When Headache Starts in the Neck: Gwen Jull & Zhiqi Liang on Migraine, Cervicogenic Headache, and Clinical Reasoning

Neck pain and headache often travel together. But as Gwen Jull and Zhiqi Liang explain in this episode, that does not automatically mean the cervical spine is driving the headache. In this AAOMPT and IFOMPT collaborative episode, hosts Amy McDevitt and Michael Boney explore the evolving science around cervicogenic headache, migraine-associated neck pain, sensitization, and clinical examination. Gwen Jull discusses the development and validation of physical criteria for cervicogenic headache, emphasizing the need for a cluster of comparable musculoskeletal signs involving joint, movement, and muscle impairments. Zhiqi Liang expands the conversation into migraine, reminding clinicians that neck pain can be part of a migraine presentation rather than proof of a cervical source. She challenges clinicians to rethink the meaning of symptom reproduction during upper cervical examination and to consider sensitivity, irritability, and migraine cycles when examining and treating these patients. Together, the guests make a compelling case for more careful clinical reasoning: listen to the patient’s story, examine without over-provoking symptoms, look for comparable signs, and match treatment to the impairments that are actually present. Big takeaway: The neck may matter — but clinicians need to prove it through the whole clinical picture. Timestamped Chapters 00:00 — Welcome to Hands On, Hands Off 00:31 — Introducing the AAOMPT and IFOMPT collaboration 01:19 — Meet Gwen Jull and Zhiqi Liang 03:19 — Why headache and neck pain matter to manual physical therapists 03:40 — Major shifts in clinical thinking around cervicogenic headache 04:09 — Validated physical criteria for cervicogenic headache 05:37 — Joint, movement, and muscle signs 07:33 — The physiotherapist’s role in differential diagnosis 08:02 — How headache can refer pain into the neck 08:51 — Are cervicogenic headache and migraine distinct or a spectrum? 09:26 — Migraine as a primary neurological condition 11:33 — Sorting out mixed headache presentations 12:05 — Patient history clues: migraine vs cervicogenic headache 13:27 — Comparable signs and why intensity matters 14:51 — How much does pain location matter? 16:20 — Why no single feature is enough 17:17 — Neck pain in migraine may not be a neck problem 17:53 — Rethinking symptom reproduction during examination 19:22 — How to decide whether the neck is a driver 20:01 — Avoiding confirmation bias 21:27 — Why non-provocative examination matters 23:08 — Scapular dysfunction and other regional contributors 24:37 — Broadening beyond the diagnostic cluster 26:05 — Sensory-motor control, dizziness, and balance 28:41 — Local cervical findings and global systems 29:31 — Listening for migraine evolution over time 30:46 — Central sensitization and comparable physical findings 31:28 — PIVM vs PAVM assessment considerations 32:08 — Avoiding symptom provocation in migraine 33:04 — Migraine cycles and changing sensitivity 34:36 — Trial treatment and rigorous re-evaluation 35:41 — Individualized care beyond guidelines 36:19 — Who may benefit from a cervical-focused approach? 37:07 — Education, exercise, sleep, stress, and lifestyle strategies 39:02 — Let the physical exam guide treatment 39:46 — PTs as rehabilitation experts, not just pain reducers 41:38 — One assumption clinicians should rethink tomorrow 42:12 — Don’t forget the jaw 42:27 — Neck pain may reflect sensitivity, not source 43:16 — Final reflections and closing