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September 16, 2016

They are the worst!  They can be severely debilitating and decrease your quality of life and ability to concentrate.  There are a variety of complaints and symptoms you will experience depending on the type of headache you have.  The International Health Society classification system lists 14 different headache forms and classifies headaches as either primary or secondary.

Primary headaches are not caused by other diseases or syndromes.  Examples of primary headaches include tension-type headaches, migraines, and cluster headaches.  Secondary headaches are caused by, or attributed to an associated disorder or disease.  Examples of secondary headaches include cervicogenic, post-traumatic, and sinus headaches, as well as headaches related to medication overuse, stress, and/or food/drink.

A common headache seen in clinical practice, which responds well to physical therapy is a cervicogenic headache.

The International Health Society defines a cervicogenic headache as;

  1. Pain localized to the neck and back of head.  This pain may refer into the forehead, behind the eye, side of the head, or pain may be experienced in the ears.
  2. Pain is aggravated with neck movement or sustained neck positioning/posture.
  3. Resistance and or limitation with neck range of motion.

In general, a cervicogenic headache tends to be felt on one side.


Typically a cervicogenic headache (headache originating from the neck) is due to musculoskeletal dysfunction in the upper cervical spine.  This can be due to a trauma to the head, a motor vehicle accident, or posture.

 An important feature of cervicogenic headache includes muscle weakness of the deep neck flexors, which can be considered the core of the neck.   If you have a weak core, your back becomes less stabilized.  This is the same issue which occurs with the cervical spine.  If you have poor deep neck flexor endurance (the core of your neck), you will have decreased stabilization of the cervical spine and head.  If you do not have good stabilization through the core of your neck, it puts more stress on other parts of the neck and head, causing increased pain and tension.

Other factors of cervicogenic headache include muscle tightness, poor posture, and sensorimotor disturbance (decreased ability to perceive where your head is in space).

All these factors are very much related to one another and tend to continue the cycle of pain.


Awareness and recognition of the underlying cause and/or of the continuance in pain is a critical part in the management of headaches.  Contributing factors of muscle tightness, muscle weakness, poor posture, and maintenance of stress should be assessed and addressed.

For most headaches, especially when they become chronic, there is tenderness to the muscles around the head and neck.  The most common muscles referring pain into the head and neck are the upper traps, temporalis, sternocleidomastoid, and the sub-occipital muscles.

Trigger point release, dry needling, mobilization, manipulation, and therapeutic exercise are treatments typically used for the management of pain.  Trigger point release is when your therapist will work with their hands to reduce increased tissue tension.  Dry needling is a technique in which a small filiform needle is placed into an area of higher muscle tension in order to release the trigger point.  Mobilization and manipulation are techniques your therapist will use in order to improve mobility in stiff segments.  Therapeutic exercise related to strengthening your postural muscles and deep neck flexors will be used in order to reduce stress on pain generating structures.  Self-treatment techniques are also important to continue to help manage and reduce symptoms.  A combination of these techniques may be used to help reduce or eliminate your symptoms.

It is not uncommon to have mixed features of migraine, tension-type headache, or other classifications of headache.  Though research isn’t as strong for the treatment of these classifications of headache, there is research supporting increased muscle tension, neck stiffness, and tenderness of the muscles of the head and neck.  Treating these deficits could help decrease intensity of symptoms and allow you to feel more capable of completing your activities of daily living.

For more information on dry needling you can visit


Biondi, David. Cervicogenic headache:A review of diagnostic and treatment strategies. April 2005;105 (4).

Dutton, Mark.(2008) Orthopedic Examination, Evaluation, and Intervention. New York, NY: The McGraw Hill Companies.

Farmer, Peter et al. An investigation of cervical spinal posture in cervicogenic headache. Physical Therapy. 2015; 95(2): 212- 222.

Fernandez – de – las Penas C, et al. Referred pain areas of active myofascial trigger points in head, neck, and shoulder muscles, in chronic tension type headache. Journal of Bodywork and Movement Therapies.  2010;14(4): 391-396.

Hall, Toby et al. Clinical evaluation of cervicogenic headache: A clinical perspective. The Journal of Manual & Manipulative Therapy. 2008; 16(2): 73-80.

Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2011; 152:S2-S15.