Headaches: Types, Symptoms, Causes & Treatment

Headaches have many possible causes, and the neck can be an important part of the picture in some people. Cervical musculoskeletal symptoms and impairments are particularly relevant in cervicogenic headache and are also common in people with migraine and tension-type headache. Identifying whether the neck is contributing to your symptoms can help guide the most appropriate treatment. You've taken paracetamol again. The headache is manageable, but it keeps coming back, two or three times a week, sometimes more. You've been told your scan is normal. No one has mentioned your neck. And yet, every time the headache builds, you notice a tightness at the base of your skull, or a stiffness you've learned to ignore. Headaches are one of the most common health complaints in the world, with a global prevalence of active headache disorders of around 52%. Understanding the type of headache you have, and what, if anything, may be contributing to it, is an important first step towards effective management.

The Types Worth Understanding

Cervicogenic Headache

Cervicogenic headache (CGH) is a secondary headache, meaning it originates from a structural problem in the cervical spine rather than the brain itself. Upper cervical afferents converge with trigeminal afferents in the trigeminocervical complex, which means that pain from the upper neck is perceived as headache. The clinical features that distinguish it include:

• Unilateral pain that does not shift sides, typically starting in the neck or base of skull and radiating forward toward the eye or temple
• Reproduced or worsened by neck movement, sustained postures (such as looking down at a screen), or pressure on the upper cervical spine
• Reduced cervical range of motion, particularly rotation and extension
• History of neck injury, whiplash is a common preceding event
• Mild to moderate intensity; not typically throbbing

The diagnostic criteria from the International Headache Society require clinical or imaging evidence of a cervical disorder and evidence that the headache originates from it. In practice, diagnosis relies on a combination of headache history, symptom behaviour and a targeted cervical examination. Tests such as cervical range of movement and the cervical flexion-rotation test can help determine whether the neck is contributing to the headache pattern.

Tension-Type Headache

Tension-type headache (TTH) is the most prevalent headache type globally, representing around 26% of all diagnosed headaches. It presents as a bilateral, pressing, band-like sensation, not throbbing, not worsened by physical activity, typically mild to moderate in intensity. Many people describe it as a tight cap or vice around the head. People with tension-type headache can also present with neck pain and cervical musculoskeletal impairments, including reduced cervical muscle performance, myofascial tenderness in the pericranial and cervical musculature, and altered pressure pain sensitivity. Research shows that patients with headache have a neck pain incidence 2.5 to 6 times higher than individuals without headache. These findings may be relevant treatment targets in people whose headaches are associated with neck symptoms.

Migraine, and Why the Neck Matters Here Too

Migraine is a neurological disorder, but people with migraine commonly experience musculoskeletal symptoms, including neck pain and cervical impairments. Studies have found neck pain prevalence of over 76% in people with migraine compared to 57% in headache-free individuals. This does not mean physiotherapy treats migraine in the same way it treats cervicogenic headache. Addressing relevant cervical musculoskeletal impairments may be a useful component of migraine management for some people, particularly when neck pain or stiffness is prominent. Physiotherapy is increasingly recognised as a valuable adjunct in migraine management, particularly for those seeking non-pharmacological strategies alongside their existing care.

When the Neck Is Part of the Problem

The anatomical basis for neck-related headache is well established. The upper cervical spine, particularly the joints at C0/C1, C1/C2, and C2/C3, shares neural pathways with the trigeminal nerve, meaning that afferent signals from the neck can be perceived as facial or head pain. This trigemino-cervical convergence is the mechanism behind cervicogenic headache, and it also helps explain why cervical symptoms often co-exist with migraine and tension-type presentations. Dysfunction in the upper cervical spine, whether joint restriction, muscle tension, or reduced deep flexor performance, does not just produce local neck pain. It can refer pain into the head and can sometimes produce symptoms that overlap with other headache presentations. This overlap is one reason accurate headache classification and appropriate clinical assessment are important, rather than assuming any single headache pattern by symptoms alone.

Interestingly, the trigeminal nerve doesn't only carry sensation from the upper neck, it's also the primary nerve supplying the jaw and temporomandibular joint (TMJ). This shared pathway is one reason jaw symptoms and headache can frequently co-exist, and why we assess the jaw as part of a thorough headache work-up where relevant.

• See our guide to TMJ Dysfunction

What Is Driving Your Symptoms?

Several factors commonly contribute to headache presentations with a musculoskeletal component:

• Upper cervical joint restriction, loss of movement and segmental stiffness, often at C1/C2, is commonly reported in cervicogenic headache. Manual assessment of these joints is a core part of examination.
• Reduced deep cervical flexor performance, the longus colli and longus capitis muscles help stabilise the upper cervical spine and influence head posture. Altered performance in these muscles has been documented in both TTH and migraine, and craniocervical flexion training targeting this has shown clinical benefit in some studies.
• Sustained positions and movement habits, long periods in one position, such as working at a computer, driving, or looking down at a phone, may aggravate neck symptoms in some people. The issue is usually not that there is a single "bad posture", but that the neck may be exposed to a sustained position or load that it currently does not tolerate well.
• Pericranial muscle tension and trigger points, sensitised points in the suboccipital muscles, upper trapezius, sternocleidomastoid, and temporalis are found at high prevalence in both TTH and cervicogenic presentations, and their treatment is a common component of management.
• Stress and psychological load, psychosocial stress is a well-established trigger and perpetuating factor for TTH in particular. This doesn't mean the headache is "in your head", it means the nervous system is more reactive, and addressing this reactivity is part of comprehensive management.
• Sleep, hydration, and lifestyle, disrupted sleep is associated with increased headache frequency and can contribute to poorer symptom control. Dehydration, irregular meals, jaw clenching (bruxism; see our note on TMJ dysfunction), and high caffeine intake may contribute to headache frequency or symptom severity in some people, and are frequently overlooked.

What the Evidence Says About Treatment

Physiotherapy has an established role as part of management for cervicogenic headache, with evidence supporting combinations of manual therapy and exercise. A 2024 systematic review and network meta-analysis of physical therapist interventions for cervicogenic headache found potential benefits across several intervention types, though the certainty of the evidence was rated low, meaning no single intervention can currently be recommended with confidence over others (Jung et al., 2024). A separate systematic review of therapeutic exercise for cervicogenic headache found potentially clinically relevant reductions in headache intensity and frequency, again with low to very-low quality evidence overall (Becher et al., 2023). For tension-type headache, evidence supports combinations of manual therapy, postural advice, and exercise as more effective than usual medical care alone, though cervical manipulation should not be presented as a standalone treatment. Physiotherapy can also play a role in managing tension-type headache and, for selected patients, as part of a broader migraine management plan, always alongside, not instead of, appropriate medical care. Treatment typically combines:

• Manual therapy, targeted mobilisation or manipulation where clinically appropriate, used alongside exercise and education to improve symptoms and movement tolerance.
• Strengthening and motor control work, craniocervical flexion training and progressive cervical and shoulder strengthening to address the muscle performance changes associated with headache presentations.
• Movement and postural strategies, addressing the sustained positions that may load the upper cervical spine and perpetuate symptoms, with practical strategies for screen use, sleep positioning, and daily habits.
• Lifestyle and trigger management, identifying and modifying the specific contributors to your presentation: sleep, stress, jaw habits, screen time, and hydration, addressed practically rather than generically.

How IP Physio Can Help

Our assessment begins with headache classification and safety screening, because headache is a medical symptom before it is a musculoskeletal one, and not every headache has a cervical component. From there, we assess:

• Headache classification and safety screening, understanding your headache pattern and ruling out features that need onward medical assessment.
• Cervical assessment, segmental mobility, particularly in the upper cervical spine, and the relationship between neck movement and your headache pattern.
• Musculoskeletal contributors, cervical movement, muscle performance and relevant functional loading, alongside pericranial muscle tenderness.
• Treatment, targeted manual therapy and exercise where a cervical component is identified.
• Self-management and exercise, a home programme and practical lifestyle strategies to support longer-term control.

If a cervical component is present, we treat it directly, with manual therapy to the relevant segments, targeted exercise for the muscles involved, and clear guidance on the postural and lifestyle factors maintaining your symptoms. We also communicate with your GP or neurologist where appropriate, because some headache presentations require a collaborative approach and accurate classification is essential.

When Should a Headache Be Medically Assessed?

Most headaches are not caused by serious underlying disease, but some require urgent medical assessment. Seek urgent medical attention if a headache:

• Is sudden and extremely severe ("thunderclap" onset)
• Follows significant head trauma
• Is accompanied by new neurological symptoms such as weakness, numbness, confusion, or difficulty speaking
• Occurs with fever and significant neck stiffness

New or substantially changing headaches should also be assessed medically, particularly when accompanied by other concerning symptoms. If you're ever unsure, see your GP first, physiotherapy is part of the management pathway, not a substitute for medical assessment.

Get in Touch

If your headaches are frequently accompanied by neck pain, stiffness, or symptoms that change with neck movement or sustained positions, a detailed musculoskeletal assessment can help determine whether the cervical spine is contributing to your presentation. Get in touch with us today.

• Have a specific question? See the Headaches FAQ

References

• Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211. doi:10.1177/0333102417738202.
• Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache. 1998;38(6):442–445.
• Liang Z, Galea O, Thomas L, Jull G, Treleaven J. Cervical musculoskeletal impairments in migraine and tension type headache: a systematic review and meta-analysis. Musculoskelet Sci Pract. 2019;42:67–83. doi:10.1016/j.msksp.2019.04.007.
• Pensri C, Liang Z, Treleaven J, Jull G, Thomas L. Cervical musculoskeletal impairments in migraine and tension-type headache and relationship to pain related factors: an updated systematic review and meta-analysis. Musculoskelet Sci Pract. 2025;76:103251. doi:10.1016/j.msksp.2024.103251.
• Jung A, Carvalho GF, Szikszay TM, Pawlowsky V, Gabler T, Luedtke K. Physical therapist interventions to reduce headache intensity, frequency, and duration in patients with cervicogenic headache: a systematic review and network meta-analysis. Phys Ther. 2024;104(2):pzad154.
• Becher B, Lozano-López C, Castro-Carletti EM, Hoffmann M, Becher C, Mesa-Jiménez JA, Fernández-de-las-Peñas C, Armijo-Olivo S. Effectiveness of therapeutic exercise for the management of cervicogenic headache: a systematic review. Musculoskelet Sci Pract. 2023;66:102822.
• Castien R, De Hertogh W. A neuroscience perspective of physical treatment of headache and neck pain. Front Neurol. 2019;10:276.
• Bizzarri P, Manfredini D, Koutris M, Bartolini M, Buzzatti L, Bagnoli C, Scafoglieri A. Temporomandibular disorders in migraine and tension-type headache patients: a systematic review with meta-analysis. J Oral Facial Pain Headache. 2024;38(2):11–24.
• Castien RF, van der Windt DA, Grooten A, Dekker J. Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia. 2011;31(2):133–143.