The International Headache Society (IHS 2013) has validated cervicogenic headache as a secondary headache, which means headache caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.

Diagnostic criteria:
A. Any headache fulfilling criterion C
B. Clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck, known to be able to cause headache
C. Evidence of causation demonstrated by at least two of the following:
1. headache has developed in temporal relation to the onset of the cervical disorder or appearance of the lesion
2. headache has significantly improved or resolved in parallel with improvement in or resolution of the cervical disorder or lesion
3. cervical range of motion is reduced and headache is made significantly worse by provocative manœuvres
4. headache is abolished following diagnostic blockade of a cervical structure or its nerve supply
D. Not better accounted for by another ICHD-3 diagnosis.

It is a chronic headache that arises from the atlanto-occipital and upper cervical joints and perceived in one or more regions of the head and/or face. These occur due to a neck disorder or lesion and feature the converging of trigeminal and cervical afferents in the trigeminocervical nucleus within the upper cervical spinal cord. By definition the headache should be abolished following a diagnostic blockade of a cervical structure or its nerve supply.

Figure 1: Cervicogenic Headache Figure 2: Upper Cervical Spine

Cervicogenic Headache

Cervicogenic Headache

Figure 1

Upper Cervical Spine

Upper Cervical Spine

Figure 2



Clinical Presentation

Challenging to diagnose clinically, but often includes:
· Unilateral “ram’s horn” or unilateral dominant headache (Excluding those with bilateral headache or symptoms that typify migrane headaches).
· Exacerbated by neck movement or posture
· Tenderness of the upper 3 cervical spine joints
· Association with neck pain or dysfunction
· Definitive diagnosis made through selective nerve blocking through injection of specific sites
· Compared to migraine headache and control groups, cervicogenic headache group patients tend to have increased tightness and trigger points in upper trapezius, levator scapulae, scales and suboccipital extensors, splenius capitis and sternocleidomastoideus
· Weakness in the deep neck flexors
· Increased activity in the superficial flexors
· Atrophy in the suboccipital extensors and so the deep muscle sleeve which is important for active support of the cervical segments becomes impaired
· upper trapezius, sternocleidomastoid, scalenes, levator scapulae, pectoralis major and minor, and short sub-occipital extensors have been implicated
– Trigger points have been reported to be present in patients with tension type headache, migraine, and cluster headache. In addition, active TrPs have been also related to neck pain, a common symptom experienced by individuals with cervicogenic headaches.

It is also important to differentiate from other types of headache:

Type Location Intensity Frequency Duration Additional Symptoms
Cluster Unilateral: (orbital, supraorbital, temporal) Severe 1x every other day -> 8x day 15-180 minutes Associated with ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, eyelid edema.

Restlessness or agitation.

Tension Bilateral Mild-Moderate >15day/mo, >3 mo Hours-continuous Pressing, tightening

<1 of photophobia, phonophobia or mild nausea

Migraine without aura Unilateral: Frontotemporal in adults, Occipital in children Moderate-Severe >14 days/month 4-72 hours Flickering lights/spots in vision, pulsating quality, nausea, photophobia, phonophobia
Cluster Tension Migrane


Physical Therapy Management

The preferred practice pattern for cervicogenic headache is 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System-Acquired in Adolescence or Adulthood. Goodman states that “Although this type of headache is responsive to therapy oriented at treating the soft tissue restrictions, the method of examination, assessment, and treatment needs to be specific to the neck and occiput.”


  • Cervical spine manipulation or mobilization
  • Strengthening exercises
    • Deep neck flexors
    • Upper quarter muscles
  • Thoracic spine thrust manipulation & exercise
  • C1-C2 Self-sustained Natural Apophyseal Glide (SNAG)
    • shown to be effective for reducing cervicogenic headache symptoms

Jull et al reported that a six week physiotherapy program including manual therapy and exercise interventions was an effective treatment option for reduction of cervicogenic headache symptoms and decreasing medication intake in both the short term and at one-year follow-up.

Other Treatment Options

Thoracic Manipulation

Seated CT Manipulation Seated Mid Thoracic Manipulation