Superior Scapula and Cervicogenic Headaches

Original Editor - Jess Bell Top Contributors - Jess Bell, Kim Jackson and Lucinda hampton

Introduction[edit | edit source]

Cervicogenic headache (CGH) is a form of headache that originates in the neck and refers to the head. Dysfunction in the upper cervical spine is recognised as the source of CGH.[1] However, the upper trapezius has a clear pain referral pattern to the head, so it too should be considered when assessing and treating CGH.[2]

As discussed here, pain is able to refer from the neck to the head (and vice versa) because of the convergence of trigeminal afferents and afferents from the upper three cervical spinal nerves.[1][3][4] This enables somatosensory, proprioceptive and nociceptive information from the trapezius, sternocleidomastoid and other cervical muscles to be exchanged at the trigeminocervical nucleus and ultimately be referred to the trigeminal sensory areas of the head and face.[5]

Common trapezius referral patterns are shown in the video below.


Upper Trapezius[edit | edit source]

The trapezius plays a significant role in the movement of the scapula.[7] The serratus anterior and trapezius muscles are the main force couple that act on the scapula. When these stabilisers are weak, or do not activate properly, scapula positioning and mechanics can be affected.[7]

The following video discusses the key shoulder muscles in general, including trapezius and serratus anterior.


The upper trapezius attaches distally to the clavicle, so the majority of its influence on scapulothoracic mobility occurs here. Contraction of the upper trapezius pulls the clavicle into elevation and retraction.[7]

Patients who have shoulder pain during arm elevation, often present with abnormal shoulder movements, as well as:[2][7]

  • Excessive activation of the upper trapezius
  • Decreased and / or delayed activation of the lower and middle trapezius and serratus anterior

This excessive activation of upper trapezius is likely associated with:[7]

  • Increased elevation of the clavicle
  • Anterior tilt of the scapula

Decreased activation of the lower trapezius is probably accompanied by reduced scapula upward rotation.[7]

Delayed activation of the middle trapezius may be related to increased internal rotation of the scapula and reduced stabilisation of the scapula on the thorax.[7]

While the upper trapezius is implicated in shoulder pain, it can also be involved in or affected by cervical dysfunction and CGH.[2][9][10] A recent study by Park and colleagues found that there was a statistically significant difference in the tone and stiffness of both the upper trapezius and suboccipital muscles in patients with cervicogenic headache when compared to healthy controls.[10]

Defining “Tight”[edit | edit source]

It is important to consider what “tight” means when assessing a muscle. It might refer to a patient who lacks length in a muscle or, alternatively, to a patient who has too much tone in a muscle:[2]

  • Length deficit:
  • Increased tone
    • While mobilising and stretching may be useful, it is necessary to reduce tone by retraining the motor control system[2]

Potential Causes for Upper Trapezius Problems[edit | edit source]

Potential causes for upper trapezius dysfunction include:[2]

Assessment of Upper Trapezius[edit | edit source]

Please click the links for more detailed discussions of cervical and shoulder assessments. The following points are particularly relevant to over-activity of upper trapezius and its relationship to CGH.

Posture[edit | edit source]

Palpate upper trapezius in a weight bearing position (i.e. sitting / standing) and check for tension. Normally, this muscle should be relaxed at rest, so any tightness would indicate overuse of upper trapezius. Then position the patient in lying and compare the amount of upper trapezius tension. If the tension has resolved, there is likely to be a tone issue.[2]

Alternatively, you can compare slumped sitting with an upright posture (i.e shoulders back). If the upper trapezius relaxes in the upright position, this again indicates a tone issue related to posture.[2]

Improper Scapula Function[edit | edit source]

Issues that may become apparent when assessing muscle strength or while performing functional exercises include:[2]

  • Shoulder dyskinesia
  • Shoulder hike

Shoulder Dyskinesia[edit | edit source]

In order to achieve arm elevation, there needs to be angular movement at all four shoulder joints. General patterns of movement during arm elevation have been identified as:[11]

  • Clavicular elevation, retraction, and posterior axial rotation
  • Scapular internal rotation, upward rotation, and posterior tilting relative to the clavicle
  • Glenohumeral elevation and external rotation

Normally, the scapula will upwardly rotate around 60 degrees during shoulder flexion and abduction.[2]

Reduction in range could be due to:[2]

  • Hypomobility
  • Decreased muscle control

On returning to neutral from abduction or flexion (i.e. the eccentric phase of motion), it is important to assess for scapula winging. Scapula winging has numerous causes.[12] Primary scapula winging refers to dysfunction, or decreased control in the scapulothoracic stabilisers, including serratus anterior, and trapezius.[2][12] Secondary scapula winging occurs in conjunction with other conditions such as subacromial bursitis, or glenohumeral joint disorders.[12]

Shoulder Hike[edit | edit source]

Shoulder hike refers to the upper trapezius lifting the shoulder during arm movements. This tends to be a compensatory movement that increases range of motion at the shoulder. If an individual regularly adopts this movement pattern, it will result in the overuse of upper trapezius and cause pain.[2]

As discussed above, the upper trapezius, serratus anterior and lower trapezius should work together to achieve arm elevation. Thus, in the case of a shoulder hike, it is important to address any imbalances in these muscles and retrain the movement pattern.[2]

NB the deep neck flexors play an important role in reinforcing the occipito-atlantal joint and also work in conjunction with some of the global anterior muscles (e.g. sternocleidomastoid). However, they also act to counteract the upper trapezius.[2]

Cervical issues[edit | edit source]

Cervical issues, such as hypomobility and radiculopathy,[13] also have an impact on the upper trapezius. For more information on assessing for and managing CGH due to upper cervical dysfunction, please click here.

Treatment[edit | edit source]

Diaphragmatic Breathing Retraining[edit | edit source]

Diaphragmatic breathing may help to reduce tone in the upper trapezius.[2] While there is no strong evidence to support its use, it has been found that psychological distress is more common in people with secondary chronic headache, like CGH than in the general population.[14]

Psychological distress (including anxiety and depression) can be helped by relaxation techniques like diaphragmatic breathing,[15][16] so it is possible that it may also help to address upper trapezius dysfunction.[2]

For more information on retraining breathing, please click here.

Initially, diaphragmatic breathing should be practised in positions such as supine or quadruped. Progressions could then include:[2]

  • Kneeling or sitting
  • Kneeling or sitting with cervical movements
  • Maintaining diaphragmatic breathing during stretching
  • Maintaining diaphragmatic breathing during exercise

The ultimate aim is for the patient to be able to achieve a normal breathing pattern (i.e. diaphragmatic in all positions at rest and during normal functional activities).

Postural Training[edit | edit source]

If patients present with increased upper trapezius tone in slumped sitting, it may be beneficial to:[2]

  • Stretch anterior structures (e.g. doorway stretch)
  • Improve posterior motor control
  • Consider taping techniques

Thoracic Manipulations[edit | edit source]

The Clinical Practice Guidelines for Neck Pain suggest that thoracic manipulations can benefit patients with neck pain and, specifically that cervicothoracic manipulations may benefit patients with headaches associated with neck pain.[17]

Moreover, thoracic manipulation may be particularly useful for patients with upper trapezius and scapula dyskinesia as it has been shown to benefit scapula function. A study by Cleland and colleagues found that lower trapezius increased in strength by 14 percent post thoracic manipulation.[18] Thus, this technique could help to facilitate lower trapezius and reduce the activation of upper trapezius prior to exercise-based interventions.[2]


Exercise Therapy[edit | edit source]

As discussed above, individuals who have shoulder or cervical dysfunction tend to present with muscle imbalances, including overactivity in their upper trapezius and underactivity in the middle and lower trapezius. A study by Cools and colleagues explored which exercises might be most effective at addressing these issues. They found the following four exercises to be most efficacious at encouraging lower trapezius and middle trapezius activity, with minimal activation of upper trapezius:[20]

  • Forward flexion in side-lying
  • Side-lying shoulder external rotation
  • Prone shoulder extension
  • Prone horizontal abduction with external rotation
    • Kaplan suggests that it may be beneficial to try this exercise in side-lying - patients lying in prone will experience gravity resistance when the arm is at 90 degrees of abduction (i.e. horizontal)[2]

This article can be accessed here.

NB: none of these exercises are performed in standing. As highlighted above, resisted positions (like standing, sitting) often cause excessive upper trapezius tone. Exercising in prone or side-lying can help to off-load the shoulder and relax the upper trapezius muscle.[2]

Cueing[edit | edit source]

If patients are unable to achieve sufficient scapula motion, providing tactile cues can be beneficial.[2]

Addressing Antagonists[edit | edit source]

When attempting to reinforce postural and scapula improvements, it is important to address any antagonists that may be contributing to excessive activation of upper trapezius (i.e. any action that is resulting in increased anterior movement or downward rotation of the scapula).[2]

  • Latissimus dorsi
    • The latissimus dorsi muscles pull the shoulders inferiorly - increasing the length of this muscle can help to reduce tone and pain in the upper trapezius. Possible exercises include: modified child's pose (i.e. bring one hand across to the opposite hand while in child's pose to stretch the latissimus dorsi)[2]
  • Pectoralis major or minor
    • These muscles pull the shoulder anteriorly. Possible stretches to counteract this include a doorway stretch (high, mid, or early range)[2]
  • Levator scapulae
    • The levator scapulae downwardly rotate the scapula. To counteract this, ask your patient to raise one arm, which upwardly rotates the scapula. Then have the patient look down towards his / her opposite armpit. This will isolate the levator scapulae[2]


Summary[edit | edit source]

  • Overactivity of the upper trapezius can play a role in CGH
  • Upper trapezius overactivity can be caused by postural issues, altered scapula function, and cervical dysfunction
  • Addressing these issues through education, manual techniques, and exercise therapy can have a positive impact on upper trapezius and, therefore, CGH

References[edit | edit source]

  1. 1.0 1.1 Biondi DM. Cervicogenic headache: mechanisms, evaluation, and treatment strategies. J Am Osteopath Assoc. 2000;100(9 Suppl): S7-14.
  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 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 Kaplan A. Superior Scapula - Cervigenic Headaches Course. Physioplus, 2020.
  3. Fernandez M, Moore C, Tan J, Lian D, Nguyen J, Bacon A et al. Spinal manipulation for the management of cervicogenic headache: A systematic review and meta‐analysis. Eur J Pain. 2020; 24(9): 1687-702.
  4. Castien R, De Hertogh W. A Neuroscience Perspective of Physical Treatment of Headache and Neck Pain. Front Neurol. 2019;10: 276.
  5. Biondi DM. Cervicogenic headache: diagnostic evaluation and treatment strategies. Curr Pain Headache Rep. 2001; 5(4): 361-8.
  6. NAT Education. Trapezius - How To Find Trigger Points. Available from [last accessed 11/12/2020]
  7. 7.0 7.1 7.2 7.3 7.4 7.5 7.6 Camargo PR, Neumann DA. Kinesiologic considerations for targeting activation of scapulothoracic muscles - part 2: trapezius. Braz J Phys Ther. 2019; 23(6): 467-475.
  8. Dr Matt & Dr Mike. Muscles of the Scapula | Musculoskeletal Anatomy. Available from [last accessed 11/12/2020]
  9. Kocur P, Wilski M, Lewandowski J, Łochyński D. Female Office Workers With Moderate Neck Pain Have Increased Anterior Positioning of the Cervical Spine and Stiffness of Upper Trapezius Myofascial Tissue in Sitting Posture. PM R. 2019; 11(5): 476-482.
  10. 10.0 10.1 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): 332-335.
  11. Ludewig PM, Phadke V, Braman JP, Hassett DR, Cieminski CJ, LaPrade RF. Motion of the shoulder complex during multiplanar humeral elevation. J Bone Joint Surg Am. 2009;91(2):378-389.
  12. 12.0 12.1 12.2 Meininger AK, Figuerres BF, Goldberg BA. Scapular winging: an update. J Am Acad Orthop Surg. 2011; 19(8): 453-62. 
  13. Sari H, Akarirmak U, Uludag M. Active myofascial trigger points might be more frequent in patients with cervical radiculopathy. Eur J Phys Rehabil Med. 2012; 48(2): 237-44.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. Modern Manual Therapy. Supine Thoracic Thrust Manipulation - most comfortable thoracic manipulation. Available from [last accessed 11/12/2020]
  20. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007; 35(10): 1744-51.
  21. AskDoctorJo. Levator Scapula Stretch - Ask Doctor Jo. Available from [last accessed 11/12/2020]