Headaches
Cervicogenic & Tension-Type — “Client presents with headache, neck stiffness, and pain that seems to come from the neck.”
Vertebral artery screening is required before treating the upper cervical region. Do not skip this step, even if the client appears well and presents without dizziness. See the Assessment tab for the full screening protocol.
If the client reports dizziness, visual disturbance, difficulty speaking or swallowing, drop attacks, fainting, or numbness in relation to neck movement — do not treat. Refer for medical investigation.
Cervicogenic headache (CGH) is a secondary headache — it originates from dysfunction in the upper cervical spine, which refers pain to the head via shared nerve pathways. Affects approximately 1–4% of people experiencing headaches (Bini et al., 2022).
Key features: Unilateral headache · Starts in the neck or base of skull and radiates forward (forehead, temple, behind the eye) · Neck stiffness or reduced ROM · Triggered or worsened by neck movement or sustained postures · No aura, nausea, or photophobia.
Tension-type headache (TTH) is the most common primary headache, with a global annual prevalence of around 46% (Falsiroli Maistrello et al., 2018). Chronic tension headache pain is driven by sensitisation — peripheral nociception from active trigger points in muscles innervated by the upper cervical segments C1–C3 and by the trigeminal nerve.
Key features of TTH: Bilateral pressing or tightening quality — often described as a “band around the head” · Mild to moderate intensity, not worsened by routine physical activity · Pericranial tenderness (tenderness over head and neck muscles).
Overlap features (common to both): Neck stiffness and tension · Trigger points in cervical and cranial muscles · Association with posture and stress · Response to manual therapy.
Trigger point referral areas:
| SCM (sternal head) | Forehead, around the eye, top of head, behind the ear |
| SCM (clavicular head) | Frontal headache, ear, cheek |
| Scalenes | Down the arm, into the chest, between shoulder blades |
| Sub-occipitals | Deep ache at base of skull, wrapping to forehead and behind the eye |
| Splenius Capitis | Top of head (vertex) |
| Splenius Cervicis | Behind the eye, into the temple |
| Temporalis | Temple, eyebrow, upper teeth, behind the eye |
| Masseter | Jaw, lower teeth, eyebrow, ear, cheek |
SCM, Scalenes, Sub-occipitals, and Splenius muscle reference pages are coming soon.
Subjective — case history:
- Where is the headache? One side or both? Does it move?
- Where does it start? Neck? Base of skull? Does it radiate forward?
- How often does it occur? How long does it last?
- What brings it on? Neck movement? Posture? Stress? Time of day?
- What relieves it? Rest? Heat? Movement? Medication?
- Any neck stiffness or pain?
- Any history of trauma — whiplash, falls, sports injury?
- Any visual disturbance, nausea, or sensitivity to light/sound? (red flag for migraine or other pathology)
- Any jaw clenching, grinding, or TMD symptoms?
- Sleep quality? Pillow and sleeping position? Screen time?
Observation:
- Head and neck posture — forward head position? Chin poke? Rounded shoulders?
- Asymmetry — head tilt? Shoulder height difference?
- Guarding — are they holding the neck stiffly?
- Breathing pattern — shallow, upper chest, or relaxed diaphragmatic?
Range of motion — active cervical movements:
The upper cervical (C0–C2) contributes ~50% of rotation and significant flexion/extension. Restriction here is common in cervicogenic headache.
| Flexion / Extension | Note range, pain on movement, and quality of end feel. |
| Rotation | Compare sides. Marked restriction to one side may indicate upper cervical involvement. |
| Lateral flexion | Compare sides. Note any reproduction of headache symptoms. |
Special test 1: Vertebral artery screening
Required before upper cervical work. Do not skip.
Step 1 — Subjective screen: Ask: “Have you ever experienced any unusual symptoms when moving your neck, looking up, or turning your head?” Do not list potential symptoms — allow them to respond freely. Listen for: dizziness, visual disturbance, difficulty speaking or swallowing, drop attacks, fainting, numbness. If any of these are reported: do not perform the positional test. Refer for medical investigation.
Step 2 — Active (if subjective is clear): Ask the client to slowly extend their neck, then rotate fully to one side. Hold 10 seconds. Return to neutral. Repeat on the other side. The client controls the movement.
Step 3 — Passive (if active is clear): Support the client’s head and passively move into extension with full rotation to one side. Hold 10–30 seconds. All movements are passive — the client does nothing. Repeat on the other side.
Interpretation: If any symptoms appear (dizziness, nystagmus, nausea, visual disturbance, numbness) — do not proceed with upper cervical work. Consider referral. If no symptoms: proceed with appropriate caution and stay alert during treatment.
Special test 2: Cervical flexion-rotation test
Question: Is there a restriction at C1–C2 contributing to the headache?
Client supine. Fully flex the cervical spine (chin to chest) to lock the lower cervical segments. Maintaining full flexion, passively rotate the head to each side — the client stays completely relaxed.
Interpretation: Normal is approximately 44° each side. Reduced range (<32–35°) or reproduction of a familiar headache suggests C1–C2 dysfunction. Good sensitivity and specificity for upper cervical involvement in cervicogenic headache.
Palpation — client supine:
| Sub-occipitals | Support the head. Palpate just below the occiput. Feel for tone, tenderness, trigger points. Compare sides. Often exquisitely tender in headache clients. |
| SCM | From mastoid process to sternum/clavicle. Have the client turn their head slightly to the opposite side and lift to engage. Note tone, trigger points, referral. |
| Scalenes | Lateral neck, between SCM and upper trapezius. Ask the client to breathe and hold — scalenes engage. Palpate anterior, middle, and posterior. Note tenderness and referral. |
| Splenius | Deep to the upper trapezius, from upper cervical/thoracic spine toward the mastoid and occiput. Often involved but frequently overlooked. |
| Temporalis & Masseter | As described in Scenario 1 (TMD). Jaw tension often coexists with headaches. |
| Cervical paraspinals | In the paraspinal groove lateral to the spinous processes, C4–C7. Note tone and asymmetry. These deep extensors are often inhibited rather than hypertonic — reduced tone or asymmetric response is as clinically relevant as tenderness. |
There’s no fixed order. Let your findings guide you. The sub-occipitals are often central to headache presentations and are a reasonable starting point — but follow what you feel.
| Hypertonic, restricted tissue | FMT — passive first, then active if tolerated |
| Localised tender spots with referral | TPT — sustained pressure, respect tissue response |
| Muscle won’t relax, guarding | MET — contract-relax to reset tone |
| Adhesions at attachments | Frictions — sparingly; sub-occipitals and upper cervical are sensitive |
Refer to individual muscle pages for technique-specific guidance and cautions.
Cautions:
- Red flags for immediate referral: sudden severe headache (“thunderclap”) · headache with fever and neck stiffness · headache with neurological signs (weakness, numbness, visual loss, confusion) · headache after head trauma · new headache in someone over 50 · headache that wakes from sleep · progressive worsening headache. These require urgent medical assessment.
- Migraine: If the client reports aura, nausea, photophobia, or severe unilateral throbbing headache, consider migraine. Manual therapy between attacks may help reduce frequency as a prophylactic approach. People with migraines are not exempt from also having cervicogenic or tension-type headaches — treat what you find.
- Medication overuse headache: If a client uses pain medication more than 10–15 days per month and symptoms are worsening, refer to their GP. Medication management is outside scope — recognise the pattern and refer.
Evidence: A 2022 systematic review found consistent support for manual therapy in cervicogenic headache, with moderate-to-large effects on frequency and intensity (Bini et al., 2022). Combined technique approaches outperformed single techniques (Núñez-Cabaleiro & Leirós-Rodríguez, 2022). A 2024 review found trigger point therapy reduced duration, intensity, and frequency of tension-type headaches, with the upper trapezius, SCM, and sub-occipitals as primary targets (Dolina et al., 2024).
Combining hands-on treatment with exercise and postural correction yields better, longer-lasting outcomes than manual therapy alone.
Postural awareness:
Chin tucks: Draw the chin back to align the head over the shoulders. Hold 5 seconds. Repeat 10 times, several times per day. Reduces forward head position, which loads the upper cervical spine and sub-occipitals.
Workstation setup: Screen at eye level, elbows at 90°, feet flat on floor. Take regular breaks — get up and move every 45–60 minutes.
Stretching:
SCM stretch: Sit tall. Rotate the head to one side, then extend slightly (look up and away). Hold 20–30 seconds. Repeat each side.
Scalene stretch: Sit tall, hold the seat with one hand to anchor the shoulder. Tilt the head away, then rotate slightly toward the anchored side. Hold 20–30 seconds. Repeat each side.
Sub-occipital compression (self): Lie supine with two tennis balls in a sock, placed at the base of the skull. Allow the head to rest on them and relax for 2–5 minutes. The weight of the head applies sustained pressure to the sub-occipital soft tissue, helping reduce trigger point activity. This is not a stretch — it works through sustained compression and mild traction at C0–C1.
Breathing:
Encourage diaphragmatic breathing. Shallow upper-chest breathing activates the scalenes and perpetuates neck tension. Practice slow, relaxed breathing — inhale through the nose, belly expands; exhale slowly. 5 minutes, twice daily.
| TMD | Jaw tension and clenching often coexist with headaches. If the client reports jaw symptoms, assess and treat accordingly. See Scenario 1: TMD. |
| Posture | Forward head position contributes to both cervicogenic and tension-type headaches. Upper trapezius and levator scapulae are frequently involved alongside the muscles in this scenario. See Scenario 3: Postural / Tension. |
| Breathing | Dysfunctional breathing patterns activate accessory muscles (scalenes, SCM, upper trapezius) and perpetuate neck tension. Address breathing as part of the treatment plan. |