Practical Assessment and Treatment of Cervicogenic Headaches

Original Editor - Jess Bell Top Contributors - Jess Bell and Kim Jackson

Introduction[edit | edit source]

As discussed here, cervicogenic headache  (CGH) is a secondary headache condition that affects between 2.5 and  4.1 percent of the population.[1] CGH begins in the neck or occipital region and can refer to the face and head. The specific sources of CGH are any structures innervated by the C1 to C3 nerve roots.[1] Pain occurs more frequently in the suboccipital region,[2] although CGH can also refer to the orbital and frontal regions.[3]

While only the upper three cervical spinal segments are specifically recognised as pain generators for CGH, a number of other structures also play an important role in the CGH, including upper trapezius and sternocleidomastoid.

This page will explore the practical assessment and treatment of CGH, building on content discussed in the pages linked to above.

Evidence for the Physiotherapy in the Management of CGH[edit | edit source]

Because CGH is related to musculoskeletal dysfunction, a multimodal approach, which includes physiotherapy, is recommended for the management of these headaches.[4]

Various studies exist to support the use of physiotherapy for the management of CGH.[4][5][6][7][8] One study which highlights the benefits of physiotherapy was published by Jull and colleagues in 2009. It examined the effect of a six week intervention of manipulative therapy, exercise therapy or a combination of the two and compared outcomes with a control group.[6]

After the intervention period, 81 percent of participants in the combined manual therapy and exercise group had a 50 percent reduction in headache and 42 percent had a 100 percent reduction.[6] 71 percent of participants in the manipulative therapy group had a 50 percent reduction in headaches and 33 percent had a 100 percent reduction. Results in the exercise alone group were similar with 76 percent reporting 50 percent reduction and 31 percent reporting 100 percent reduction. 29 percent of the control group had a 50 percent reduction, but only 4 percent had 100 percent reduction.[6] This study highlights the improvements that can be achieved with targeted physiotherapy interventions for CGH.

Assessment[edit | edit source]

When assessing CGH, it is important to consider structures beyond the upper three cervical segments. While not all patients will be symptomatic in all the areas discussed here, management will be enhanced if all dysfunctional areas are identified and addressed.[9]

Information on a full cervical spine examination is discussed here, including the subjective assessment. Key points relevant to CGH are discussed here, but it is important to remember to find out about:[9]

  • Headache history
    • Intensity of headache
    • Headache frequency
    • Duration of headaches
  • Irritability levels

It is also essential to screen for any red flags during the subjective and objective assessment. Specific cervical red flags include:[9]

  • Cranial artery dysfunction
  • Intracranial issues
  • Cervical spine instability

Headache red flags are discussed here and here. Upper limb tension tests are also necessary to rule out radiculopathy.

Assuming red flags are ruled out, an objective CGH assessment should examine the:[9]

Upper Cervical Spine[edit | edit source]

  • Range of motion testing (flexion, extension, side flexion, rotation)
  • OA nod (C0-1)
  • Cervical flexion rotation test (to assess C1-2)
    • This test has been found to have the highest reliability and strongest diagnostic accuracy for cervicogenic headache[10]
    • A range of 40 degrees or more is considered normal[11]
    • A result less than 40 degrees is likely associated with C1-2 impairment, but it can also indicate soft tissue dysfunction (specifically the suboccipitals)[9]
  • C2-3 (and beyond) can be assessed with PPIVMs and PAIVMs
  • The first rib should also be assessed


Superior Scapula[edit | edit source]

  • Posture - a slumped posture is often associated with CGH.[9] Assessing upper trapezius in a weight bearing position (slumped sitting / standing) indicates if there is any overactivity. If tension decreases in upright sitting or supine, there is likely overuse of upper trapezius[13]
  • Scapula function
    • Elevate arms to check for major dyskinesia
    • Assess scapula movement during exercises (such as prone shoulder extension / abduction)
      • Check for upper trapezius activation and control

Sternocleidomastoid[edit | edit source]

  • Unlike upper trapezius, there may not be substantial increases in SCM tone in sitting[14]
  • Posture is again significant, specifically a forward head posture[4][14]
  • The nod test can be used to determine how SCM is functioning in relation to the deep neck flexors.[4] Initially, a single nod can be assessed followed by a sustained hold. The mean hold time of the deep neck flexors is 38.9 seconds for men and 29.4 seconds for women.[15] When the patient performs this test, the therapist can palpate SCM and the anterior scalenes to determine how much activation is present[9]
  • Breathing pattern - patients with chronic neck pain and deep neck flexor inhibition often present with overactive accessory respiratory muscles (including SCM and scalenes).[4] More information on a breathing assessment is available here, but it is important to check for chest vs abdominal breathing, mouth breathing, ratio of inhalation to exhalation etc

Treatment[edit | edit source]

Treatment of CGH varies based on the patient. The assessment findings will guide the treatment approach. Specific treatment options for CGH are discussed in the following pages:

The rest of this page will explore treatment options based on a case study. It will also provide ideas for treatment progressions and long-term maintenance options.

Case Study[edit | edit source]

A female patient presents with a long-standing history of headache. These are primarily in the occipital region but extend to the orbital area as well. She denies aura, or light and sound sensitivity. Her headaches appear to be cervicogenic in nature. Potential red flags have been ruled out. Upper limb neural tension tests are negative. Key assessment findings:[9]

  • Reduced range of motion, particularly side flexion and rotation
  • Reduced mobility of C1-2 (right flexion rotation test is 20 degrees, left is 15 degrees)
  • Reduced OA nod, particularly on the right side
  • Guarding and hypomobility at C2-3
  • Bilateral hypomobility of the first rib
  • Posture - slumped, forward head position
  • Shoulder dyskinesia - overactive upper trapezius and reduced lower trapezius on prone shoulder abduction
  • Overactive SCM
  • Reduced deep neck flexors strength and endurance (<5 second hold)
  • Normal breathing pattern

Manual Techniques[edit | edit source]

The first aim of treatment for this patient is to reduce the tension in her neck. Initial treatment may focus on gentle suboccipital release. Always remember to recheck relevant objective tests post-intervention to determine effectiveness. In this case, suboccipital release resulted in improvement in cervical flexion rotation scores (right and left side increased to 25 degrees).[9]

Following on from this, joint mobilisations (e.g. PA glides) can be used to target areas that are hypomobile.[9]

Sternocleidomastoid tone could then be addressed with soft tissue release, focusing on the more restricted side. Because of the relationship between SCM and the deep neck flexors, it is useful to reassess deep neck flexor endurance after treating SCM.[9]

Progressions[edit | edit source]

Potential progressions for manual techniques could include thoracic manipulations. Any progressions must be made based on the patient's irritability levels.[9] However, thoracic manipulations can benefit patients with neck pain and headaches associated with neck pain.[16] They may also be particularly useful for patients with upper trapezius and scapula dyskinesia.[17]

Exercise Rehabilitation[edit | edit source]

Specific exercises that may be useful for this patient include:[9]

  • Open book stretch (to enhance her thoracic mobility)
  • Side lying horizontal abduction (to decrease over-activation of her upper trapezius)
  • Chin nod (to improve her deep neck flexor strength)
  • Diaphragmatic breathing (for relaxation and to reduce some of the overuse of accessory respiratory muscles (SCM / scalenes)
  • AA self SNAGs


Taping[edit | edit source]

Taping to reinforce postural improvements can be beneficial.[9]

Timing of Progressions[edit | edit source]

The speed at which you progress a patient will depend on his / her unique presentation. Some patients may progress through the early phases of rehabilitation quickly, particularly if they have low irritability levels and high function. For this type of patient, you may spend more time on later phase functional rehabilitation. Patients who have complex, chronic headaches and who are highly irritable may need to spend longer in the early phase of rehabilitation.[9]

Examples of Exercise Progressions[edit | edit source]

  • Deep neck flexor strengthening - progressions include adding overpressure and increasing the hold time. This can be increased by a second every few days


  • Shoulder exercises - progressions include performing exercises in more challenging positions like prone or quadruped:
    • Prone shoulder extension (I)
    • Prone horizontal abduction (T)
    • Prone arm lift at around 135 degrees (Y)


    • Quadruped - add in contralateral cervical rotation (to inhibit upper trapezius)
    • Add in theraband exercises
  • Diaphragmatic breathing can be practised in standing or tall kneeling
  • Doorway stretch - this can be performed in a "high 5" position or a "low 5" position
  • Thoracic rotation stretch
  • Latissimus dorsi stretch
  • Press-ups - wall press-ups may be a good initial starting point. It is key to avoid a forward head position and to maintain lordotic control
  • Plank to V - this is a useful closed chain serratus anterior exercise[9]


Other Considerations[edit | edit source]

Many patients who present with CGH may also have other areas of back pain (lumbar or thoracic). These issues may be long-standing or chronic. While the focus of CGH treatment will be on the cervical spine and thoracic region, it can also be beneficial to include some exercises that may enhance a patient’s hip or lumbar mobility (e.g. a hip flexor stretch with upper extremity raise). This could result in longer-lasting improvements.[9]

Exercise Post-Discharge[edit | edit source]

It may be beneficial for patients to continue with certain exercises post-discharge as part of the long-term self management plan. Exercises that may be beneficial are:

  • AA self SNAGs - regularly performing this exercise results in a 54 percent reduction in Headache Index scores at 12 months[5]
  • Ongoing deep neck flexor strengthening - patients who have deep neck flexor inhibition are more likely to experience a return of CGH[9]
  • Theraband or prone scapula exercises (I, T, Ys see above)
  • Thoracic rotation exercises (e.g. in quadruped)
  • Doorway stretch
  • Latissimus dorsi stretch

If these exercises are performed 2-3 times per week, it may help to reduce the frequency of CGH.[9]

Summary[edit | edit source]

  • CGH has many causes and each dysfunction should be addressed in order to reduce headache frequency
  • Management should be multimodal, including exercise therapy and manual techniques, as well as breathing retraining and other adjuncts like taping
  • Management will vary depending on a patient’s unique presentation
  • Patients should have long-term self-maintenance plans to reinforce improvements

References[edit | edit source]

  1. 1.0 1.1 Stovner LJ, Nichols E, Steiner T, Abd-Allah F, Abdelalim A, Al-Raddadi R et al. Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2018; 17(11): 954-76.
  2. Uthaikhup S, Barbero M, Falla D, Sremakaew M, Tanrprawate S, Nudsasarn A. Profiling the Extent and Location of Pain in Migraine and Cervicogenic Headache: A Cross-sectional Single-Site Observational Study. Pain Med. 2020 Sep 11:pnaa282.
  3. Kaplan A. Introduction to Cervicogenic Headache Course. Physioplus, 2020.
  4. 4.0 4.1 4.2 4.3 4.4 Page P. Cervicogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther. 2011;6(3):254-66.
  5. 5.0 5.1 Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K.  Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther.  2007; 37(3): 100-7.
  6. 6.0 6.1 6.2 6.3 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.
  7. Mohamed AA, Shendy WS, Semary M, Mourad HS, Battecha KH, Soliman ES et al. Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache. J Phys Ther Sci. 2019; 31(4): 376-81.
  8. Kocjan J.  Effect of a C1-2 Mulligan sustained natural apophyseal glide (SNAG) in the treatment of cervicogenic headache. J of Education, Health, and Sport. 2015; 5(6): 79-87.
  9. 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18 Kaplan A. Practical Assessment and Treatment of Cervicogenic Headaches Course. Physioplus, 2020.
  10. Rubio-Ochoa J, Benítez-Martínez J, Lluch E, Santacruz-Zaragozá S, Gómez-Contreras P, Cook CE. Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review. Man Ther. 2016; 21: 35-40.
  11. Kaplan A. Cervicogenic Headache - Upper Cervical Course. Physioplus, 2020.
  12. Physical Therapy Nation. Flexion Rotation Test. Available from: [last accessed 7/12/2020]
  13. Kaplan A. Superior Scapula - Cervigenic Headaches Course. Physioplus, 2020.
  14. 14.0 14.1 Kaplan A. Cervicogenic Headaches - Anterior Neck Course. Physioplus, 2020.
  15. Domenech MA, Sizer PS, Dedrick GS, McGalliard MK, Brismee JM. The deep neck flexor endurance test: normative data scores in healthy adults. PM R. 2011; 3(2): 105-10.
  16. Blanpied PR, Gross AR, Elliott JM, Devaney LL, Clewley D, Walton DM, Sparks C, Robertson EK. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017; 47(7): A1-A83.
  17. Cleland J, Selleck B, Stowell T, Browne L, Alberini S, St. Cyr. H, Caron T. Short-Term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength. Journal of Manual & Manipulative Therapy. 2004; 12(2): 82-90.
  18. [P]Rehab. SNAGs for Cervicogenic Headaches. Available from: [last accessed 7/12/2020]
  19. Spire Injury Clinic. Chin Tuck with Overpressure. Available from: [last accessed 28/12/2020]
  20. AskDoctorJo. Prone ITWYs for Shoulder - Ask Doctor Jo. Available from: [last accessed 28/12/2020]
  21. React Physical Therapy. Downward Dog to Plank. Available from: [last accessed 28/12/2020]