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Woman sitting at a desk rubbing her temples to ease headache pain
Woman grimacing from pain while holding her forehead and neck
Woman grimacing from pain while holding her forehead and neck


by Adam Brown
updated July 16, 2020

For many people headaches are a regular occurrence and have a significant impact on their daily lives. It has been reported that up to 96% of people between 25 and 64 years of age experience headaches at some point in time. However, as common as they are, knowing how to fix a headache can be difficult. There are many different causes and types of headaches, so effective treatment requires a correct diagnosis by a trained professional.

Physiotherapy can be very effective for one category of headaches called cervicogenic headaches (CGH) or neck headaches. These are headaches that are caused by a painful structure in the neck. If diagnosed properly, then alleviating these headaches can be straightforward, and often dramatically reducing their future occurrences.


Diagnosis of Cervicogenic (neck) headaches

A skilled physiotherapist will conduct an assessment with the following goals:

  • ruling out serious pathology as a cause
  • documenting the characteristics of your headaches
  • comparing them to Criteria (see below) for the diagnosis of CGH.

Using this information, your physiotherapist will evaluate the likelihood that your headaches are actually caused by your neck. If your headaches meet this CGH criteria, your physiotherapist will create an appropriate treatment plan to eliminate your headaches.


Cervicogenic Headache International Study Group Criteria (CHISG)

The gold-standard outline for evaluating whether a headache is caused by the neck, was developed by the Cervicogenic Headache International Study Group (CHISG). This criteria states that a headache may be cervicogenic if:

  • There are signs and symptoms of neck involvement either by creating the headache with neck movement or positioning, by applying pressure in the upper cervical (neck) region or a loss in neck range of motion combined with shoulder and/or arm pain.
  • Confirmation by injections of anesthetic into structures of your neck. (impractical in most settings)
  • Pain on one side of the head that does not shift sides

Some additional points that are often associated with CGH can help you to feel more confident of your findings, but these are often inconsistent and therefore not required to make a diagnosis. These are:

  • Little benefit from use of common medications (indomethacin, ergotamine and sumatriptan succinate)
  • Female sex
  • Significant history of head or neck trauma


Screening for a More Serious Cause of the Headache

If the answer to the following five questions is no, the likelihood that your headache is caused by a serious disease is very low. It is also important to note that if the answer is yes to just one or two of these questions it doesn’t indicate that there is a serious problem present. Rather, the more “yeses” you have, the more likely your physiotherapist will be to work with your doctor in ruling out serious pathology.

  • Is the headache of recent onset (less than 6 months)?
  • Is there any worsening in the frequency or severity of the headaches?
  • Was the initial onset sudden and severe?
  • Are there any clues suggesting hard or true neurologic signs associated with the headaches?
  • Are there any cognitive changes associated with the headaches (e.g., memory loss, confusion, personality changes)?


Physiotherapy Treatment for Cervicogenic Headaches

After arriving at a diagnosis and screening for more serious pathology, your physiotherapist will use all of the information from the history and physical exam to devise an effective treatment plan aimed at eliminating your headaches. Depending upon the factors contributing to your specific case, your treatment plan may consist of a mix of any of the following components.

1. Manual Therapy for Headaches

A therapist skilled in manual therapy will use gentle but effective hands-on techniques to restore range of motion to stiff joints in the upper neck. You will often be asked to perform some movement or stretch between appointments to maintain the range of motion in the area being treated. This can be extremely effective at eliminating headaches for many patients.

Manual therapy may also be directed at soft tissues of the upper neck. In particular the sub-occipital muscles can become a cause of headaches. Trigger point release and gentle stretching of these structures can be effective at breaking the pain cycle.

2. Exercises for Headaches

Many patients who suffer from neck headaches have weakness of the muscles that support the upper cervical joints and head. This weakness results in the head being maintained in postures that place increased stress on the upper neck. If weakness is present, a focused strengthening program is a critical component of an effective treatment plan.

3. Postural and Ergonomic Changes for Headaches

If the history of your headaches suggest that they are influenced by posture and ergonomics (worse with computer work or driving, or worse as the day goes on) your physiotherapist will make suggestions that will reduce this stress. For example, many headache sufferers notice that their symptoms are worse when they work on a computer for extended periods of time. By making small changes to your seating and workstation we can reduce upper neck stress and reduce your headaches.

4. Pain Modalities for Headaches

Some patients who suffer from cervicogenic headaches for an extended period of time experience a phenomenon called ‘central sensitization’. Put simply, this is when the central nervous system (your brain) becomes increasingly sensitive to stimulation in the head and neck area. This results in pain being produced during movements, activities, and positions that should not be painful at all.  Your physiotherapist may use a number of techniques to desensitize the area including gentle manual therapy, thermal modalities, acupuncture and special exercises.


Final Thoughts

Cervicogenic headaches can have a significant impact on a patients’ quality of life and productivity. With proper diagnosis and treatment most people are able to eliminate their headaches and prevent them from coming back. If you think you may suffer from this type of headache, come in for a thorough evaluation by one of our experienced physiotherapists. If your headaches are coming from your neck we can help.

Adam Brown

Adam Brown        MClScPT
Registered Physiotherapist

Adam is a well-respected physiotherapist known for successfully treating complex orthopaedic patients throughout the Greater Toronto Area. He helped launch the Inter-Professional Spine Assessment and Education Centre (ISAEC) program and provides mentorship and leadership to many physiotherapists.



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