Are your headaches really neck aches?
Cervicogenic headache refers to pain felt in the head that is referred from the neck. This is because nerves that supply the neck (or originate from the neck) also supply sensation the the head, jaw and face. The headache is usually unilateral (only on one side of the head), but in clinical practice we do often see other headache patterns (such as pain on both sides of the head) that can be related to the neck. The key feature of cervicogenic headache is that we can reproduce the headache with some findings related to the neck. Often, palpation of one of the joints or muscles in your neck (but sometimes even your upper back/shoulders, jaw or muscles in your head) will bring on the exact headache you have been experiencing. This shows a relationship between your headache and the symptomatic area of the neck – meaning that your headache will likely respond to treatment of this area. Studies have estimated that cervicogenic headaches account for up to 18% of all headaches. (Although some other studies have reported incidence around 2.2 -4%. In clinical practice, however, we believe this to be much higher based on the presentations we see every day).
Cervicogenic headache should be differentiated from other types of headache. There are over 100 types of headaches described in the literature (although many are very rare). These can include conditions as interestingly named as “thunderclap” headache and orgasm headache (yes these really do exist). The most common are Migraine, Tension-type headache and Cervicogenic headache.
Migraine is a very specific condition (or group of conditions) that is usually a neurological issue. This should not be confused with a “bad headache” that people will often refer to as a migraine. Migraine is usually diagnosed by a GP or neurologist, and can be well managed with a team approach and appropriate medication.
Tension type headache is a primary headache, usually of unknown cause that causes tightness/tension feelings around the head. In clinical practice, we often see patients who have been diagnosed with “tension-type” headaches who have many clinical signs of neck involvement and postural involvement
In reality, there is often a great overlap between the different types of headache and their symptoms and contributing factors. Studies have shown that over 50% of migraine sufferers had signs of neck dysfunction, and neck pain was often a contributing factor to their migraine. Similarly, Tension-type headache sufferers often have significant postural issues and neck issues that contribute to their symptoms. Because of this, people who suffer with migraines or tension type headaches will often benefit from physiotherapy treatment to address these contributing issues. At the very least we can reduce the severity of the headache symptoms.
I personally believe that many sufferers of “tension-type” headaches also have a strong postural component, myofascial (muscle) component or are in fact suffering from cervicogenic headaches and have been mis-diagnosed. Tension-type headache appears to be the “go-to” diagnosis when no serious pathologies are found by GPs, but further assessment often indicates these other contributing factors play a part. This can unfortunately lead to ongoing pain and disability as the underlying causes have not been properly identified, so the proper treatment has not been provided.
On a side note, those with TMJ (jaw) pain or those who grind their teeth will also often complain of neck pain and headaches. This is also very treatable with physiotherapy management.
Management of cervicogenic headache is usually quite straightforward once the underlying causes have been identified. Your physiotherapist will perform a thorough assessment of your neck and upper back, including: movement, posture, palpation, functional testing, strength testing and specific pain provocation tests to identify where exactly your headaches are coming from and what is causing them. If we suspect that the cause of your headaches is not appropriate for physiotherapy treatment (such as Migraine without cervicogenic component) we will refer you onto the appropriate medical professional to get this further investigated.
Treatment usually involved addressing the underlying issues (often postural) and restoring the structural and musculoskeletal function of the neck and upper back. This will often involve specific manual therapy treatments (when the physio will use their hands, or other appropriate tools, to perform safe and appropriate treatment techniques), soft tissue techniques and exercises. For example, If you are getting headaches due to referred pain from a stiff C2/3 facet joint (a joint in your upper neck) – treatment to restore the movement and reduce irritation of that joint will also resolve your headaches. Now if that joint was getting stiff/irritated because your posture at the computer all day is poorly managed, then providing postural exercises and retraining would also be required to stop the headaches coming back. Simple really.
Take Home Messages:
- Headaches can often be caused by issues with the neck, upper back and posture.
- Other types of headaches can often have a cervicogenic component (be related to the neck) so treatment of the neck will often help to manage the headaches.
- Cervicogenic headaches are easily manageable with appropriate physiotherapy treatment, which will involve treating the symptoms as well as the underlying causes.
As always if you have any queries regarding this or any other issue you may have, please do not hesitate to contact us. We are always happy to hear form you.
Julian BowenJulian is the Director of Parmelia Physiotherapy. He has spent over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 35,000 individual treatments in that time. He has worked with everyone from paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues. He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues and exercise rehabilitation for the prevention and treatment of injuries. Julian is available for expert review or second opinion assessment by prior arrangement. He currently manages and mentors at five physiotherapy clinics across Perth.
Bogduk N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther. 1992;15:67-70
Blau JN, MacGregor EA. Migraine and the neck. Headache. 1994;34:88-90
Kaniecki RG. Migraine and tension-type headache: an assessment of challenges in diagnosis. Neurology. 2002;58 (9 Suppl 16):S15-S20
Marcus D, Scharff L, Mercer MA, Turk DC. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups.Headache. 1999;39:21-27
Biondi D., cervicogenic headache: a review of a diagnostic process and treatment strategies, JAOA, 2005
Becker WJ. Cervicogenic Headache: Evidence that the neck is a pain generator. Headache. 2010;4 699-705
Haldeman S. Dagenais S. Choosing a treatment for cervicogenic headache: when? what? how much?. The Spine journal 2010;10 169-171
*This post originally appeared on the South Perth Physiotherapy blog page.