by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT


It is theorized that individuals who suffer from migraines are more likely to present with neck pain and cervical muscle dysfunction. There is a lack of information regarding endurance of the neck extensors, the only muscle group with reported weakness in patients with migraine. The authors in the study, Cervical Muscular Endurance Performance in Women with and Without Migraines, looked at cervical muscle endurance of neck flexors and extensors in a population of women most at risk for suffering from migraines.


Women between the ages of 18 and 55 with a history of migraines were recruited for the study. Study inclusion criteria included a diagnosis of migraine by a neurologist and a frequency of at least three migraine attacks per month for the past three months. Exclusion criteria included presence of a concurrent diagnosis, a history of headache medication overuse, a history of head or neck trauma, current pregnancy, history of cancer, use of recent anesthesia, history of cervical disc disorder, and history of degenerative spine disease. The control group was comprised of women who were age, height, and weight-matched to the study group.

The neck extensor endurance test was performed with patients in a prone position with their head over the end of a plinth and strap support around pelvis and thoracic spine. A separate strap was used to suspend a 2-kg weight approximately 30 cm above the floor. The test ended when the participant was no longer able to sustain the head position, the neck/head position changed more than 5 degrees for three seconds, or the participant opted to terminate the test due to neck pain or fatigue.

The neck flexor endurance test was performed with patients in a hook-lying position with supportive straps at the sternum and pelvis. Patients were asked to perform slight head and neck flexion off the table. The test was concluded when the participant was unable to maintain the unsupported head position or the participant decided to terminate the test due to neck pain or fatigue.


A total of 26 women with migraines and 26 control subjects were included in the study. The migraine group demonstrated a shorter cervical flexor and extensor muscle holding time than the control group. The median hold times for neck flexion were 35.0 seconds and 60.5 seconds for the migraine and control groups, respectively. The median hold times for neck extension were 166.5 seconds and 290.5 seconds for the migraine and control groups, respectively.

Patients in the control group with a history of neck pain showed lower endurance in both flexor and extensor muscle groups. In the migraine group, those with a history of neck pain had lower endurance for the neck extensors but, in contrast, slightly higher endurance for the neck flexors. The proportion of participants who reported neck pain during both endurance tests was similar between the migraine and control groups.


The study results suggest that migraines may be associated with reduced neck flexor and extensor cervical muscle endurance. Based on the study findings, it should be considered that the presence of migraines is associated with a lower endurance of the cervical spine musculature; however, the higher prevalence of neck pain reported by those with migraines could have also influenced muscle endurance. When the frequency of neck pain during the test was considered, there were similar rates between those with or without migraine. However, findings of this study along with other recent reports, suggest that decreased cervical muscle performance may be associated with migraines and often coexisting neck pain, particularly for the neck extensors.


Women with migraines had a lower holding time for cervical spine flexor and extensor musculature compared to that of a matched control group. These results suggest that cervical spine muscle endurance may be an important and potentially overlooked aspect of cervical spine muscle function in this population.

Physical Therapy First Implications

This study demonstrates that the endurance of cervical flexors and extensors is important in the evaluation and treatment of patients with migraines and neck pain. Our therapists have the resources to perform these cervical muscular endurance tests and can recommend exercises for strengthening the neck. If you suffer from neck pain or migraines, a tailored home exercise program that includes neck flexor and extensor strengthening created by a skilled physical therapist could be beneficial for decreasing pain and improving function.


Florencio, L., Oliveira, I., Lodovichi, S., Bragatto, M., Benatto, M., Dach, F…Bevilaqua-Grossi, D (2019). Cervical Muscular Endurance Performance in Women With and Without Migraine. Journal of Orthopaedic and Sports Physical Therapy. Vol 49, No 5, pages 330-336