Cervicogenic headache: the headache that comes from your neck

A cervicogenic headache is head pain referred from structures in the upper neck, usually the joints, discs, muscles or ligaments of the top three cervical segments. It is usually one-sided, and it stays on that side. It starts at the base of the skull and spreads forward towards the temple or behind the eye. It is set off by neck movement or by holding one position, rather than by light, noise or food. It is often mislabelled as migraine or tension headache.

I am Dr Alex Freeman (chiropractor) and I practise in Victoria Park, Perth. Headache is one of the most common things I see. And there is a pattern I see over and over. Someone has been managing what they were told is migraine, sometimes for years. Their headaches reliably start in the neck. Nobody has ever examined their upper neck.

How a neck problem becomes head pain

This is the mechanism, and it is genuinely elegant.

The nerves from the top three segments of your neck share a junction in the brainstem with the trigeminal nerve. The trigeminal nerve is the one that supplies sensation to your face and forehead. That shared junction has a name, the trigeminocervical nucleus, but the name matters less than what it does.

Because those signals arrive at the same place, your brain cannot always tell which one is which. So irritation from a joint at the top of your neck gets felt as pain in your forehead, your temple, or behind your eye.

The problem is at the top of your neck. The pain is in your head. Both are true at once.

That convergence is also why the picture overlaps so heavily with migraine, and why the two get confused.

How to tell it apart

No single feature is definitive, but the pattern is usually recognisable.

Points towards cervicogenic headache

• One-sided, and it stays on the same side from episode to episode rather than swapping

• Starts at the base of the skull or the upper neck and spreads forward

• Provoked or worsened by neck movement, or by holding one position such as a desk, a car or a phone

• Reduced neck range of motion, particularly rotation

• Tenderness on the upper cervical joints on the painful side

• Often associated with shoulder or arm discomfort on the same side

• Usually a moderate, non-throbbing ache rather than a pounding pain

Points towards migraine instead

• Throbbing or pulsating quality, often moderate to severe

• Nausea or vomiting

• Genuine sensitivity to light and sound

• Visual aura or other neurological symptoms before onset

• Side can vary between attacks

• Worse with routine physical activity

Points towards tension-type headache

• Both sides, often described as a band or pressure

• Mild to moderate, not usually aggravated by ordinary activity

• No nausea, and at most one of light or sound sensitivity

A caution worth stating clearly. Many people have more than one headache type, and neck involvement can coexist with and trigger migraine. Finding a cervical contribution does not mean your migraine diagnosis was wrong. It may simply mean part of the picture has not been addressed.

Why it gets missed

Three reasons, in my experience.

First, people present complaining of headache, so attention goes to the head. The neck often does not hurt much, or the person has had a stiff neck for so long that they no longer register it as abnormal.

Second, there is no blood test or scan that diagnoses it. Imaging of the cervical spine may show degenerative change, but plenty of people with those changes have no headaches at all. The diagnosis comes from the history and a careful physical examination, which takes time.

Third, the first thing that helps often becomes the label. If a migraine medication takes the edge off, the working diagnosis tends to stick.

When a headache needs urgent medical attention

Please do not treat these as something to book in for next week. Get urgent medical assessment if you have:

• A sudden, severe headache that reaches maximum intensity within seconds

• Headache with fever, neck rigidity or a rash

• New neurological symptoms such as weakness, slurred speech, facial droop, double vision or difficulty walking

• Headache following a significant head or neck injury

• A headache pattern that has changed markedly, or a new headache after age 50

• Headache that is consistently worse in the morning, or worse with coughing or straining

These are screened at every new patient examination here, and if any are present my job is to direct you to the right care rather than to treat you.

What I actually examine

A first appointment at Freeman Chiropractic is a consultation and examination rather than treatment. For headache I want to know the side, the pattern, where it starts, what provokes it, what relieves it, what medication you use and how often, and what was going on in your life and your work when it began.

Then the physical examination. I check:

• How far your neck moves, and where in that range the symptoms turn up

• How each joint at the top of your neck is moving individually

• A flexion-rotation test, which loads the top two segments fairly specifically

• Tenderness and tightness through the small muscles at the base of the skull, and through the upper trapezius

• How long your deep neck muscles can hold position before they fatigue

• A neurological screen

I also look at how your head sits over your shoulders, and what your upper back is doing underneath it. A stiff upper back reliably makes the neck work harder.

If the examination reproduces your familiar headache from the neck, that is meaningful information.

Where chiropractic care fits

Chiropractic care may help manage cervicogenic headache, and of the headache types it is the one with the most sensible rationale for manual therapy, because the source is a musculoskeletal structure.

In practice that usually means four things together. Adjusting the restricted joints in your neck and upper back to restore movement. Soft tissue work or dry needling through the tight muscles around them. Strengthening the deep neck muscles and the shoulder blade muscles. And specific advice on desk setup, screen height, pillow choice and how long you sit in one position.

I would rather be honest about expectations than sell you something. Some people notice a change within the first two or three weeks. Others take longer, particularly where the headaches have been present for years. I reassess formally at a progress examination rather than letting care run on the assumption that it is working. What I compare is your neck range of motion, how often the headaches come, how long they last, and how much medication you are using. Not simply how you feel on the day.

What helps in the meantime

Break up sustained postures before the neck complains rather than after. Get your screen to eye height. Be honest about how long you spend looking down at a phone. Check your pillow, because one that is too high or too flat will hold the upper neck at end range all night. And keep an eye on medication use, since frequent use of painkillers can produce medication overuse headache, which then becomes its own problem.

Common questions about cervicogenic headache

How do I know if my headache is coming from my neck?

The usual clues are pain on one consistent side, onset at the base of the skull spreading towards the temple or eye, provocation by neck movement or sustained posture, and reduced neck rotation. A clinical examination that reproduces your familiar headache from the upper cervical joints is the strongest indicator.

Can a chiropractor help with headaches?

Chiropractic care may help manage headaches that have a musculoskeletal or cervical contribution, including cervicogenic headache and some tension-type headache. It is not a treatment for every headache type, and headaches with warning features need medical assessment first.

Is cervicogenic headache the same as a tension headache?

No. Tension-type headache is usually felt on both sides as a band or pressure. Cervicogenic headache is typically one-sided, starts in the neck or base of the skull, and is provoked by neck movement or position. They can coexist.

Can my neck trigger migraines?

Neck pain is very common in people who experience migraine, and cervical structures can contribute to or trigger attacks in some people. Addressing a cervical contribution does not replace migraine management, but it may reduce how often attacks are provoked.

How long does it take to see a change?

This varies. Some people notice a reduction in headache frequency or intensity within the first few weeks, while long-standing headaches usually take longer. Care should be formally reassessed against objective measures rather than continued indefinitely.

Get your neck examined properly

If your headaches start in your neck, or if you have been managing headaches for years without anyone examining your upper cervical spine, that examination is worth having. We are at 249B Albany Highway, Victoria Park, and we see patients from East Victoria Park, Kensington, South Perth, Como, Lathlain, Carlisle, Burswood and Belmont.

Book online or call 0493 290 505. You can also read about headache care in Perth, neck pain, dizziness that comes from the neck, and neck pain that travels into the arm.

This article is general information and is not a substitute for individual assessment. Dr Alex Freeman is a registered chiropractor practising in Victoria Park, Western Australia.