Most people will suffer from a headache at some point in their life. In fact, the WHO reports that up to 47% of people will have suffered from a headache within the past 12 months.

The cause of a headache is often multi-variate. It can be the result of a physical injury or illness, emotional or psychological stress, pharmacological overuse or genetics. They can have a huge impact on a persons quality of life and can often result in time off work. Neck pain and cervical muscle tenderness are commonly featured in primary headache disorders.


According to the International Classification of Headache Disorders (ICHD) headaches can be classified into primary and secondary causes. Primary headache classification includes:

  • Migraines
  • Tension-Type headache 
  • Cluster headache 
  • Other primary headaches

Migraine headaches are uncommon and are generally attributed to a vascular inflammatory cause.  They can often begin early in life and be life long. Features of migraine are the sporadic 'attack' type nature, increasing intensity, short duration of a few hours, association with auras (such as light and sound) and nausea. Most effective management is medical with correct use of non-steroidal anti-inflammatory (NSAIDs) and analgesia (aspirin/panadol) medication. Acupuncture and relaxation techniques have also been shown to be effective in prevention of recurrence. New evidence with the work of Dean Watson however is showing that Migraine type headache can result from a sensitisation of the nerves of the upper 3 cervical vertebrae... more on that below.

Tension-Type headaches (TTH) are by far the most common type. They account for nearly 90% of headaches. The pressure-like pain from TTH is often felt from the base of the skull and can radiate to the forehead, eyes and neck. It usually effects both sides. Causes can include stress, sleep deprivation, posture, eyestrain and even hunger.

Cluster headaches are very rare and are identified by frequently recurring but brief, extremely severe headaches. These are usually felt one sided and with pain around the eye. There may be some associated autonomic symptoms such as tears, redness, nasal congestion, swelling and eyelid droop. There are limited effective treatments available. Most treatment options involve medication which are best discussed with your doctor.

In treating headaches, it is useful to understand the difference between a primary headache (such as TTH) and and secondary headache (such as cervicogenic). Management of these headache types vary though their symptoms may be similar. There is a vast list of secondary causes of headache, most needing further investigations and management with your medical doctor. Any severe headache that is new or different to your normal headache pattern should be investigated medically first.

Cervicogenic headache

Physiotherapy can successfully treat TTH, migraine and cervicogenic headaches that arise from the neck and surrounding soft tissue structures and help to prevent their recurrence. The symptoms experienced in relation to a headache that is referred from the upper 3 vertebra (C1/2/3) in the cervical spine (neck), can mimic a migraine, including the associated aura and nausea.

The upper 3 vertebra can refer pain to the face and head through the links between the nerves in the neck and the trigeminocervical complex (TCC) found in the upper cervical spinal cord. This linkage of nerve pathways allows pain from the neck to be referred to the face. Muscle spasm, joint stiffness, neural hypersensitisation and vascular changes can all be a source of pain in headaches referred from the neck. It is not uncommon for people who suffer from headaches to have identified certain triggers for their headaches. Certain foods, hormone cycles, dehydration and posture are all possible triggers which can sensitise the structures in the upper neck and result in a headache. 

Poor loading patterns of the neck and head can result in postural causes (relating to muscles and joints of the neck) that are associated with headaches, the term cervicogenic headache is often used. This term relates to headache symptoms that include:

  • neck and/or jaw pain (such as following a whiplash injury)
  • pain felt in the forehead or back of head
  • feelings of dizziness or light-headedness

The symptoms often worsened with prolonged/sustained neck positions or repetitive neck movements (such as when using computers/phones/tablets). They are often eased by manual pressure to the base of the skull.


Hands on treatment (manual therapy) of these types of headaches has been shown to be effective in reducing the severity of symptoms and frequency of occurrence. Your physiotherapist can use various manual techniques such as massage, joint mobilisations, dry needling and taping to correct any imbalances around the neck and to restore normal movement and mechanics to the joints in the upper cervical vertebrae. Your physiotherapist can help you recognise your triggers associated with the headaches and use these as a re-assessment tool to monitor the progress of your treatments.

Postural re-education is an important component of managing these headaches as stress on the lumbar and thoracic spines can create sub-optimal patterns of loading in the head and neck. Re-training of the deep stabiliser muscles around your neck and mid back (thorax) with a biofeedback tool and correcting the imbalances of the larger muscle groups has been shown to be effective in long term headache management. 

Your physiotherapist can show you how to alleviate your symptoms through self-massage and specific self-mobilising techniques to maintain the mobility of the upper cervical joints. It is important to identify the patterns of movement and the structures in the body that are responsible for your symptoms. Your physio will identify which static postures or dysfunctional movement patterns that you have adopted in your daily movement tasks or sports are contributing to your headache. Restoring normal movement patterns in your thorax and neck can help prevent further occurrences. 

An ergonomic assessment of your work station will often be recommended by your physiotherapist. Correct setup of your computer at work (or home) can help manage symptoms. This may require changes to chair/desk height, monitor position and height, foot placement and sitting postures. Using a standing desk may be an appropriate alternative, read more here to learn about this. Your physio will help you understand how your posture at the computer is related to your headache.

Finally, management of a headache is multifaceted and will often require attention to other factors such as:

  • Diet  
  • Sleep patterns
  • Medication (prevent overuse)
  • Lifestyle choices and stress management strategies

Discuss these and other treatment options with your physiotherapist.