by Margaret Blount, SPT

Introduction to Neck Pain and Cervicogenic Headache

Neck pain is a complex and multifaceted issue. A collection of leading physical therapists gathered in 2017 to better define the diagnostic criteria and best treatments for neck pain, published in 2017 as a Clinical Practice Guideline for Neck Pain: Revision 2017. This article will summarize the suggestions of the CPG¹, which defined 4 types of neck pain:

  • with mobility deficits
  • with movement coordination impairments (including whiplash-associated disorder)
  • with radiating pain (radicular)
  • with headaches (cervicogenic headaches).

This review will focus on the definition, diagnosis, and treatment recommendations of neck pain with headache, or cervicogenic headache. Cervicogenic headaches commonly include symptoms of non-continuous, one-sided neck pain with associated headache. Also, the headache is preceded or aggravated by neck movement or sustained postures. Further, symptoms can be defined by time since onset with classifications of acute, sub-acute, or chronic. Knowing when the injury happened and how irritable the tissues are can help the PT determine which treatment strategies are appropriate.

Physical Therapy Evaluation of Cervicogenic Headache

To evaluate if you have cervicogenic headache, a physical therapist will look at various issues relating to your head and neck movement and strength, and possibly some special tests. First, you may fill out a few questionnaires that investigate your pain levels, your ability to function, and/or your thoughts about pain (NDI, TSK/PCS, DHI). Next a therapist will take your medical history, so come prepared to describe the onset, quality, distribution, and intensity of your neck pain and headaches. Then, a PT will take a variety of measures of your neck and head movement, both with you actively and then the PT passively moving your head and neck. The PT may also apply pressure through the muscles and vertebrae in your neck to gauge the degree of muscular tension and quality of motion available at the joints in the neck. One special test the PT may perform is called the Cervical Flexion-Rotation Test which is used to determine the patient’s pain free ROM, with cut off scores of less than 32 degrees or a 10 degree reduction to either side². They will also measure the strength and endurance of various muscles in the neck, upper back, and arms.

According to the CPG¹, cervicogenic headache will present with a cluster of similar findings from these examinations.

  • Cervical Flexion test positive for decreased pain free range of motion.
  • Decrease in overall active range of motion of the neck.
  • Headache reproduced with palpation of the bony segments of the upper cervical spine.
  • Limited mobility of the cervical vertebral segments, meaning that there will be decreased motion between the segments compared to what is normally expected.
  • Deficits in the strength, endurance, and coordination of the neck muscles.

Treatment of Cervicogenic Headache

With the findings of the evaluation and the time frame of the injury in mind, the PT can begin treatment. The 2017 CPG outlines various exercises that are confirmed by high level evidence to be effective for neck pain with headache, depending on the chronicity of the injury¹. For acute cervicogenic headache, they recommend the C1-C2 self-SNAG, which stands for self-sustained natural apophyseal glide, and supervised instruction in active mobility exercises. For subacute patients, the CPG recommends more active exercises as the irritability of the local tissues has decreased. These activities should include cervical manipulation and mobilizations (in the absence of any contraindications) and can also be followed by a self-SNAG exercise. For patients with chronic neck pain with headache, PTs can provide cervical or cervicothoracic manipulations based on clinical judgement. These manipulations should be performed in conjunction with shoulder girdle and neck strengthening, stretching, and endurance exercises.

How Physical Therapy First Can Help You

The Physical Therapists at Physical Therapy First are experts in the diagnosis and treatment of cervicogenic headaches as proposed by the CPG. They can help to put together the puzzle pieces of your symptoms and create a plan for your treatment. Here at PT First you receive an hour one on one with a physical therapist to address your specific needs. We at PT First look forward to working together with you to decrease your pain and increase your quality of life.


  1. Blanpied P R et al. 2017. Neck Pain Revision 2017. J Orthop Sports Phys Ther. 47(7):A1-A83. doi:10.2519/jospt.2017.0302

Rubio-Ochoa J, Benítez-Martínez J, Lluch E, Santacruz-Zaragozá S, Gómez-Contreras P, Cook CE. Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review. Man Ther. 2016;21:35-40.