Migraine is a neurological condition that impacts approximately worldwide 15% of the global population and regarded as principal cause of disability (Antonio et al., 2023). Over last 32 years, its incidence is highest in the 10–14 years age group, while both prevalence and DALYs(disability-adjusted life years) begin to rise in 40–44 years age group subsequently arrive at their peak (Dong et al., 2024). Migraine is identified by recurring headaches usually unilateral or bilateral, pulsating in nature, and often presented symptoms like nausea, vomiting, sensitivity to light, and sensitivity to sound (Abo-Elghiet et al., 2025). Moreover, individuals with migraine may experience suboccipital muscle tension which causes neck pain along with neck disabilities, which can progress the condition. In a study examining episodic migraine, 70% of patients reported neck pain prior to the onset of a migraine attack, suggesting that neck pain might serve as a trigger for migraine. Additionally, active trigger points are considered a peripheral source of nociceptive stimuli that aggravate the pain. (Aoyama et al.,2021) The Neck Disability Index (NDI) indicated that 69% of patients with episodic migraine (EM) and 92% of those with chronic migraine (CM) experienced disabilities. (Abo-Elghiet et al., 2025).

Craniosacral therapy (CST) is a well-established approach that involves gentle fascia traction and release, tailored to individual palpation restrictions has also been utilised as a treatment for headaches and migraines (Muñoz-Gómez et al.,2022). CST was developed to release restrictions and regulate the balance of the cranium and the spine using standardized applications. Although, Non-invasive neurostimulation for the treatment of migraine has become popular in recent years which include transcutaneous electrical nerve stimulation of different nerves (tNS) (Evers et al., 2021). Transcutaneous occipital nerve stimulation (tONS), and supraorbital transcutaneous stimulation (STS) are effectively accepted peripheral nerve stimulations for migraine (Cheng et al.,2022).  Top of FormBottom of FormFurthermore, migraine is associated with impaired oxygen utilization and cerebrovascular dysfunction (Singhal et al., 2017). Since 1998, numerous studies have shown that high-flow oxygen therapy (HFOT) is a safe and effective acute treatment for migraines(Çöme et al.,2025). In this context, Diaphragmatic breathing seems to explicate the negative impact of stress on the brain, body muscles, and the rate and depth of breathing (Rahimi et al.,2021).

Need of study

Due to risk ratio of medication of migraine such as chest pain, throat tightness, skin irritations and possible contraindications including heart diseases, hypertension and pregnancy emphasize the requirement for alternative treatment options like neurostimulation therapies, patient education, guided physical activity, and manual techniques. (Abo-Elghiet et al., 2025). Till now, the literature stated the individual effect of transcutaneous nerve stimulation and craniosacral therapy on migraine but there is no study comparing the effectiveness of both treatments along with breathing exercises.

Aim and objectives

1.     To assess the effectiveness of transcutaneous nerve stimulation in comparison to craniosacral therapy combined with breathing exercises on neck pain in migraine patients.

2.     To assess the effect of both treatments on degree of neck disability in migraine.

3.     To compare the impact of both treatments on the frequency and severity of migraine episodes.

4.     To examine the effect of these interventions on the quality of life of migraine patients.

5.     To assess the effectiveness of transcutaneous nerve stimulation and craniosacral therapy on neck range of motion.

6.     To assess the effectiveness of both treatments on sleep quality.

Hypothesis

Alternative hypothesis: There is a remarkable difference in the effectiveness of transcutaneous nerve stimulation (tNS) and craniosacral therapy with breathing exercises in improving musculoskeletal impairments like pain relief, muscle tension reduction, and improvement in cervical mobility among migraine patients.

Null hypothesis: There is no notable difference in the effectiveness of transcutaneous nerve stimulation (tNS) and craniosacral therapy with breathing exercises in improving musculoskeletal impairments in migraine patients, including pain relief, muscle tension reduction, and improvement in cervical mobility.

Methodology

Study design: Experimental comparison study design

Study population: Adult population (18 to 50 years) with symptoms of migraine and neck pain

Source of data collection:  Health centre Guru Nanak Dev University and RG sports rehabilitation and physiotherapy clinic, Amritsar.

Sampling method: Simple random sampling technique

Sample size: 66; calculated by G power 3.1.9.4, with the effect size is 0.4 and power of study is 0.80.

Inclusion criteria

·       Subjects aged 18 to 50 years

·       Both male and females.

·       Meet ICHD 3rd edition criteria for migraine ( Jiang et al., 2023)

·       Headache frequency/month 3-7

·       Subjects with occipital and neck pain

·       Migraine patients with either episodic migraine or chronic migraine

Exclusion criteria

·       Head or neck injury in past 2 years

·       Head or neck implanted device

·       History of head, neck and spine surgery

·       Pregnancy

·       History of medicine overuse headaches

·       Skin lesions in the location of stimulating electrodes

Measurement tools

1.     NPRS(Numeric Pain Rating Scale)                                     

2.     MIDAS(Migraine Disability Assessment) (Araci et al., 2024)                                                                    

3.     NDI(Neck Disability Index)                                            

4.     SF-36(Short Form 36 health survey)                                 

5.     GONIOMETER                                                             

6.     FRT(Flexion Rotation Test)( Anarte-Lazo et al., 2021)

7.     PSQI(Pittsburg Sleep Quality Index)

 Outcomes variables

1.     Age

2.     Height

3.     Weight

4.     Pain

5.     Frequency and intensity of migraine

6.     Quality of life

7.     Neck range of motion

8.     Quality of sleep

·       Pain intensity : NPRS will be used to measure in intensity of neck pain in migraine patients

·       Migraine intensity and frequency: MIDAS is used to assess the frequency and intensity of migraine of episodic attacks

·       Quality of life :  The quality of life affected by migraine epispdes will be assessed by SF-36 health survey questionnaire.

·       Range of motion: The cervical range of motion ( extension, flexion, rotation ) will be examined with goniometer by the process goniometery .

·       Quality of sleep: The sleep quality in migraine patients is to be assessed by PSQI during assessment.

Interventions

The intervention techniques will be applied in a total of 8 sessions, 2 days a week for 6 weeks with session duration of 20 to 30 minutes.

Group 1: Patients will be given electrical stimulation with parameters of symmetrical biphasic waveform, phase width 400 us, pulse frequency 80 Hz for 10 minutes and 2 days a week.

·       Supraorbital nerve stimulation intensity up to 6 mA and electrode placement will be over the forehead just above eyebrows.

·       Occipital nerve stimulation intensity up to 12 mA and electrode placement would be at back of the head near base of skull.

Group 2:

·       Patients will be treated with atlanto-occipital release and cranial base release for 20 minutes with 10 minutes of each.

·        The therapist put 2 thumbs behind the patient’s ears, overlapped the palms, wrapped the patient neck, and slowly and regularly adjusted the frequency of traction and release of fascia.

·       Thoracic breathing will be performed with expansion and contraction of chest rather than the diaphragm along with CST.

Group 3:

·       Patients included will follow the regular drug regimens and conventional physiotherapy treatment which includes neck muscle stretching and ultrasound therapy.

Procedure

Study participants will be recruited on the basis of selection criteria of the study.

All possible procedures, techniques and interventions would be demonstrated to the subjects and a written consent will be taken from the patients.

Demographic data of study participants will be recorded prior to the assessment and treatment sessions

                    For assessment, one subject will be taken at a time.

                         Participants will be recruited into treatment and control groups

Pre-data of the variables (aforementioned) will be collected and interventions will be given to participants

         Post data will be collected after treatment and follow up sessions

Clinical implications

The findings of this study may help to expand the treatment options for migraine as well as enhancing the evidence based practice. These may be incorporated in clinical practice to improve the quality of life of patients with migraine.