Updated: Jul 8
Cervicogenic Headache Causes
Take a look at this image courtesy of ccsbismarck.com which shows the pain map for cervicogenic headaches. If you suffer from headaches in these areas, then you are in the right place. I am going to discuss the causes and symptoms of these headaches and give you some ideas on how to get rid of your pain. Headaches can be frustrating and confusing, so let’s get right to the information!
One of the most important regions to understand with cervicogenic headaches is the suboccipital area. I have discussed this area before in my blog post about upper neck stiffness. A quick review is beneficial. There are four muscles on either side of your neck, making eight total suboccipital muscles. These run from the base of your skull to the first and second vertebrae along the back of your neck. If you place your fingers right along the base of your skull and provide some pressure, you are probably making contact with the muscles.
Another important structure to understand are the occipital nerves. They are pictured below courtesy of migraineurmagazine.com
These occipital nerves emerge from your suboccipital area and go over your head to your eyes. This is why the first image shows pain from cervicogenic headaches following this pathway and ending at the eyes. Tightness of the suboccipital muscles can compress the occipital nerves, causing pain anywhere along their pathway.
Another important anatomical consideration in this region are the first and second cervical vertebrae. They have a unique shape that optimizes for motion. In fact, these two vertebrae are responsible for approximately 50% of your rotation when turning your head. If you fused all of your cervical vertebrae except the top two, you would be able to turn your head about 45 degrees. Because these vertebrae are designed to be mobile, any restrictions can cause significant issues in the region. Joint restrictions can lead to compression of the occipital nerves as well. Pictured below courtesy of spineuniverse.com are the first and second cervical vertebrae, notice how little bony support they provide to allow for increased mobility.
The cause of tightness or restrictions in the suboccipital region can vary significantly. Sleeping in an unfamiliar position or turning your head too quickly can cause muscular spasms. Posture can also play some role, as a forward head position can create tightness and compression in the upper cervical region. Other factors such as stress play a role in these conditions as well.
Cervicogenic Headache Symptoms
The exact cause of a headache can be difficult to determine as many can be caused by hormones or other non musculoskeletal factors. However, there are several typical signs that point to a cervicogenic headache. These headaches are normally only on one side of your head. If there is muscular tightness, it can be on both sides, but more often it is only on one side. As mentioned before, the pain typically follows a “ram’s horn” pattern going around the top of your head. Symptoms are typically worst at the base of the skull or at the eyes.
Because there is musculoskeletal involvement, movement should impact the pain. If your pain is typically worse with sitting, it could be from postural stress on the back of your neck. Also, if you feel more pain when turning to one side, it could be due to joint or muscular restrictions. Finally, you should feel pain when pressing at the base of your skull. If pressing in that region makes your pain significantly better or worse, then your pain is probably based in that region.
Cervicogenic Headache Diagnosis
Diagnosing a cervicogenic headache can be difficult as exact causes of headaches are difficult to determine. However, there are a few practical tests that can determine if the suboccipital region is the cause. The first is palpating or pressing on the base of your skull. A medical provider should be able to identify the suboccipital muscles and provide greater clarity if they are the cause of your symptoms.
The flexion rotation test is a simple measure to look at range of motion and pain while comparing one side of the neck to the other. It is pictured below courtesy of sciencedirect.com
The patient should fully relax and let the examiner control their head. The examiner will flex the head as far forward as it can go and then turn it to one side and the other. You are looking for significant differences in range of motion as well as provocation of pain. The reason that this test is beneficial is that the flexion of the neck locks the lower cervical spine and prevents it from rotating. Any rotation is from the upper cervical spine, so about 45 degrees is expected. This should isolate the area that we are trying to test and provide accurate results about potential causes of a cervicogenic headache.
Another simple test is the chin tuck and lift test. This is performed as pictured below courtesy of summitortho.com
Research by Harris, et al. showed that individuals with no neck pain averaged 39 seconds in this position, while those with neck pain averaged only 24 seconds. This test is examining your deep neck flexor muscles and their endurance. These muscles work opposite your suboccipital muscles, so theoretically if they are stronger then the suboccipital muscles will have less tension. This test is performed by tucking your chin and lifting your head approximately one inch off of the ground. Most people tend to lift their head up too much or engage their superficial neck muscles. You should feel fatigue deep in the front of your neck.
The final way to diagnose cervicogenic headaches is to treat it and see if the condition improves. There should be no harm in mobilizing and exercising this area so the worst consequence is a waste of time and a slightly more mobile neck. Unfortunately, this may be the easiest path to ascertain the true cause of the headache.
Is There a Cervicogenic Headache Pillow I Can Just Use?
This is a question I hear more than any other. The answer is no, there is no best pillow for your neck. My boring answer is to try different pillows in your house to see if one is more comfortable and use it. In general, if you sleep on your back you want a thinner pillow to allow for a more neutral neck position. Sleeping on your side should benefit from a thicker pillow to keep your head and neck in line. However, I see people who use all kinds of pillows and there is no compelling research about what is best.
Cervicogenic Headache Treatment
Treatment for cervicogenic headaches should begin with physical therapy as soon as possible. A study by Jull, et al. showed that a combination of manual therapy and exercises was 10% more effective than either one individually. Manual therapy is an excellent starting point to provide relaxation of the suboccipital muscles through soft tissue mobilization. This can be performed statically by simply holding your fingers at the base of the skull to desensitize the muscles. A lacrosse ball or similar tool can be used at home to replicate this depending on your comfort. Joint mobilizations can also be effective to decrease guarding and allow for increased mobility of the upper cervical vertebrae. Trigger point dry needling is particularly effective to decrease muscle guarding and allow for a faster return to full range of motion.
In some cases, steroid injections can be utilized to decrease inflammation in the area. These may be more common in patients suffering chronic headaches or those who saw no benefit from physical therapy. The injection should provide a temporary decrease in swelling, allowing physical therapy to proceed.
Cervicogenic Headache Exercises
The first exercise is a simple chin tuck as shown here courtesy of thestudentphysicaltherapist.com
The key is to keep your neck as relaxed as possible and only engage the deep neck flexors. You should not see the big muscles in the front of the neck engage and you should not feel an excessive strain. A stretch in the suboccipital region is a normal sensation and a sign that you are performing the exercise correctly. This provides light strengthening of the deep neck flexors while also stretching the suboccipital muscles.
Another great exercise is cervical retractions, shown here courtesy of alliancewellness.ca
The key to this exercise is to gently push your head backwards without looking up. Focus on a specific point in front of you and keep your gaze level. You can also put your hand on your chin to prevent yourself from looking up. You should feel some stretch in the suboccipital region with this movement.
The next exercise is the chin tuck and lift test that I showed before, but used for strengthening purposes. A good chin tuck is required before progressing to this, as there will be further stress on the deep neck flexor muscles. As I mentioned before, most people will bring their head too far into the air and use the superficial muscles on their neck. Start by only holding this for 5-10 seconds with significant rest periods.
The final exercise is a cervical retraction and rotation. You will push your head back as you did with the cervical retraction and then turn to one side and then the other. This puts further stretch on the joints on each side. You should not have significant rotation with a full retraction, so only turn as far as your body will allow.
Hopefully this information on cervicogenic headaches is beneficial to you. As I mentioned before, headaches are one of the most difficult conditions to treat because it can be difficult to figure out what is causing the headache, let alone treat it. Fortunately, conservative care with physical therapy can provide good results for cervicogenic headaches using the strategies I mentioned along with others.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about cervicogenic headaches and their symptoms and treatment. If you have interest in other neck injuries, check out our neck page. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you want to subscribe so that you don’t miss any other posts, click the sign in button on the top right of this page. Once you have created an account, click the drop-down menu in the top right next to your name and go to your settings page. Click the subscribe button next to “Blog Subscription” and you won’t miss any future posts! If you are in the Sterling, Virginia area and would like to work with me or you have any questions, please email me at firstname.lastname@example.org or follow me on Instagram or Twitter @drdannydpt.