Upper cervical headaches
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Upper Cervical Headaches. Margaret Anderson. Headaches. Symptom of a disorder in articular, muscular or other soft tissue of the neck

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Upper cervical headaches

Upper CervicalHeadaches

Margaret Anderson


  • Symptom of a disorder in articular, muscular or other soft tissue of the neck

  • Occur thro the convergence of cervical and trigeminal afferents on common neurones in the trigeminocervical nucleus and any structure innervated by any of upper 3 cervical nerves.

Other sources of headaches
Other sources of headaches

  • TMJ

  • Intercranial conditions: neoplasm or meningitis

  • Vascular headaches

    • Migraineous type:

    • Cluster headaches


  • Common areas of cervical headaches are frontal, orbital, temporal and occipital

  • Headaches are commonly unilateral but can be bilateral.

  • Does not change sides as can occur in migraine


  • Quality :

    • Ache, deep, boring and less commonly throbbing pain.

    • Superficial, shooting pain of lancinating pain is typical of true neuralgia.

  • Neurogenic symptoms in benign cervical musculoskeletal headaches is rare.

  • Headache is a referred pain rather that an irritation or compression of cervical nerve root but one must always ask about sensory changes in the scalp

Behavior of headaches
Behavior of Headaches

  • Often cause and effect difficult to establish

  • When do they occur: daily, 2 or 3 times a week or once a month. Establish a pattern and their duration

  • Initiating factors

  • Associated symptoms

    • Nausea/vomiting

    • Eye or ear symptoms

  • Consider provoking activities

    • Driving

    • Reading with chin in hand

    • Hairdressers basins

    • Difficulty swallowing may indicate a C3 discogenic problem


Ease factors

24 hour day

  • Rest, usually posture: lying down or sitting quietly

  • Medications

    • If chronic analgesics or NSAID offer little relief

  • May wake with headache because of poor sleeping position or busy previous day

  • Cervical stiffness

  • May build up at end of day


  • May present with headaches for weeks, months

  • May result from injury or past history of neck trauma

  • Perpetual strain to upper cervical joints can be poor posture.

  • Insidious onset of headaches may be direct response to onset of DJD

  • Headaches of upper cervical origin often coexist with migraines.

Case study
Case Study,

  • 65 year old female. Looks after grandchildren, works on various charitable committees, ‘always busy’

  • AREA

    • Left sided dull sub-occipital pain which radiates behind left eye.

    • Sub-occipital area ‘sore to touch’ and ‘feels swollen’

    • She denies right-sided pain, pain radiating into the upper extremity or any numbness and tingling.


  • Her headaches come on for no apparent reason, but she will wake at midnight after a busy day or 4am if not busy.

  • If severe she will take Tylenol and return to sleep

  • During the day she never has a headache but will sometimes wake with one, which lasts for about an hour; she is unaware of any cervical stiffness.


  • Her headaches came on about 6 months ago when her husband was seriously ill. She thought it was due to stress. Her husband recovered but the headaches remain.

  • She had headaches about 7 years ago which were successfully treated with manipulation

Planning the physical exam
Planning the Physical Exam

  • Severity

  • Irritability

  • Nature

  • Stage & stability

  • Precautions and contraindications

  • Do you think you will reproduce the headache or find a comparable sign?

Physical exam
Physical Exam

  • Observation: poking chin posture, unable to correct, stuck in upper cervical extension because of tight upper cervical and upper trapezius musculature

  • Flexion unable to unroll upper cervical, no pain with overpressure

  • Left rotation 85° stiff, no pain

  • Right rotation 70° tight Left sub-occipital, no pain

  • PPIVMS C2/3 blocked to opening and closing in rotation and lateral flexion

  • Palpation: tight upper cervical muscles, L>R, tender to touch

  • L C2/3 unilateral PA stiff local pain IV >> R

  • L C1/2 stiff, pain IV



Assessment at the end of oe
Assessment at the end of OE

  • Patient says she is no worse/same

  • Diagnosis

    • Headache of C2/3 > C1/2 origin

    • Secondary/chronic muscle shortening and spasm

    • Postural adaptation because of aging


  • Severity

  • Irritability

  • Stage

  • Stability


Think about

  • Mechanical factors

  • Functional

  • Psychosocial: well balanced elderly woman

  • Possible causes

Think about1
Think about:

  • Prognosis

    • Natural history of the disorder

      • Chronic problem

      • Level of recovery

    • Rate depends on initial response to treatment, so would expect how many visits?

      • Age

    • Likelihood of recurrence

Treatment planning
Treatment Planning

  • Outline treatment for next 2 visits

  • Remember 3 aspects of the patient’s problem

    • Headache of C2/3 > C1/2 origin = stiff upper cervical joints.

    • Secondary/chronic muscle shortening and spasm

    • Postural adaptation because of aging

  • Think about options & what you expect to change easily and start there.

  • Note: traction in upper cervical spine tends to exacerbate headaches.