Could Undiagnosed Structural Anomalies Be a Hidden Cause of Migraines?

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Migraines have been documented throughout history—long before modern diagnostic tools or pharmaceutical treatments were available. From ancient Mesopotamian texts to descriptions by Hippocrates, these debilitating episodes have persisted across cultures and centuries. While DNA supports modern medicine has made significant strides in understanding the biochemical and neurological underpinnings of migraines, one question still lingers: could some migraines actually be caused by undiagnosed structural abnormalities?

The Craniocervical Junction: A Critical but Overlooked Region

One area of growing interest is the craniocervical junction (CCJ)—the anatomical interface between the skull and the upper cervical spine. This region includes the foramen magnum (the large opening at the base of the skull), and the first cervical vertebra (C1 or atlas), which supports the skull and plays a pivotal role in head movement and vascular flow.

Subtle congenital anomalies in this region—such as an incomplete posterior arch of the atlas, hypoplasia (underdevelopment) of the C1 vertebra, or misalignment between the skull and cervical spine—may be more common than we think. These abnormalities can go undetected on standard MRI scans, especially since imaging is typically performed with the head in a neutral position.

However, certain head movements, particularly neck extension or rotation, could temporarily compress critical vascular structures such as the vertebral arteries or internal jugular veins, both of which are essential for maintaining proper blood flow to and from the brain. Intermittent vascular insufficiency in these areas could explain symptoms often seen during migraines—especially those involving visual disturbances, ocular motor issues, dizziness, or even transient numbness.

A Hypothesis: Mechanical Triggers and Migraines

When a person tilts their head backward—during activities like looking up, stretching, or even certain sleeping positions—it’s plausible that dynamic compression of the vertebral arteries or jugular veins occurs, particularly if there's an unrecognized anatomical irregularity. This could momentarily restrict blood flow to the brainstem or cerebellum, regions involved in pain processing, autonomic regulation, and eye movement control—all commonly affected in migraine episodes.

This raises a provocative question: Are we missing a mechanical component in certain migraine sufferers?

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Why Standard Imaging May Not Be Enough

Traditional MRIs provide a static snapshot of the brain and cervical spine, typically with the head in a neutral position. But if symptoms are triggered or exacerbated by motion, dynamic or positional imaging might be necessary to reveal transient compressions or misalignments that would otherwise remain invisible.

Emerging imaging techniques—such as flexion-extension MRI, upright MRI, or CT angiography performed during head movement—may help uncover structural abnormalities that standard scans often miss. These advanced methods have already shown value in diagnosing hard-to-detect conditions like spinal instability and Chiari malformations—one of which I’ve inherited genetically—and could offer important insights for a subset of migraine sufferers.

A Modern Treatment Meets an Ancient Condition

Recent pharmacological advances, such as Atogepant—a CGRP receptor antagonist—offer effective symptom control for many migraine sufferers. Yet, it’s worth noting that migraines long predate the era of neurochemistry and receptor-blocking drugs. If migraines have been part of the human condition for millennia, perhaps some cases originate not in neurochemical imbalances alone, but in mechanical disruptions that modern imaging often overlooks.

This isn't to say that structural causes account for all migraines—clearly, they don’t. But for a subset of patients, especially those whose symptoms are posture-dependent, motion-triggered, or unresponsive to conventional treatments, it may be time to expand our diagnostic lens.

The Path Forward: A Multidisciplinary Approach

Understanding migraines as potentially multifactorial—including biochemical, neurological, and biomechanical components—could open new avenues for diagnosis and treatment. Collaboration between neurologists, radiologists, spine specialists, and vascular surgeons may be key to identifying these hidden anomalies.

In sum, while medications like Atogepant represent a breakthrough in symptom management, we shouldn’t overlook the possibility that structural anomalies at the craniocervical junction could be contributing to migraines in certain patients. Exploring this hypothesis further—with motion-specific imaging and careful anatomical evaluation—could provide answers for those still searching for relief from this ancient and complex condition.

Further questions to explore:

  • Should flexion-extension MRI become routine in treatment-resistant migraine cases?

  • How common are congenital anomalies of the atlas in the general population?

  • Could postural therapy or targeted cervical interventions offer relief in structurally linked migraines?

The connection between form and function in the human body is intricate. Perhaps, for some migraine sufferers, the key to healing lies not just in neurotransmitters—but in the bones and vessels just beneath the skull.

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© 2000-2025 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742

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