Headache: Why Look beyond the Neck?

Let’s look at one of the more common contributing areas of headache - the neck.

Headaches can be a real pain in the neck, that is literally, they can also be associated with neck pain. 

There are several different types of headaches with different causes, and it is well accepted in clinical settings as well as in research findings that the neck can either cause or contribute to the pain of headache. But if structures like tight muscles and stiff joints in the neck can contribute to headaches, why can’t similar structures further away from the neck, such as in the shoulders or thoracic spine, contribute to headaches? And how can this be explained if it is possible?

In our experience at NWPG, more remote regions can contribute to headaches, and we have examples of clients that have had significant improvement in frequency, duration and intensity of their headaches when other remote contributors have been found and treated.

But first, let’s look at one of the more common contributing areas of headache, the neck. Understanding the contribution of the neck will open the door to understanding how remote areas can contribute to headaches.

Cervicogenic Headaches

Cervicogenic headache is a type of headache with distinct signs and symptoms that has been classified by the International Headache Society, an organisation that researches and classifies all types of headaches.

Headaches are generally classified as Primary or Secondary. Primary headaches occur without an identifiable source within the body or CNS(Central Nervous System). Examples are migraine, tension and cluster headaches.

Secondary headaches arise from an identifiable source, such as the eyes, sinuses or neck, or potentially other musculoskeletal regions.

Cervicogenic headache (CGH) is a secondary headache, and research shows that it makes up for 15-20% of all chronic and recurrent  headaches. (1)

The good news for sufferers of CGH is that there is scientific evidence that it can be treated effectively once it is recognised and diagnosed (2).

How do I know if I have Cervicogenic Headache?

CGH is defined as pain that occurs in the neck or occipital (back of head) region but may spread forward to the side or front of the head. It is generally aggravated by neck movements or sustained neck postures, eg sitting at a computer or driving.

You may also experience one or more of the following characteristics:

  1. The pain is generally dull and not throbbing or piercing.
  2. It is generally one sided but you may also experience shoulder pain on the same side.
  3. May be eased by massage or external pressure over the neck.
  4. There may be a history of trauma to the head or neck/shoulder from a fall or car accident.
  5. You may be able to feel tension/tightness in the muscles at top or bottom of the neck, and there may be “lumps” in the muscles that may be tender to touch
  6. You may notice stiffness or even pain when you turn your head to one side.
  7. CGH is more common in females. 

What Causes CGH?

The pain of CGH is thought to be of somatic origin, ie arising from joint capsules, ligaments or muscles in the neck, especially the upper cervical segments C1-3. These structures are innervated by sensory nerves that detect excessive load or inflammation. When these nerves are stimulated, impulses are sent to the brain (noxious input) where these signals are processed. If these signals (noxious input) exceed a safe threshold, then the brain perceives there is a problem, ie it cannot maintain balance in the body. It then sends an output signal to our conscious awareness that there is a problem and we need to address the underlying cause. The pain of a headache is an output signal from the brain that the body is out of balance.

So why do these structures become irritated?

Well it is usually as a result of joint stiffness or muscle tension developing, ie dysfunction.  Why does this occur? This is a slightly more difficult question to answer, as there may be several factors involved. One of the main factors is poor neck and back posture, which may be accentuated in sitting, especially at a poor workstation . There may also be muscle imbalances or weaknesses in the upper body that may lead to neck pain and headaches, such as weakness in shoulder blade retractors , elevators or deep neck flexors. Finally there may be degenerative changes in the facet joints or discs of the neck which can cause inflammation and hence irritation of sensory nerves.

Dysfunction in the upper cervical segments may give rise to neck pain, but could also give rise to pain in the back, side or front of head. Pain can even be transferred to the eye socket, jaw or temple region. Pain that originates in one part of the body, in this case the upper cervical segments, but is felt in other regions is called Referred Pain. The headache pain of CGH is a type of referred pain, and usually originates in the cervical segments C1-3. This region of the neck has nerve connections with nerves that supply the head and face (Trigeminal Nerve) and so the brain can misperceive the origin of this pain, ie the brain sends the signal to us that the pain is in the head when it is actually originating from the neck. This is similar to Sciatic pain, which is leg pain referred from the lumbar spine (low back) usually secondary to disc bulge or prolapse.

There are characteristic referral patterns that relate to the specific segments that pain is arising from in CGH. 

O- C1: a band of pain around the head much like head band/sweat band.
C1-2: an arc of pain over the head between each ear.
C2-3:  pain radiating for the back of head/occiput into the eye/orbital region.  

So if you have pain in any of these areas, there is a good chance that you may have Cervicogenic Headache.

Can Other Areas of the Body Contribute to Headaches?

From our experience the answer to this question is a resounding “YES”!

There is a growing body of evidence (4,5) that suggests “seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint. “

This is called the Regional Interdependence Model of musculoskeletal dysfunction. Put simply, it is the theory that the body is interconnected, and impairments or dysfunctions in one region can influence other anatomically remote regions.

We have a few case studies on clients who have had significant remote contributors to their headaches. Finding and treating these made a big difference to their headaches.

How can remote dysfunctions contribute to headaches?

If we consider that all dysfunctions in the body( tight muscles, joints that are stiff, nerves that do not glide, altered movement patterns, etc), are detected as noxious input by the brain. When the total level of all these inputs exceeds a safe level, then the brain may perceive there is a problem and create a warning to signal to the individual. This warning signal may be in the form of a headache.
This is called the Accumulative Strain theory of Musculoskeletal Health.

So what do I do if I think I have CGH, or suspect other areas may be contributing to my headaches?

The good news is that there is scientific evidence that CGH can be treated effectively with Physiotherapy (2, 3). Research has shown that cervical manipulation and specific exercise can reduce the frequency, severity and duration of CGH when compared to placebo treatments (sham treatments), and that these results are maintained at 1 year follow up.

Determining if remote areas are contributing to your headaches requires a systematic whole body problem solving approach, called Ridgway Method. This is a method we practice at NWPG. It is important with this approach to assess a good objective measure of upper cervical dysfunction to determine if other areas of the body are contributing to headaches. The cervical flexion/rotation test has been shown to be a valid measure of musculoskeletal contribution to a headache (1). This means, if this test is restricted in a headache sufferer, and we can change it by treatment to dysfunctional areas of the body, those areas may be contributing to the headache symptoms.

Physiotherapy may also have a role in the treatment of other types of headache, such as tension headaches or migraines, as these headaches may have a cervical or remote musculoskeletal component, ie neck, spinal or other dysfunctions may contribute to pain inputs to the brain which can make you more susceptible to headache.

So if you think you may have CGH, or other areas in your body that may be contributing to your headaches, book in for an assessment at Northwest Physiotherapy Group

The initial consultation (1hr) includes a comprehensive assessment of cervical and spinal posture, range of movements, muscle strength and imbalance tests, nerve tests and passive spinal segmental mobility tests to determine the cause of your headaches and any possible musculoskeletal factors that may contribute to them. We will treat all associated dysfunctional areas to restore balance to your musculoskeletal system.

Simply call our rooms on 9370 5654 to book your appointment, or send us a request through our website.


  1. T. Hall*, K. Robinson(2004): The flexion–rotation test and active cervical mobility comparative measurement study in cervicogenic headache. Manual Therapy 9 (2004) 197–202
  2. Gert Bronfort, DC, PhD,a Willem J.J. Assendelft, MD, PhD,b Roni Evans, DC, Mitchell Haas, DC,c and Lex Bouter, PhDd (2001). Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review
  3. Journal of Manipulative and Physiological Therapeutics 24:(7)2001.
  4. Niere K, Robinson P (1994): Determination of manipulative Physiotherapy outcome in headache patients.
  5. Manual Therapy 1997: 2(4):199-205.
  6. Wainer RS, Whitman JM, Cleland JA, Flynn TW. Regional Interdependence: A musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther(2007); 37(11): 658-660.
  7. Sueki DG, Cleland JA, Wainner RS(2013): A Regional Interdependence Model of musculoskeletal dysfunction: research, mechanisms and clinical implications. J Man Manip Ther 21(2):90-102
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