2 ± 3.6 0.51** < 0.001
Pain intensity 5.5 ± 1.4 0.41** 0.001
Harm_subscale 10.6 ± 3.6 0.31* 0.016
Activity Avoidance_subscale 17.2 ± 5 0.29 0.026
Pain behaviour_avoidance behaviors subscale 4.1 ± 2.3 0.50** < 0.001
Pain behaviour_Rest subscale 3.8 ± 1.6 0.40** 0.001
Pain behaviour_passive non-verbal complaint subscale 2.6 ± 1.4 − 0.01 0.927
Pain behaviour_active non-verbal complaint subscale 3.1 ± 1.8 0.07 0.586
Pain behaviour_medication subscale 1.5 ± 0.9 0.23 0.070
Pain behaviour_verbal complaint_subscale 2.3 ± 1.5 0.31* 0.014
CROM_FE 97.8 ± 13.9 − 0.19 0.132
CROM_ROT 111.8 ± 20.8 − 0.16 0.217
CROM_LF 70.1 ± 17.8 0.11 0.410
LROM_F 37.3 ± 7.5 − 0.23 0.067
C_Endurance 21.4 ± 7.3 − 0.31* 0.016
L_Endurance 60.3 ± 26.7 − 0.16 0.195
CE_Strength 20.5 ± 5.9 − 0.23 0.070
CF_Strength 12.5 ± 4.1 − 0.17 0.173
Handgrip strength 33.9 ± 7.1 − 0.32* 0.012
LE_strength 44.4 ± 14.5 − 0.28 0.030
IPAQ 1634.8 ± 1278.2 0.15 0.238
Tab le 3. Pearson correlation coecients in CM group. Values are presented as mean ± SD; CROM_FE Cervical
Range of motion_exoextension, CROM_ROT Cervical range of motion rotation, CROM_LF Cervical range
of motion lateral exion, LROM_F Lumbar range of motion exion, C_Endurance Cervical Endurance, L_
Endurance Lumbar Endurance, CE cervical extension, CF cervical exion, LE lumbar extension, IPAQ physical
activity questionnaire.
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In our study, the BMI in the migraine group (25.9) was slightly elevated but did not reach the threshold for
obesity. While previous studies have linked migraine with obesity, our sample’s BMI does not fully represent
this association, as the asymptomatic group had a BMI of around 23. is discrepancy could be related to the
reduced levels of physical activity observed in the CM patients, rather than obesity itself. Lower levels of physical
activity, which were signicantly dierent between groups, might contribute to the overall burden of migraine,
inuencing headache frequency and severity, as suggested in the literature. us, it is plausible that reduced
physical activity, rather than higher BMI, could be a more critical factor in migraine pathology.
Several literature reviews agree on the preventive eect of exercise on CM and EM56–58, and it has been
observed that women with headaches who are more physically active have a lower consumption of analgesics59.
Meta-analyses have reported that aerobic exercise can decrease the frequency, duration and intensity of migraine
attacks and improve the quality of life of these patients60–62, a clinical trial with similar results using general
strength training has recently been published63. However, another trial found no eect of specic strength
training on the cervical region64.
e neurophysiological relationship between the upper cervical region and the trigeminal nerve has been
extensively documented, with an observed increase in the mechanosensitivity of the cervical region aer dural
stimulation65. e explanation for this phenomenon might be the convergence of both cervical and trigeminal
innervation in the trigeminocervical nucleus in the brainstem65. is relationship could perhaps explain the
high prevalence of neck pain in patients with migraine8. According to this assumption, some researchers have
hypothesized that manual therapy and specic exercise interventions directed to the cervical region could
improve both neck pain and migraine conditions. However, scarce evidence exists regarding the eectiveness of
manual therapy in the cervical region for migraine treatment that supports its application62,66–68. Regarding the
eectiveness of specic exercise interventions directed to the cervical region, they seem not to be superior to
sham ultrasound nor aerobic exercise for the treatment of migraine64; moreover, at 3months, aerobic exercise
showed a greater reduction in migraine frequency compared to cervical exercises69. In contrast, aerobic exercise
and full-body resistance training have shown signicant results for reducing migraine symptoms and improving
quality of life, as previously mentioned61,63. e presence of central sensitization in thalamocortical and cortical
levels in patients with migraine represents evidence of dysfunctional central pain mechanisms that could aect
pain sensitivity throughout the body70. Cutaneous allodynia and temporal summation in extracephalic regions
have also been associated with a worse outcome and a higher migraine frequency71,72. It is hypothesized that
exercise could produce a generalized decrease in pain due to exercise-induced analgesia, a phenomenon that
seems to involucrate mainly opioid and endocannabinoid systems73. Aerobic exercise and full-body resistance
exercise have also been shown to decrease pain sensitivity in other chronic pain populations, such as bromyalgia
and chronic low back pain74–77. ese results demonstrate that it is not necessary to directly apply an exercise
intervention to a specic region to obtain an improvement in pain.
For this reason, it is possible that the cervical region is not a specic therapeutic target for patients with
migraine. A more general physical assessment such as the one performed in our study should therefore be
conducted to identify possible decits in variables related to range of motion and strength/endurance to better
determine the ideal exercise prescription for these patients.
It is important to note that our study did not specically record the presence of low back pain (LBP) in migraine
patients. However, what we did observe and record was that patients with chronic migraine (CM) exhibited
signicantly lower lumbar muscle endurance compared to asymptomatic participants. is nding raises the
possibility that undiagnosed or unreported LBP could have contributed to the reduced lumbar endurance seen
in the CM group. Previous studies, such as those by Yoon et al. (2013), have demonstrated a strong association
between chronic headaches, including CM, and frequent LBP, suggesting that the neurobiology of chronic
headache may involve generalized pain processing dysfunction that extends beyond the trigeminal system78.
is broader pain sensitization could potentially explain the lumbar decits observed in our study.
Additionally, a recent study by Deodato et al. (2024) identied musculoskeletal dysfunctions throughout
the spine in patients with chronic primary headaches, including CM and chronic tension-type headache, with
no signicant dierences in postural alterations or musculoskeletal dysfunctions between these two headache
types79. is nding further supports the hypothesis that musculoskeletal dysfunctions, including in the lumbar
region, could be related to central sensitization in chronic migraine patients.
Given the evidence linking chronic headache with LBP, future studies should consider incorporating a
direct assessment of LBP in CM patients to explore its potential role in the observed physical impairments,
particularly in the lumbar region. e high prevalence of LBP in individuals with chronic headaches underscores
the importance of a more comprehensive evaluation of musculoskeletal function in this population.
Findings related to headache-related disability show that the predictors are headache frequency, and activity
avoidance and rest of the PBQ. Other studies have independently found relationships between disability and
variables such as headache frequency, activity avoidance80,81 and social avoidance81. In relation to these three
variables, it has been observed that patients with migraine who avoid physical activity were more likely to
experience CM and more frequent headaches82.
Aer the present results, authors’ recommendations for future research would be to assess the eects of a
combined intervention including aerobic and full body strength exercises. In addition, the assessment of the
physical condition of the migraine patients in a general approach would be needed over a segmental cervical
assessment.
Limitations
is study has limitations to consider. Physical activity data relied on self-reports, which are subjective and
prone to recall bias and inaccuracies. Future research should employ objective instruments like accelerometers
to capture precise physical activity data. Additionally, measuring cardiorespiratory tness could oer a more
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Content courtesy of Springer Nature, terms of use apply. Rights reserved
comprehensive understanding of patients’ physical tness. e cross-sectional design limits predictive insights.
Comorbidities were not assessed, and comparisons with patients having episodic migraines (EM) could be
benecial in future studies, enhancing our understanding of physical variables’ behavior in CM versus EM
patients.
Conclusions
is study revealed that patients with CM exhibit reduced overall range of motion, lower endurance and strength
in cervical and non-cervical areas, and lower physical activity levels compared to asymptomatic participants.
Headache-related disability was primarily associated with headache frequency, activity avoidance behaviors,
and rest.
Data availability
e datasets used and/or analysed during the current study available from the corresponding author on reason-
able request.
Received: 28 March 2024; Accepted: 29 November 2024
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Author contributions
Author RL contributed to the conception and design of the manuscript. Author RL, author MGA, author ARV,
and author APA have given substantial contributions to acquisition, analysis and interpretation of the data. All
authors have participated to draing the manuscript, author TGP revised it critically. All authors read and ap-
proved the nal version of the manuscript.
Funding
e Centro Superior de Estudios Universitarios La Salle provided funding and support for this study.
Declarations
Competing interests
e authors declare no competing interests.
Additional information
Correspondence and requests for materials should be addressed to A.P.-A.
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