Clinical Pilates in Practice: Migraines (April 2022)

This Masterclass / review article discusses current literature and clinical practice for physiotherapists working with patients with migraines.


Carvalho, Gabriela F., Annika Schwarz, Tibor M. Szikszay, Waclaw M. Adamczyk, Débora Bevilaqua-Grossi, and Kerstin Luedtke. "Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice." Brazilian Journal of Physical Therapy 24, no. 4 (2020), 306-317. doi:10.1016/j.bjpt.2019.11.001.



  • Migraines are under-diagnosed and under-treated.

  •  Patients may present with episodic, highly frequent, or chronic migraines.

  • Neck pain is common as part of the migraine cycle, and is related to worse clinical presentations.

  • Most patients present with at least three of the following:

    • Increased prevalence of cervical trigger points.
    • Decreased cervical ROM.
    • Decreased cervical flexion and extension strength.
    • Decreased upper cervical rotation.
    • Forward head posture.
    • Decreased pressure-pain thresholds in the head and neck. 

A possible mechanism is the trigeminocervical complex: afferents from C1, C2, and C3 converge onto second-order neurons that also receive afferents from the first division of the trigeminal nerve.

  • "Accordingly, a dysfunction in the musculoskeletal area that has afferents into the trigeminocervical complex, may reinforce sensitization and thereby facilitate chronicity." (p. 308)
  • Nociceptive afferents from the TMJ may also sensitise this system.
  • Vestibular symptoms are inherent in the migraine condition, and can include the following symptoms:
    • Dizziness.
    • Vertigo.
    • Self-motion perception.
    • Spatial disorientation.
  • Postural control impairments such as decreased balance in quiet standing, and a reduction of the limits of stability are also observed.
  • Impairments in postural control deteriorate over time.
  • Balance deficits and vestibular dysfunction can be present in the absence of dizziness or other vestibular symptoms.
  • Sensory mismatch between the vestibular, visual, and proprioceptive systems can lead to a variety of vestibular symptoms.
  • Conflicting expected and perceived cues from labyrinthic, visual, proprioceptive, and exteroceptive afferents may be exacerbated by malfunction in the brainstem, cerebellum, inner ear, basal ganglia, and cortical hemispheres.
  • Delayed development of visual motion processing and orientation perception is observed in patients with migraine conditions.

Convergence of the cervical and trigeminal nerves in the brainstem.
(Adapted from Haldemann and Dagenais, 2001.)


  • Trigger point releases and stretching of the SCM and upper trapezius, combined with suboccipital treatment.
  • Combine with exercises to strengthen the neck and scapula control.
  • Thoracic and cervical mobility exercises are useful for those with decreased range of motion.
  • Cervical and thoracic strength training are also warranted, as there is evidence that these improve neck pain.
  • Nerve tissue mobilisation. 
  • Treat TMJ dysfunction if indicated.
  • High-intensity aerobic exercise.



  • Progressive gaze stabilisation exercises, visual motion desensitivity training, and vestibular habituation.
  • (Note: presence of migraines delays treatment success for vestibular rehabilitation.)
  • Balance and gait training, as well as global endurance and strength training are indicated for falls prevention.
  • Balance and gait training have not, however, been studied in a migraine population.


  • Work to increase upper cervical range of motion and strength.
    • Nose clocks.
    • Prone "pecking" with mobility.
    • Integrate head and cervical alignment and strength exercises through all postures.
  • Increase thoracic mobility and scapulothoracic biomechanics to create a base for head and neck alignment.
    • Rotated Diamond Press on the Mat.
    • Supine Scapulae Series on the Trapeze Table/Cadillac.
    • Lifted Swan Series on the Wunda Chair.
    • Archer on the Reformer.
    • Windmill/Twist at the Tower.
  • Work to increase limits of stability in sitting and standing.
  • Integrate Neurodynamics.



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