Anterior Neck and Cervicogenic Headaches

Original Editor - Jess Bell Top Contributors - Jess Bell, Tarina van der Stockt, Kim Jackson and Vidya Acharya

Introduction[edit | edit source]

Cervicogenic headache (CGH) is caused primarily by dysfunction in the upper cervical spine. However, patients with CGH are also highly likely to have myofascial trigger point pain from overactivity in their anterior neck muscles (including sternocleidomastoid) and weakness of their deep neck flexors.[1] It is, therefore, important to consider the role of the anterior neck when assessing and treating patients with CGH.

For more information on the role of the upper cervical spine, please click here.

For more information on the superior scapula region, please click here.

Sternocleidomastoid[edit | edit source]

While there is debate over whether or not the SCM is specifically implicated in CGH,[2] its trigger points have a similar referral pattern to that seen in CGH.[1] Palpating SCM may recreate the patient's CGH.[1][2] The SCM typically refers pain to the head and orofacial region (primarily the ear and temporomandibular joint), supraorbital and suboccipital areas.[3] The deep clavicular part of the muscle can also refer pain to behind the ear and above the eye.[3] The following video shows the most common SCM trigger points and their referral patterns.


Potential Causes for Anterior Neck Dysfunction[edit | edit source]

  • Poor posture
  • Deep neck flexors dysfunction
  • Disordered breathing pattern

Assessment[edit | edit source]

Posture[edit | edit source]

It is important to assess the posture of patients presenting with CHG. In particular, the Janda upper crossed syndrome is a postural pattern commonly seen in patients with neck pain and headaches.[1] The upper crossed syndrome refers to a specific pattern of muscle activation (particularly in the neck, trunk, and scapular muscles) with altered movement (i.e. scapula dyskinesia).[5]

These altered patterns exist alongside recognised postural changes, including:[5][6]

  • Forward head position
  • Rounded shoulder posture
  • Increased thoracic kyphosis

These changes have an impact on the biomechanics of the non-contractile parts of the cervical spine. Because of these changes, individuals with upper crossed posture typically have more active (or over-active) neck muscles in order to achieve cervical stability.[6]

Common changes associated with upper crossed posture are:[1][2][6]

  • Inhibited deep neck flexors (see below)
  • Overactive or tight pectoral muscles
  • Overactive upper trapezius
  • Inhibited lower trapezius and serratus anterior


Deep Neck Flexors[edit | edit source]

CGH and neck pain are often associated with weak or inhibited deep neck flexors.[2] To assess the strength and endurance of the deep neck flexors, you can position your patient in supine with knees bent. The patient is then asked to lift his / her head and look at his / her toes. A normal test would result in a smooth reversal of cervical lordosis and the chin would remain tucked. If the patient has deep neck flexor weakness, SCM tends to compensate.[1] The patient may also protract his / her chin at the beginning of the movement.[1]

The craniocervical flexion test (CCF), described by Jull and colleagues, can also be used to assess deep neck flexor strength.[1] It is a reliable measure of deep neck flexor performance.[8] During this test, it has been found that greater activation of the superficial flexor muscles indicates reduced deep cervical flexor activity.[9]

It does, however, rely on the use of an inflatable cuff (biofeedback). The cuff is placed under the patient’s neck while she / he lies supine. The patient is asked to nod, and maintain a target pressure on the cuff. Cuff pressure is started on 20 mm Hg and is progressed by increasing by 2 mm Hg over five levels. The test is concluded if / when the patient performs craniocervical flexion while maintaining 30 mm Hg.[1]

When performing these tests, it is important to look for activity of SCM during the nodding movement. Normally, SCM should not activate during a nodding motion.[2] Falla and colleagues demonstrated that individuals without neck pain had less SCM and scalene muscle activity during this movement on EMG when compared to individuals with neck pain.[10] The activation of SCM became more pronounced as the degree of flexion increased.[10]  Individuals whose deep neck flexors are inhibited typically develop hypertonic / overactive SCM.[2]

Breathing Pattern[edit | edit source]

It is recognised that there is a relationship between breathing pattern disorders, pain and motor control deficits.[11] Patients with neck pain often present with various musculoskeletal deficits and respiratory dysfunctions,[12] so it is important to assess the breathing pattern of patients with neck pain and CGH.[2]

A normal breathing pattern at rest should be nose / abdominal.[13] The diaphragm and intercostal muscles should be the only muscles that are active during quiet inspiration.[14] During quiet exhalation, the rib cage and chest wall relax and return to their original position, while the diaphragm relaxes and lifts. This movement expels air from the lungs.[15] However, this pattern can be disturbed by a number of factors (including habitual mouth breathing, environmental factors, stress, hormones etc).[13] These factors are discussed in more detail here.

A full breathing assessment is described here, but when assessing breathing patterns, it is important to remember that:[13]

  • Movement should be regular
  • Exhalation should be slightly longer than inhalation
  • There should be a slight pause at the end of exhalation
  • Breathing be nose / abdominal at rest
  • A normal adult respiratory rate is 10-14 breaths per minute

It is also important to note that patients with chronic neck pain and deep neck flexor inhibition often present with overactive accessory respiratory muscles (including SCM and scalenes).[1] Adopting an upper chest breathing pattern will reinforce these muscle imbalances with every breath.[1]

Treatment[edit | edit source]

Deep Neck Flexors[edit | edit source]

Low-load craniocervical programmes, which focus specifically on motor control of the deep neck flexors have been shown to be beneficial for neck pain and headache.[2] In particular, Jull and colleagues found that participating in six weeks of craniocervical flexion exercises was as effective as spinal manipulation at reducing cervical pain, and headache frequency and intensity for up to one year.[16]

These exercises are typically performed using some form of pressure sensor biofeedback. Various protocols are discussed here, but patients are usually directed to perform craniocervical flexion (i.e. nodding) aiming for a target pressure of 20 mm Hg. They then work their way up to around 30 mm Hg.[2] While performing the exercises, it can be useful to advise patients not to:[2]

  • Lift their head from the table
  • Drop their head back onto the table
  • Over-activate SCM and anterior scalenes

The number of repetitions and the time that the contraction is held varies across studies, but patients are generally asked to maintain craniocervical flexion for between two and ten seconds, followed by a rest period. The target pressure is then increased in increments of 2 mm Hg.[17][16]

If therapists do not have access to a biofeedback device, it is possible to ask patients to palpate their SCM while performing a chin nodding exercise. Patients will be able to feel if their SCM activates and can use this as a guide to know if they are performing the exercise correctly (i.e. trying to avoid activation of SCM).[2]


NB: while deep neck flexors are often weak, it may be beneficial to initially identify and focus on other dysfunctions that are contributing to muscle imbalances. Kaplan notes that some patients may appear to have low strength on muscle testing, but when other dysfunctions (such as hypomobility or trigger points of SCM) are addressed, activation of the deep neck flexors actually improves on retesting as patients are less inhibited by pain.[2]

Breathing[edit | edit source]

As discussed here, there is limited research exploring the relationship between breathing and headaches. However, there is some evidence to suggest that diaphragmatic breathing helps to reduce psychological distress, which is often associated with headache.[19][20][21] Moreover, when patients adopt an upper chest breathing pattern, they over-use their accessory respiratory muscles (SCM and scalenes).[1][2] Thus, breathing retraining may have a positive impact on SCM overactivity.

Breathing retraining is discussed in detail here, but some cues for the patient might include:[2]

  • Lying supine: place one hand on stomach and feel it rising up and down (i.e provide tactile feedback)
  • If the patient is unable to achieve diaphragmatic breathing with this cue, it is possible to place a small amount of resistance (i.e. a small weight or Theraband) across the abdomen. This may help to facilitate increased movement of the lower ribs and stomach

Reinforcement[edit | edit source]

Postural Reinforcement[edit | edit source]

Postural interventions are not designed to force a patient to be in an "optimum" posture all day. Patients should be able to relax and move around freely.[2] However, some strategies to counter a forward head posture might include:[2]

Deep Neck Flexors[edit | edit source]

Progressions to reinforce improvements in deep neck flexor strength include performing exercises in other functional positions, such as while standing, or while doing other exercises (e.g. planks, rowing).[2]

Breathing[edit | edit source]

Breathing retraining can also be practised in other positions and during functional activities to ensure carryover.[2]

Summary[edit | edit source]

  • Structures of the anterior neck can have a significant impact on CGH even if they do not specifically cause this form of headache
  • An assessment of the anterior neck should include an examination of:
    • posture
    • deep neck flexors
    • breathing pattern
  • Any dysfunctions should be managed to enhance outcomes in CGH patients

References[edit | edit source]

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Page P. Cervicogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther. 2011; 6(3): 254-66.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 Kaplan A. Cervicogenic Headaches - Anterior Neck Course. Physioplus, 2020.
  3. 3.0 3.1 Cook S, Moule AJ, Diagnosing Pain Referral from Neck and Shoulders. In: Moule AJ, Hicks ML, editors. Diagnosing Dental and Orofacial Pain: A Clinical Manual. Chichester: John Wiley & Sons, Ltd, 2016. p89-95.
  4. NAT Education. Sternocleidomastoid Muscle (SCM) Trigger Points. Available from: [last accessed 22/12/2020]
  5. 5.0 5.1 Seidi F, Bayattork M, Minoonejad H, Andersen LL, Page P. Comprehensive corrective exercise program improves alignment, muscle activation and movement pattern of men with upper crossed syndrome: randomized controlled trial. Sci Rep. 2020; 10(1): 20688.
  6. 6.0 6.1 6.2 Arshadi R, Ghasemi GA, Samadi H. Effects of an 8-week selective corrective exercises program on electromyography activity of scapular and neck muscles in persons with upper crossed syndrome: Randomized controlled trial. Phys Ther Sport. 2019; 37: 113-9.
  7. NAT Education. Posture - Upper Crossed Pattern Syndrome. Available from: [last accessed 24/12/2020]
  8. Falla D, Jull G, Dall'Alba P, Rainoldi A, Merletti R. An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion. Phys Ther. 2003; 83(10): 899-906.
  9. Jull G, Falla D. Does increased superficial neck flexor activity in the craniocervical flexion test reflect reduced deep flexor activity in people with neck pain? Man Ther. 2016; 25: 43-7.
  10. 10.0 10.1 Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine (Phila Pa 1976). 2004; 29(19): 2108-14.
  11. Bradley H, Esformes J. Breathing pattern disorders and functional movement. Int J Sports Phys Ther. 2014; 9(1): 28-39.
  12. Wirth B, Amstalden M, Perk M, Boutellier U, Humphreys BK. Respiratory dysfunction in patients with chronic neck pain - influence of thoracic spine and chest mobility. Man Ther. 2014;19(5): 440-444. 
  13. 13.0 13.1 13.2 Clifton-Smith T. The Science of Breathing Well Course. Physioplus. 2020.
  14. Clifton-Smith T. How We Breathe Course. Physioplus. 2020.
  15. Bains KNS, Kashyap S, Lappin SL. Anatomy, Thorax, Diaphragm. [Updated 2020 Apr 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:
  16. 16.0 16.1 Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man Ther. 2009; 14(6): 696-701.
  17. Park SK, Yang DJ, Kim JH, Heo JW, Uhm YH, Yoon JH. Analysis of mechanical properties of cervical muscles in patients with cervicogenic headache. J Phys Ther Sci. 2017; 29(2): 332-5.
  18. BSR Physical Therapy. Craniocervical Flexion Exercise. Available from: [last accessed 6/12/2020]
  19. Kristoffersen ES, Aaseth K, Grande RB, Lundqvist C, Russell MB. Psychological distress, neuroticism and disability associated with secondary chronic headache in the general population - the Akershus study of chronic headache. J Headache Pain. 2018;19(1):62.
  20. Ma X, Yue ZQ, Gong ZQ, et al. The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults. Front Psychol. 2017; 8: 874.
  21. Hopper SI, Murray SL, Ferrara LR, Singleton JK. Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review. JBI Database System Rev Implement Rep. 2019; 17(9): 1855-76.
  22. John Gibbons. Athletic Taping to control Posture and reduce Back and Neck Pain! Available from: [last accessed 24/12/2020]
  23. John Gibbons. Try this Kinesiology Taping technique for poor posture - its incredible. Available from: [last accessed 24/12/2020]