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%. They are also one of the most undertreated, partly because the cervical component, which is present in far more headache presentations than most people realise, is rarely investigated in standard medical assessments. Understanding the type of headache you have, and what is driving it, is the starting point for managing it properly rather than just suppressing it.
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. It arises because of convergence between the trigeminal nerve and the upper three cervical spinal nerves in the trigemino-cervical nucleus, 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, a skilled musculoskeletal assessment, identifying which cervical segment reproduces the headache and how treatment to that segment changes it, is the most reliable clinical tool available.
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. TTH has a strong musculoskeletal component that is well-supported by evidence. People with TTH consistently show weakness of the deep cervical flexor muscles, myofascial trigger points in the pericranial and cervical musculature, and reduced pressure pain thresholds in the neck and head. Research shows that patients with headache have a neck pain incidence 2.5 to 6 times higher than individuals without headache. The involvement of cervical musculature in TTH is not incidental, it is a primary driver in many cases, and addressing it directly is more effective than relying on analgesia alone.
Migraine, and Why the Neck Matters Here Too
Migraine is the most common disabling headache type and is usually thought of as a purely neurological condition. What is less widely known is that the majority of people with migraine also have significant cervical musculoskeletal impairments, reduced neck mobility, deep cervical flexor weakness, and pericranial muscle tenderness. 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. But it does mean that identifying and addressing cervical dysfunction in a person with migraine may meaningfully reduce headache frequency and severity, particularly in those whose attacks are frequently preceded by neck tension or triggered by sustained postures. Physiotherapy is increasingly recognised as a valuable component of migraine management, particularly for those seeking to reduce reliance on medication.
Why the Neck Is Central
The anatomical basis for neck-driven 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 explains why cervical dysfunction can worsen or trigger both migraine and tension-type presentations. Dysfunction in the upper cervical spine, whether joint restriction, muscle tension, or deep flexor weakness, does not just produce local neck pain. It can reliably refer pain upward into the head in patterns that precisely mimic other headache types, which is why cervicogenic headache is frequently misdiagnosed as migraine or tension-type headache, and why patients cycle through medication management without addressing the structural driver.
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 one of the most consistent findings in cervicogenic headache. Manual assessment of these joints is fundamental to diagnosis and treatment.
- Deep cervical flexor weakness, the longus colli and longus capitis muscles stabilise the upper cervical spine and influence head posture. Their weakness is documented in both TTH and migraine, and craniocervical flexion training to address this has shown clinical benefit.
- Forward head posture, sustained positions that place the head ahead of the shoulders increase the mechanical load on the upper cervical joints and musculature significantly. Screen-based work, prolonged driving, and extended phone use are common contributors.
- Pericranial muscle tension and trigger points, sensitised points in the suboccipital muscles, upper trapezius, sternocleidomastoid, and temporalis are found in high prevalence in both TTH and cervicogenic presentations, and their treatment is a core component of management.
- Stress and psychological load, psychosocial stress is a well-established trigger and perpetuating factor for TTH in particular. It does not mean the headache is "in your head", it means the nervous system is more reactive, and that addressing this reactivity is part of comprehensive management.
- Sleep, hydration, and lifestyle, disrupted sleep is an independent driver of headache frequency. Dehydration, irregular meals, jaw clenching (bruxism), and high caffeine intake are all modifiable contributors that are frequently overlooked.
What the Evidence Says About Treatment
For cervicogenic headache, the evidence for physiotherapy is the strongest of any headache type. A systematic review and meta-analysis found moderate-to-large effects of manual therapy on headache frequency and intensity in the short term, with small-to-moderate effects sustained at long-term follow-up. Spinal manipulation showed moderate-quality evidence specifically for cervicogenic headache in a sensitivity analysis of low-risk-of-bias trials. For tension-type headache, growing evidence supports deep cervical flexor strengthening exercises, manual therapy to the cervical spine, and trigger point treatment as effective interventions for reducing headache frequency and intensity, both short and long term. Treatment combines:
- Manual therapy, targeted mobilisation or manipulation of restricted upper cervical segments, addressing the structural source of referred pain and restoring normal movement.
- Strengthening and motor control work, craniocervical flexion training and progressive cervical and shoulder strengthening to address the deep muscle weakness consistently associated with headache presentations.
- Postural retraining, addressing the sustained postures that 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 are addressed practically rather than generically.
How IP Physio Can Help
We begin by assessing whether your headaches have a cervical component, because the answer to that question determines the most effective treatment approach. Our assessment examines upper cervical segmental mobility, deep cervical flexor strength and endurance, head posture, pericranial muscle tenderness, and the relationship between neck movement and your headache pattern. 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. If you have been managing headaches with analgesia alone, or have been told there is nothing structural to address, a thorough cervical assessment may offer a different and more useful picture. Get in touch with us today.
References
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211.
- Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache. 1998;38(6):442–445.
- Luedtke K, Starke W, May A. Musculoskeletal dysfunction in patients with migraine, a systematic review and meta-analysis. Cephalalgia. 2018;38(1):139–150.
- Demont A, Lafrance SG, Gaska C, et al. Efficacy of physiotherapy interventions for the management of adults with cervicogenic headache: a systematic review and meta-analyses. PM R. 2023;15:613–628.
- Castien R, De Hertogh W. A neuroscience perspective of physical treatment of headache and neck pain. Front Neurol. 2019;10:276. PMC6443880.
- Ferracini GN, Florencio LL, Dach F, et al. Cervical musculoskeletal impairments in migraine. Front Neurol. 2021;12:705782. PMC8653561.
- De Morais Barbosa L, et al. Cervical impairments in subjects with migraine or tension-type headache: an observational study. Front Neurol. 2024;15:1373912.
- 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.