Managing Cervicogenic Headaches with Physical Therapy

Cervicogenic headaches are caused by musculoskeletal dysfunction in the upper cervical spine that refers pain to the head, often developing on one side of the head. Cervical spine dysfunction can be caused by irritation or compression of cervical nerves, muscle strains to the neck, shoulder, or upper back, arthritis, poor posture, or from an sports or whiplash injury.  Physical therapy is often the first line of treatment for cervicogenic headaches and can help manage pain and address the underlying cause of the headache pain through a targeted manual therapy and strengthening exercises program.

Understanding Cervicogenic Headaches

Cervicogenic headaches are a type of headache that begins in the upper cervical spine (the top seven vertebrae of the neck) and refers pain to the head, often developing on one side of the head, starting from the back of the head and neck and radiating toward the front. Cervicogenic headaches tend to affect people ages 30 to 44 more often and women have a four times higher risk of developing a cervicogenic headache.

Common symptoms of a cervicogenic headache include:

• Pain that radiates through the neck to the head with sudden movements or prolonged positions

• Pain that is felt on one side of the head, behind, around, and above the ear and which can radiate to the forehead, temple, or behind the eyes.

• Pain that feels constant rather than throbbing

• Pain in the shoulders or upper back

• Limited range of motion in the neck

• Numbness or tingling in the arms or hands

• Neck stiffness that makes it difficult to move normally

Cervicogenic headaches (CGH) develop due to dysfunction in the cervical spine, often from long-term issues with the neck’s bones, joints, or muscles. A CGH can result from irritation or compression of the cervical spinal nerves, soft tissues, and blood vessels in the neck as well as from muscle strains in the neck, shoulder, or upper back that refer pain to the head. CGHs can be caused by structural issues like arthritis, degenerative disc disease, or a herniated disc in the cervical spine.

CGHs can also develop in those in professions in which they must hold their head a certain way (hair stylists or truck drivers) as the repetitive strain can contribute to a headache. Bad posture, such as sticking the head out in front of the body or hunching over a computer, can place extra weight on the neck and upper back, leading to a headache. A sudden incident like a fall, sports injury, or whiplash from a car accident can also trigger a CGH if the nerves in the neck are pinched.

Physical Therapy Management of Cervicogenic Headaches

Physical therapy is often the first line of treatment for cervicogenic headaches and can help manage pain and address the underlying cause of the headache pain through a targeted manual therapy and strengthening exercises program. Physical therapy aims to strengthen weakened neck muscles, relieve pinched nerves, relax tight shoulder and upper back muscles, and enhance neck joint mobility.

Physical therapy treatment for a cervicogenic headache can include:

• Pain management may involve the use of a TENs unit, which uses electrotherapy via a low-voltage electric current to stimulate nerves and treat pain.

• Manual therapy involves soft tissue and upper cervical spine joint manipulations to help soothe muscles and decrease pressure in the region as well as restore range of motion in the neck. Research has shown that SMT (spinal manual therapy) to the cervical spine and upper thoracic spine can lead to a significant reduction in headache frequency and intensity.

• Dry needling involves the insertion of thin filiform needles into trigger points (taut bands of muscle) in the neck and shoulder muscles to ease tension and reduce referred pain from these trigger points.

• Myofascial release (MFR) involves manual stretching to address adhesions in fascial connections which can restrict normal movement of muscles between fascial planes in the neck and shoulder regions. MFR can restore the length and integrity of fascial tissue, helping alleviate pain by reducing strain on sensitive structures like blood vessels and nerves in the area.

• Targeted stretching of the neck, upper back, and chest muscles (upper trapezius, levator scapulae, and pectoral muscles) to relieve tight muscles. Stretching can involve alternate cycles of contraction and relaxation to help relax and lengthen tight muscles to improve range of motion in the neck.

• Postural training particularly of the lumbar and thoracic spines to correct any postural deficits contributing to neck pain and headaches. The therapist may guide the patient through sensorimotor exercises, such as progressive exercises on unstable surfaces, to promote reflexive stabilization and postural stability. The therapist also strengthens the core to support proper posture of the spine and neck.

• Muscle strengthening of the deep neck flexor muscles and scapular muscles to reduce neck tension and address weak muscles or muscle imbalances in the neck, shoulders, and upper back. Stronger muscles can reduce the pressure on tight nerves in the neck that may be referring pain to the head and causing headaches. Exercises can include lateral flexion, rotation of neck muscles, chin tucks, and shoulder blade stretching and strengthening.

• Aquatic therapy involves exercising in a heated pool as the water reduces the weight and pressure on the neck, allowing patients to more easily strengthen neck muscles. The hydrostatic pressure of the water also pushed against the body, helping reduce swelling in and around the neck.

• Cervical traction treatment involves the use of a manual traction table or cervical traction device to gently stretch the spinal muscles and lightly pull on the head to create space between the cervical vertebrae. This helps to reduce pressure and tension in the neck.

Research has shown that physical therapy treatment can dramatically reduce pain and improve outcomes for those with cervicogenic headaches. Various studies have noted the benefits of spinal manipulation, dry needling, manual therapy techniques, and targeted strengthening exercises in relieving cervicogenic headache pain and restoring neck mobility and function.  In one study assessing 28 patients with cervicogenic headaches, spinal manipulation was shown to cut down on pain-relieving medications by 36% and lower headache frequency by 69%.

A recent 2024 study noted that spinal manipulation plus dry needling was quite effective in reducing short-term headache intensity and frequency. Muscle-energy techniques combined with exercise as well as soft tissue techniques combined with exercises were also effective in reducing short-term headache intensity.

Another 2024 study assessed the effect of lumbar control training combined with cervical stabilization exercises on CGH patients, compared to cervical stabilization exercises alone. Researchers found that there was a high statistically significant difference in post-treatment mean values of headache frequency, duration, intensity, and neck functional disability between the two groups in favor of the lumbar control training group. Therapeutic exercise involving strengthening exercises has also been shown to improve headache intensity and frequency. One study compared low-load endurance cervico-scapular exercises to no treatment and found statistically significant changes in headache intensity and frequency at 7 weeks and 12 months post-treatment.

Are you experiencing chronic cervicogenic headaches? Work with a physical therapist to find relief and address the underlying musculoskeletal issue causing your headaches!