Physical Therapy Examination for the Diagnosis of Cervicogenic Headaches

By Stephanie Beatty, SPT

What is a cervicogenic headache?

  • At some point in their lives, ~96% of people will experience headaches. The cause of headaches may be unknown, due to another condition, or due to referred pain from an adjacent area of the body such as the ears, neck, or facial structures including the mouth and nose. A cervicogenic headache is a headache that results from a musculoskeletal impairment in the upper part of the neck, known as the upper cervical spine. Cervicogenic headaches stem from a dysfunction in the complex nervous system connections between the trigeminal nerve (a nerve the originates in the region between the spinal cord and the brain) and the nerves of the upper cervical spine. This dysfunction causes neck pain to refer to different areas of the head, resulting in a headache. People will often experience referred pain around one or both eyes as well.

How are cervicogenic headaches diagnosed?

  • Cervicogenic headaches are typically diagnosed through a subjective examination, also known as a patient interview, and an objective examination during which a physical therapist examines the cervical spine and uses tests and measures to determine the cause of the patient’s headaches. According to a systematic review by Rubio-Ochoa et al., a physical examination of the cervical spine for a patient presenting with cervicogenic headaches should consist of sensitive tests such as accessory motion testing (PAIVMs) of the joints of the upper cervical spine as well as specific tests such as the cervical flexion-rotation test. During this test, the therapist will bend your head forward and rotate it side to side while monitoring any changes in your symptoms. The use of these tests assists the therapist in accurately diagnosing cervicogenic headaches and can guide treatment planning. Cervicogenic headaches have been shown to respond well to physical therapy intervention, so an accurate diagnosis is essential.

How can Physical Therapy First help with cervicogenic headaches?

  • Here at Physical Therapy First, we will evaluate you to determine the cause of your headaches and the best approach to treating them. Your initial examination will begin with a subjective interview during which the physical therapist asks questions about your headaches, any neck pain, and other pertinent medical history. The physical therapist will then conduct a physical examination that includes evidence-based tests and measures such as the ones mentioned above. The physical therapist will then develop a comprehensive, individualized treatment plan consisting of exercises and manual therapy to help alleviate your cervicogenic headaches and other symptoms.


Rubio-Ochoa J, et al., Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review, Manual Therapy (2015),



Can Physical Therapy help my Headache?

By Maureen Ambrose PT, DPT, OCS


Headaches are a common complaint for many people, and most assume that it is just normal part of life. Some may experience headaches multiple times per week or even daily. Patients often report that headache medication may help reduce the severity of the symptoms, but does not eliminate them entirely or stop them from coming back.  If this is true for you, it may be a sign that your headaches are related to dysfunction in your neck. Both tension headache and the various forms of migraine headaches will likely have a musculoskeletal component.


The term “cervicogenic headache” indicates that although pain is felt in the head, the root cause of the symptoms related to the neck (cervical spine). Common root causes of head and facial pain include:

– Altered cervical spine alignment

– Forward head posture

– Muscle tightness or trigger points in the following muscles (see figure above)

– Upper Trapezius

– Suboccipitals

– Sternocleidomastoid

– Splenius capitus and Splenius cervicis

– Shallow breathing pattern using the neck muscles

– Jaw clenching or grinding


 Now, what about those who just attribute their headaches to work-life stress? While it may be true that the headache feels worse during times of stress, it could be related to some of the root causes listed above. During a stressful meeting, do you resort to a shallow breathing pattern and overwork the neck muscles? Or, while concentrating on work, are you holding tension in your jaw or facial muscles and clenching? Each of these, over time and with repetition, has the potential to create trigger points in the neck muscles that can lead to referred pain in the head and face.

Physical Therapy for headaches begins with an exam of your neck alignment, posture, muscle strength, and breathing pattern. Treatment involves postural correction and neck strengthening, releasing trigger points, correcting breathing patterns, and improving postural and muscle awareness. If you feel that these factors could be a cause of your headaches, Physical Therapy First can help identify and treat these issues.


There are times when the headache is more than “cervicogenic,” and the following red flags from The Amercian Migraine Foundation indicate the need for medical attention:

  1. Thunderclap Headache: very severe headache that reaches its maximum severity immediately (within a couple of minutes). Thunderclap headaches require emergent medical evaluation.
  2. Positional Headache: headache that substantially changes in intensity in association with changes in position – e.g. standing from lying or vice-versa.
  3. Headaches Initiated by Exertion: headache starting while coughing, sneezing, and/or straining.
  4. New Headaches: especially if older than 50 years of age, or if there are medical conditions that make worrisome headaches more likely (e.g. cancer, blood clotting disorder).
  5. Substantial Change in Headache Pattern
  6. Constant Headache Always in the Same Location of the Head
  7. Worrisome Neurologic Symptoms: about 1/3 of people with migraine have neurologic symptoms (“migraine aura”) that typically precede onset of a migraine headache. Commonly, aura symptoms consist of slowly spreading visual symptoms sometimes accompanied by tingling of the face and upper extremity. These symptoms resolve within 60 minutes. If these symptoms have immediate onset (as opposed to a slow progression of symptoms), last longer than 60 minutes, or do not completely resolve, medical attention is required. Medical attention is also required if other symptoms are present, such as weakness of one side of the body, change in level of consciousness, significant difficulty walking, or other symptoms that worry you.
  8. Headache that never goes away
  9. Systemic symptoms: including fever, chills, weight loss, night sweats


(1)Travell JG, Simons DG. Myofascial Pain and Dysfunction, The Trigger Point Manual, Vol. 1. Baltimore. Williams and Wilkins. 1993

(2) American Migraine Foundation

Cervicogenic Headaches and Conservative PT

by Sean Phillips, PT, DPT

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial
Stephanie Racicki, Sarah Gerwin, Stacy DiClaudio, Samuel Reinmann, Megan Donaldson


Headaches are a very common complaint, affecting nearly 47% of the population. Of these headaches, cervicogenic headaches (CGHs) account for ~20% and typically affect women more often than men. This condition can be debilitating and limit your ability to work, sleep, perform household chores, or even ruin the time you want to be relaxing. These types of headaches are very common following a trauma such as whiplash, but just because you may have never been in an auto-accident doesn’t mean you can’t have CGHs. Unfortunately, these can also be caused by the prolonged and poor postures many people assume in their everyday lives.

The International Headache Society (IHS) has classified CGHs as “pain referred from a source in the neck and perceived in one or more regions of the head and/or face”. This means that neck pain usually accompanies the headache, but it is also possible to complain of arm/shoulder pain, dizziness, nausea, lightheadedness, “eye” pain, and visual disturbance.

The next time that you are suffering from a headache, try feeling the back of your neck, specifically right below your skull, to see if there is any muscular tenderness. If so, you may be suffering from a CGH, especially if pressing into these muscles make your headache worse. But the big question is: “What do I do to make my headache go away?”

Review of existing research and literature:

In a systematic review by Racicki et al, researchers attempted to determine the effectiveness of conservative PT approaches to manage patients suffering from cervicogenic headaches. There have been many techniques utilized, including invasive and non-invasive treatments. Invasive approaches can include injections, dry needling, or surgery. Non-invasive treatments can include TENS, massage, mobilization, manipulation, and exercise.

The researchers were able to find a total of 6 articles that fit their criteria which required randomized control trials and an assessment on at least one type of conservative treatment. In these studies, the interventions which were utilized included: cervical manipulation and mobilization, self-mobilization (by the patient), exercise (cerico-scapular strengthening), and thoracic manipulation.

Although the studies reviewed different techniques, many involved similar outcome measures. These included headache frequency, intensity, and duration, as well as disability, neck pain, and amount of analgesic use (pain killers).


Although the studies assessed different techniques, the overall results demonstrated that the most effective conservative treatments for CGH pain included cervical mobilization and manipulation, as well as exercise to strengthen the cervicoscapular muscles. These were especially helpful in improving headache frequency, intensity, and neck pain.

In addition to the 6 articles that were utilized for this review, the authors reported that some articles that were not included indicated that conservative management could reduce analgesic use as well.

Although this article displayed good success with cervical manipulation and mobilization, the studies included did not report on many of the other conservative treatments that physical therapists offer. These can include deep tissue massage, modalities such as cold packs and TENS, or cervical traction, which could also provide benefits to this patient population.


Headaches are a common disorder facing many Americans everyday. Conservative physical therapy management, including mobilization, manipulation, and exercise have been shown to have a positive effect on reducing headache intensity, frequency, and neck pain.

If you are suffering from persistent headaches that are affecting your quality of life, physical therapy may be an effective way to reduce your pain and get you back to where you want to be, while teaching self-management techniques to potentially reduce their recurrence.

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial
Stephanie Racicki, Sarah Gerwin, Stacy DiClaudio, Samuel Reinmann, Megan Donaldson
Journal of Manual and Manipulative Therapy
2013; Vol. 21 ; No. 2