Concussion Sensitizes the Migraine Pathways The trigeminovascular system mediates migraine. Migraine involves activation of the trigeminovascular system: trigeminal nerve fibers innervating brain blood vessels release neuropeptides (including CGRP) that produce vasodilation, inflammation, and pain. The system is hypersensitive in migraine patients (Patricios et al., 2023). Concussion further sensitizes this system. The neuroinflammation that follows concussion adds to the migraine sensitization. The threshold for triggering migraine attacks drops. Triggers that previously did not produce migraine now do. The dose-response curve shifts toward more migraine for the same trigger exposure. Central sensitization develops. Both migraine and concussion produce central sensitization (amplified pain processing in the central nervous system). The combined sensitization produces pain perception that exceeds the actual peripheral input. Pain that would not have registered pre-injury becomes significant after concussion. The cervicogenic contribution adds new headache type. Concussion frequently produces cervical injury that produces cervicogenic headache. This adds to the migraine the patient already has. The combined headache pattern includes both migraine features and cervicogenic features. The combination is more complex to treat than either alone. The Threshold Concept Explains the Increased Frequency Migraine has a trigger threshold. Each migraine patient has an individual threshold above which triggers produce attacks. The threshold reflects the cumulative trigger load: sleep deprivation, stress, dietary triggers, weather, hormones, sensory load. When cumulative triggers exceed threshold, migraine occurs. Concussion lowers the migraine threshold. The sensitization from concussion lowers the threshold substantially. Patients who previously needed multiple triggers to produce migraine now have attacks from single triggers. The same daily life now produces more migraine. PCS adds triggers. The cervical dysfunction, autonomic dysregulation, sleep disruption, and stress of PCS all add to the trigger load. The added triggers combined with lowered threshold dramatically increase migraine frequency. Recovery raises the threshold back. As PCS resolves, the threshold returns toward pre-injury level. The migraine frequency returns toward baseline. The recovery timeline often extends 8-16 weeks for substantial migraine improvement. Mobility Support for Combined Headache Conditions JME 155 Diaphragmatic breathing addresses the autonomic dysregulation that drives both PCS and migraine. The parasympathetic activation reduces sympathetic-driven migraine triggers. Regular breathing practice reduces both daily symptoms and migraine attack frequency. 10 breaths every 60-90 minutes, plus longer sessions during stress. JME 14 Chin tucks address the cervicogenic component that compounds migraine. Many patients with combined PCS and migraine have substantial cervical contribution. Treating the cervical component reduces total headache load. 10 repetitions with 5-second holds. JME 1 Cervical rotation maintains the mobility that supports cervical recovery. The cervical work addresses the contributor that PCS adds to migraine. 10 repetitions each direction. JME 150 Thoracic rotation supports the breathing that autonomic regulation requires. The mobility supports the foundation of headache recovery. 8 repetitions per direction. Start your 3-day free trial for migraine-PCS combined mobility programming. Treatment Adjustments Needed Migraine preventives may need dose adjustment. Pre-injury migraine preventive medications may be insufficient after concussion. Discuss with prescriber about dose increases or addition of second preventive. The combination of PCS and lowered threshold often requires more aggressive prevention. Consider CGRP-targeted medications. CGRP antibodies (erenumab, fremanezumab, galcanezumab) and gepants (rimegepant, ubrogepant) target migraine specifically without affecting concussion recovery. These newer medications often work well for post-concussive migraine intensification. Acute migraine treatment may be less effective. Triptans and other acute treatments may be less effective during PCS. The combined headache (migraine plus cervicogenic) may not respond fully to migraine-specific treatments. Add cervical PT to acute migraine treatment. Avoid medication overuse headache. The increased headache frequency tempts increased acute medication use. Medication overuse headache (rebound headache) can develop, worsening the situation. Limit acute medications to 2-3 days per week maximum. Sub-symptom aerobic exercise helps both conditions. The Buffalo Concussion Treadmill Test exercise protocol benefits both PCS and migraine. Aerobic exercise is well-established for migraine prevention. The combined benefit makes this intervention particularly valuable for combined patients. Trigger Identification Becomes More Important Track triggers more carefully. The lowered threshold means triggers that were sub-threshold pre-injury now produce attacks. Track sleep, stress, dietary intake, hormones, weather, and sensory exposures alongside migraine occurrence. Patterns reveal new triggers. Reduce avoidable triggers aggressively. Eliminate avoidable triggers (alcohol, specific foods, irregular sleep, skipping meals) during recovery. The trigger reduction may be greater than pre-injury but produces fewer migraines. The trade-off is worthwhile. Address the new PCS-related triggers. Cervical dysfunction, autonomic dysregulation, and screen sensitivity are new triggers PCS adds. Treating these specifically reduces the trigger load. The cervical work and autonomic regulation work address triggers that medications cannot. Sleep is essential trigger to manage. Disrupted sleep triggers migraine and impairs PCS recovery. Aggressive sleep optimization benefits both conditions substantially. Same bedtime and wake time, dark cool room, no screens before bed. Daily Movement Routine JME 3 Lateral cervical flexion daily addresses the upper trapezius tension that triggers both cervicogenic headache and migraine. The cervical work reduces the trigger load. 8 repetitions per side with 15-second holds. JME 42 Shoulder circles release the postural tension that contributes to headache. 10 repetitions each direction. JME 15 Cervical extension supports cervical health that affects both headache types. 8 repetitions. JME 151 Lateral side bends with breathing combine mobility and the parasympathetic activation that supports both conditions. 8 repetitions per side. Manage combined headaches with simplmobility's mobility programming. The Long-Term Outlook Most patients return toward baseline migraine. As PCS resolves over 8-16 weeks, migraine threshold returns toward pre-injury level. Migraine frequency typically returns to within 30-50% of pre-injury baseline. Most patients see substantial improvement. Some patients experience permanent migraine worsening. A subset of patients experience long-term increase in migraine frequency or severity after concussion. The permanent worsening may require ongoing modified treatment. New treatment options may help. The PCS experience often introduces patients to migraine treatments they had not tried. Some patients end up with better migraine control after PCS recovery than before, because they engaged with treatment more thoroughly. Cervical treatment provides lasting benefit. Many migraine patients have unrecognized cervical contribution to their headaches. PCS treatment that addresses cervical dysfunction often produces lasting migraine improvement even after concussion recovery. The cervical work continues benefiting long-term. Migraine-Specific Lifestyle Modifications During PCS Hydration is more important than usual. Dehydration triggers migraine and worsens PCS. Aggressive hydration (90-120 ounces daily) supports both conditions. Caffeine management. Caffeine can both help and trigger migraine. The combined recovery may require consistent caffeine timing rather than varying intake. Limit to morning only during PCS recovery. Magnesium supplementation. Magnesium supports both PCS recovery and migraine prevention. 300-400 mg elemental magnesium glycinate daily provides benefit for both conditions. B2 (riboflavin) supplementation. Research supports B2 for migraine prevention. 400 mg daily is the typical preventive dose. Generally safe and may benefit during the combined recovery period. CoQ10 supplementation. Research supports CoQ10 for migraine and may support mitochondrial function affected by concussion. 100-300 mg daily. The dual benefit makes this worth considering. Will my migraines return to baseline frequency? For most patients, yes, with appropriate combined treatment over 8-16 weeks. Some patients retain modest persistent worsening. Many patients with previously undertreated migraine actually achieve better control through the comprehensive treatment that PCS recovery introduces. Should I start CGRP medications because of post-concussion migraine increase? If your migraine frequency increases substantially and previous prevention is insufficient, CGRP medications are reasonable. They do not interfere with concussion recovery and provide effective migraine prevention. Discuss with your headache provider. Can I take my migraine acute medications during PCS? Yes, in moderation. Triptans and other acute migraine medications continue working during PCS. Limit to 2-3 days per week to avoid medication overuse headache. Address the cervicogenic component with PT to reduce overall acute medication need. References Patricios, J. S., et al. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport, Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695-711. PubMed Silverberg, N. D., et al. (2020). Management of concussion and mild traumatic brain injury: a synthesis of practice guidelines. Archives of Physical Medicine and Rehabilitation, 101(2), 382-393. PubMed