Cervicogenic Headaches Normal Anatomy

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Cervicogenic Headaches
Normal Anatomy

  • There is a vast amount of soft tissue and joints within the upper cervical spine.

  • The suboccipital nerve branches from C1 nerve root and supplies muscles of suboccipital region and atlano-occipital joint which is purely motor without any sensory aspect.

  • Greater occipital and lesser occipital nerves branch from C2 nerve root and supplies C1/2 and C2/3, vertex and posterior scalp

  • Third Occipital nerve branches from C3 nerve root and supplies the lower scalp and C2/3

  • The trigeminal nerve and upper cervical spinal nerves in the brain share a common “Trigeminocervical nucleus”

  • The structures innervated by C1,2,3 spinal nerves are

    • Atlanto occipital joint

    • Ligaments of the atlanto-occipital joint

    • C2,3 facet joints

    • Sub-occipital and upper posterior neck muscles

    • Upper cervical spinal dura mater

    • Verterbral arteries

    • C2-3 intervertebral discs

    • Trapezius and SCM muscles


  • Dysfunction to the any structure supplied by the upper cervical nerves can cause pain anywhere within the distribution of these nerves

  • This often results in “Cervicogenic Headaches” i.e a headache due to a cervical origin

Mechanism of Injury



  • Poor Posture

  • Muscular Imbalance

  • Degenerative Disc Disease/Spondylosis

  • Arthritis

  • Disc Herniation

Associated Pathologies

Differential Diagnosis of Headache

Clinical features

Cervicogenic headache


Tension-Type headache

Female: Male





Unilateral without sideshift

60% unilateral with sideshift

Diffuse bilateral


Occipital to frontoparietal and orbital

Frontal, Periorbital , temporal



Chronic, episodic

1-4 per month

1-30 per month



Moderate/ severe



1 hour to weeks


Days to weeks

Pain Character

Non- throbbing and non- lancinating, pain usually starts in the neck

Throbbing , pulsating



Neck Movement and postures, limited ROM, pressure over C0-C3

Multiple , neck movement not typical

Multiple, neck movement not typical

Associated Symptoms

Usually absent or similar to migraine but milder, decreased ROM

Nausea, vomiting, Visual changes, phonophobia, photophobia

Occasionally decreased appetite, phonophobia or photophobia


Cervicogenic Headache International Study Group Diagnostic Criteria

Major Criteria

  1. Symptoms and signs of neck improvement

  1. Precipitation of comparable symptoms by:

  1. Neck movements and/or sustained , awkward head positioning and/or

  2. External pressure over the upper cervical or occipital region

  1. Restriction of range of motion in the neck

  2. Ipsilateral neck, shoulder or arm pain.

  1. Unilaterality of the head pain, without side shift

Head Pain Characteristics

  1. Moderate – severe, non-throbbing pain, usually starting in the neck. Episodes of varying duration, or fluctuating, continuous pain.

Other Characteristics of some importance

  1. Only marginal or lack of effect of indomethacin. Only marginal of lack of effect of ergotamine and sumatriptan. Female gender. Not infrequent history of head of indirect neck trauma, usually of more than medium severity.

Other Features of Lesser Importance

  1. Various attack- related phenomena, only occasionally present , and /or moderately

expressed when present

a. Nausea

b. Phono-and photophobia

c. Dizziness

d. Ipsilateral “ blurred vision”

e. Difficulties swallowing

f. Ipsilateral oedema, mostly in the periocular area



  • A Headache in occipital or trigeminal nerve distribution

  • Aggravated by neck movements or prolonged postures

  • Neck, shoulder or arm pain

  • Non throbbing

  • Traumatic or insidious onset


  • Abnormal cervical posture

  • Altered and painful cervical movements- usually extension and ipsilateral rotation

  • Restricted upper cervical movements, usually ipsilateral rotation

  • Pain on sustained postures, usually protraction

  • Pain on palpation sub occipital soft tissue

Special Test

  • Cervical Flexion-Rotation Test

Further Investigation

  • Diagnosis usually made clinically

  • Imaging used to investigate/exclude more serious pathology

  • Blood work used to exclude other pathology

  • Zygapophyseal joint, cervical nerve or medial branch blockage



  • Ergonomic advise

  • Reduce pain and decrease inflammation

    • Medication, ice and/or heat, massage

  • Increase range of movement

    • Reduce tone

      • Soft tissue techniques, diaphragmatic breathing, stretches, dry needling

    • Increase articulation of joints of upper cervical spine, particularly flexion and rotation

      • Soft tissue techniques, stretches, joint mobilisation, manipulation, exercise

  • Restore Normal Motor Control and Strength

    • Deep neck flexors, Deep cervical extensors, Scapular stabilisers

  • Restore Dynamic Stability and proprioception


  • Anaesthetic injections

    • Spinal nerve, medial branch or facet joint blockade

  • Radiofrequency thermal neurolysis

  • Surgical Liberation of occipital nerve

  • Surgery to underlying pathology (e.g disc pathology)


(Jull et al., 2002, Piovesan et al., 2003, Biondi, 2005, Zito et al., 2006, von Piekartz et al., 2007, Hall et al., 2008, Page, 2011, Fernandez-de-Las-Penas and Courtney, 2014)

Biondi, D. M. (2005) 'Cervicogenic headache: a review of diagnostic and treatment strategies', J Am Osteopath Assoc, 105(4 Suppl 2), pp. 16s-22s.

Fernandez-de-Las-Penas, C. and Courtney, C. A. (2014) 'Clinical reasoning for manual therapy management of tension type and cervicogenic headache', J Man Manip Ther, 22(1), pp. 44-50.

Hall, T., Briffa, K. and Hopper, D. (2008) 'Clinical evaluation of cervicogenic headache: a clinical perspective', Journal of Manual & Manipulative Therapy, 16(2), pp. 73-80.

Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D., Emberson, J., Marschner, I. and Richardson, C. (2002) 'A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache', Spine (Phila Pa 1976), 27(17), pp. 1835-43; discussion 1843.

Page, P. (2011) 'CERVICOGENIC HEADACHES: AN EVIDENCE-LED APPROACH TO CLINICAL MANAGEMENT', International Journal of Sports Physical Therapy, 6(3), pp. 254-266.

Piovesan, E. J., Kowacs, P. A. and Oshinsky, M. L. (2003) 'Convergence of cervical and trigeminal sensory afferents', Curr Pain Headache Rep, 7(5), pp. 377-83.

von Piekartz, H. J., Schouten, S. and Aufdemkampe, G. (2007) 'Neurodynamic responses in children with migraine or cervicogenic headache versus a control group. A comparative study', Man Ther, 12(2), pp. 153-60.

Zito, G., Jull, G. and Story, I. (2006) 'Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache', Man Ther, 11(2), pp. 118-29.

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