Is Your Headache A Pain In The Neck?

February 22, 2018 6:29 pm Published by

Most of us have experienced a bad headache once in a while. The majority of the time, the headache will resolve independently. However, a persistent headache can be mood altering, frustrating and energy draining.   

Some common sources for a headache may include:

  • concussion – from a trauma, fall or motor vehicle accident
  • migraines
  • consuming too much alcohol
  • weather – barometric pressure changes
  • tension type – from tight and shortened muscles in the neck or scalp
  • dysfunction in the vestibular system
  • increased stress, lack of sleep

But what about a cervicogenic headache? You’re probably wondering what this even means. There are different classifications of headaches. Primary headaches are migraines without aura and tension-type headaches. The International Headache Society (IHS) has defined cervicogenic headache as a secondary headache. It’s usually caused by a dysfunction of the cervical spine. This may include the bony cervical vertebra, the disc, the ligaments, soft tissue and nerves.   

As Physiotherapists, we are often trying to determine if headaches are tension-type headaches, cervicogenic or migraines without an aura. Often, differentiating between these 3 types of headaches can be challenging as the symptoms can overlap. However, it’s important to properly diagnose the source of the headache in order to provide appropriate treatment.   

The upper cervical spine (C0-C2, C2-4), aka craniovertebral region, can be overlooked as a source for headaches. The nerves at C2-3 directly supply the back of the head and the spinal nucleus of the trigeminal nerve which extends through the medulla to the upper 3 levels of the cervical spine and converge with sensory fibres of the upper cervical nerve roots. The trigeminal nerve supplies sensation to the jaw, cheek and temporal/eye areas. Ligaments, discs, joints and muscles that are supplied by these nerves can all be a source of a cervicogenic headache.   

Features of cervicogenic headaches are:

  • varying duration, episodic, fluctuates
  • usually unilateral or side locked
  • neck stiffness (decreased range of motion) and neck pain, can start in the neck and refers to the back of head and temporal area
  • associated with shoulder and arm pain
  • moderate to severe aching pain, non-pulsating
  • aggravated by neck positions and neck motions
  • often a history of trauma
  • yields a positive response to diagnostic blocks

Other features may include:

  • dizziness
  • unsteady or off balance
  • facial pain
  • nausea

Migraines without an aura are often associated with nausea or vomiting, light and noise sensitivity, moderate to severe pain, have a pulsating quality, aggravated by physical activity, usually unilateral, lasting 4 – 72 hrs and respond to migraine medication.   

Tension-type headaches are more chronic, bilateral tenderness over jaw and neck muscles, mild to moderate pain, tightening sensation, no nausea or vomiting, not aggravated by physical activity, lasting 30 mins to 7 days. Light and noise sensitivity may be present. Tenderness on palpation is often noted over the temporal and frontal areas of the head, in the upper trapezius muscles, in the jaw and anterior neck muscles and can increase the pain intensity of the headache.  

Assessment of the cervical spine as a source for headaches starts with a cervical scan exam which includes peripheral nerve testing, ligament stability testing and vascular screening. This is then followed by a detailed biomechanical exam of the whole cervical spine/thoracic spine with focus on the upper areas – craniovertebral (C0-C2) region and C2-4.   

Assessing posture, ROM, segmental mobility tests and muscle recruitment and patterning will provide information to rule in the neck as a source for the headache. Testing somatosensory function is also important in determining a cervicogenic source.

A thorough assessment of the muscle system around the neck is important for guiding treatment. There are two major groups of muscles that support the neck, upper thoracic spine and shoulder girdle – the prime movers and the joint stabilizers. Both groups of muscles need to have adequate strength and control in order to move the joints properly.  If there is an imbalance between these two groups, compensation and dysfunction will be present.   

Contributing factors to a cervicogenic headache are:

  • cervical spine joint restrictions
  • poor posture – slouching, forward head postures
  • muscle imbalance – overuse of larger primer movers and weak neck stability muscles
  • poor thoracic spine mobility
  • ligament instabilities or hypermobilities
  • poor shoulder joint alignment
  • weak scapular stability muscle strength
  • poor proprioception – the inability to detect where the neck is in space relative to the body
  • degenerative changes in the cervical spine (i.e. arthritis)

Many of these factors can be improved and corrected but it can be a slow process. However, the majority of people will see some noticeable improvement with treatment. Objective findings used to measure, change or improve include pain scale/pain intensity, muscle length tension, cervical range of motion, tenderness on palpation of trigger points, joint mobility/restriction, postural alignment to neutral, ability to perform functional day to day activities, as well as leisure activities and muscle strength testing.

Treatment for cervicogenic headaches include:

  • Manual Therapy – hands on joint mobilizations and manipulations
  • soft tissue techniques, myofascial release techniques
  • somatosensory retraining – proprioception and kinaesthetic awareness, eye movement control retraining, balance retraining
  • modalities – Dry Needling, heat, electrical current
  • muscle recruitment, down-training and strengthening
  • home exercise programs to maintain treatment gains and prevent future flare ups
  • education and pain management and prevention strategies

As a society, there are more individuals now who sit and stare at a computer screen longer than we ever have historically. Our usage of handheld electronic devices has risen significantly over the last decade. As much as we can have the best ergonomic set up, our bodies are not designed to be static for hours at at time. We are designed to move and our bodies like movement. Each joint in our bodies should be moved into full range of motion at some point throughout the day. Prolonged static postures will eventually lead to shortened, weak muscles which will in turn lead to pain and dysfunction.   

Improving muscle endurance and changing poor muscle recruitment patterns will require effort and daily hard work. But if you have a plan and work hard at making some small changes over time, the severity of your cervicogenic headaches will significantly improve.  As Physiotherapists, we have many treatment options that can help to alleviate cervicogenic headache pain. We are here to help – give us a call to get rid of the pain in your neck!  


Written by Joyce Lang

Registered Physiotherapist

FCAMPT, CAFCI, Gunn IMS certified

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