Headaches: Causes, Types, and Treatment

Headaches affect approximately 50% of the world's population each year.¹ They are one of the most frequent reasons for consultation. What many people don't know is that a large proportion of these headaches originate from neck dysfunction. These cervicogenic headaches can be effectively treated with physiotherapy, offering lasting relief.

Having frequent headaches can be exhausting and worrying. Here's the good news: serious causes are rare, accounting for less than 2% of cases.² Better understanding your headaches is the first step towards controlling them. Physiotherapy can significantly reduce the frequency and intensity of your headaches if they originate from the neck.

What is a headache, and what are the different types?

A headache, also known as cephalalgia in medical terms, is pain felt anywhere in the head or neck region. This pain can come from blood vessels, nerves, muscles, or structures surrounding the skull. Interestingly, the brain itself does not feel pain because it lacks pain receptors.

The term 'headache' encompasses over 200 different types.⁵ Some originate from within the head without an underlying cause (primary headaches). Others are caused by a problem elsewhere in the body (secondary headaches).

Cervicogenic headache, tension headache, and myofascial headache: they are the same thing

Here’s an important point that many people are unaware of: cervicogenic headache, tension-type headache, and myofascial headache are essentially the same condition, described under different names.^2,3 In all these cases, the neck has a significant influence on the symptoms. The underlying mechanism is similar: a dysfunction of the cervical structures (joints, muscles, nerves) that refers pain to the head.

These different names simply reflect different medical traditions:

• Cervicogenic Headache: a term used by neurologists and pain specialists
• Tension Headache: a popular term, often associated with stress
• Myofascial Headache: a term used in physiotherapy, highlighting muscle involvement

In all three cases, physiotherapy treatment targeting the neck is effective. This is why these conditions can be treated in the same way.

What is a Migraine?

A migraine is a type of headache with distinct characteristics: pain typically on one side, throbbing, moderate to severe in intensity, often accompanied by nausea and sensitivity to light or sound. It affects approximately 15% of the population.⁵

A migraine is more than just an intense headache. It is a neurological condition with distinct phases. Some people experience an 'aura' before the pain, which includes visual symptoms like flashes of light or zigzag lines.

Typical symptoms of migraine:

• Pain on one side of the head (but can be on both sides)
• Throbbing or 'pounding' pain
• Nausea, sometimes vomiting
• Sensitivity to light and sound
• Worsening with physical activity
• Lasts 4 to 72 hours

If you think you have migraines, consult our complete guide to migraines, which covers this condition in detail, including specific treatments.

Other Types of Headaches

Cluster headaches are rare but intense. They manifest as episodes of severe pain around one eye, accompanied by tearing and nasal congestion. This type of headache requires specialized medical care.

Other types of headaches include medication overuse headaches (rebound headaches), sinus headaches, and headaches related to high blood pressure. These conditions are beyond the scope of this guide and require medical evaluation.

What is a Cervicogenic Headache and How Does It Manifest?

Cervicogenic headaches are a type of headache that originates in the neck structures, rather than the head itself. Unlike typical migraines, this pain begins in the neck and spreads towards the skull. These headaches respond particularly well to physiotherapy.

Approximately 15 to 20% of chronic headaches are thought to originate from the neck.² This is a significant percentage. Yet, this condition often goes unrecognized or is misdiagnosed.

Which structures in the neck are involved?

Cervicogenic headaches are caused by irritation of the structures in the neck innervated by the C1, C2, and C3 nerves.² Among the joints of the neck, the C2-C3 joint is most commonly involved in cervicogenic headaches, accounting for approximately 70% of cases. This joint is particularly stressed during rotational and extension movements of the head. The suboccipital muscles at the base of the skull frequently have trigger points that contribute to headaches.

How can neck dysfunction cause a headache?

This mechanism is known as referred pain. The upper cervical nerves connect with the trigeminal nerve in your brainstem, forming what is called the trigeminocervical nucleus.² This connection explains how irritation in the neck can cause pain that you feel in your head, around your eyes, or even in your forehead.

To better understand this, consider a heart attack: pain might be felt in the arm or jaw, even though the issue is with the heart. The same principle applies to cervicogenic headaches: the problem is in the neck, but the pain is felt in the head.

How can you tell the difference between a cervicogenic headache and a migraine?

This distinction is important because the treatments differ. Cervicogenic headache involves pain that is always on the same side, begins in the neck, and is dull and constant. Triggers typically include neck movements and prolonged postures. Nausea and sensitivity to light are rare or absent, and there is no visual aura. Neck stiffness is present.^2,3

In comparison, migraines can switch sides. The pain starts in the head and is often throbbing or pounding. Triggers include light, stress, and certain foods. Nausea and sensitivity to light are common, and a visual aura may sometimes be present. A typical migraine lasts from 4 to 72 hours.⁵

Clues that your headache comes from your neck:

• Pain begins after a prolonged posture (e.g., looking at a screen, driving)
• Turning or tilting the head triggers or worsens the headache
• You experience neck stiffness along with your headache
• The pain is always on the same side
• Anti-migraine medication is ineffective

A subtle point to note: migraines can also involve neck pain. This is why a professional evaluation is crucial for an accurate diagnosis. Some individuals may even experience both conditions simultaneously. For more information on migraines, please consult our complete guide to migraines.

What are the causes and how is it diagnosed?

Pain can stem from three main sources: the joints of the neck vertebrae or jaw may become irritated, the nerves in the neck may be compressed or irritated, and the muscles of the neck, jaw, or head may develop tension or trigger points.^2,3

The most common triggers include prolonged postures (sitting in front of a screen with the head jutted forward), stress and tension (clenched jaws, tense shoulders), sleep problems (lack of sleep, an unsuitable pillow), and repetitive activities (prolonged driving, manual labor). Alcohol doesn’t just trigger migraines. It can trigger ordinary headaches just as much as it can trigger migraines.

A sudden movement of the head or neck—such as during a stiff neck—can trigger headaches. Similarly, a car accident, a fall, or a blow can injure the cervical structures and set off a cycle of referred pain to the head. The neck is a major source of headaches, especially after a whiplash injury. After a whiplash injury, up to 53% of headaches are cervical in origin—that is, cervicogenic headaches.

A jaw problem, often associated with clenching your teeth or nighttime bruxism, can also cause headaches. If you experience jaw clicking or pain while eating, check out our guide on jaw pain (TMJ). Treating the upper neck can relieve headaches related to a jaw disorder. In a randomized trial, women with TMJ disorder saw a marked reduction in the severity of their headaches after 5 weeks of neck mobilization and exercises.

How is it diagnosed?

Diagnosis primarily relies on a clinical examination and the patient's medical history. According to the International Classification of Headache Disorders (ICHD-3), a diagnosis requires clinical evidence of a cervical source, a temporal link between the headache and the neck issue, and improvement as the neck problem resolves or if there is reduced range of motion.⁵

The Rotational Flexion Test (RFT) specifically assesses the mobility of the C1-C2 joint. Significant asymmetry in rotation towards the affected side strongly suggests a cervicogenic origin. This test has a sensitivity of 91% and a specificity of 90%.³

Imaging tests (such as CT scans or MRIs) are not typically needed for most headaches. They are reserved for cases with 'red flags' or when the diagnosis is unclear.

How can physiotherapy help relieve your headaches?

Physiotherapy is the primary treatment for cervicogenic and tension headaches. Studies indicate that manual therapy combined with therapeutic exercises can significantly reduce both the frequency and intensity of headaches.⁴

How effective is physical therapy?

The results are encouraging. A landmark study revealed that 72% of patients who received manual therapy and exercises experienced a significant reduction in their headaches after 12 months. Of these patients, 42% reported 80% or more relief.⁴

With a combination of manual therapy and exercises, 81% of patients experience an improvement of 50% or more, and 42% experience a 100% improvement. With manual therapy alone, 71% experience an improvement of 50% or more. With exercise therapy alone, 76% experience an improvement of 50% or more.⁴ For this type of headache, manual therapy is no more effective than exercise therapy alone, and combining the two does not further improve outcomes. Patients can therefore take control of their condition through exercise therapy, without relying on passive techniques.

What Physiotherapy Can Offer

Manual therapy : The joint mobilizations and manipulations of the upper cervical joints aim to restore normal mobility. Strengthening exercises : Exercises targeting the deep neck muscles (deep cervical flexors) are particularly effective. The stabilizing muscle exercises of the neck stabilize the cervical region and prevent recurrence. Motor Control Rehabilitation : Cranio-cervical flexion training improves control of the stabilizing muscles. Six weeks of cranio-cervical flexion exercises, which strengthen the deep neck muscles, were as effective as manual therapy in reducing the frequency and intensity of headaches, with effects lasting up to one year.

How Long Does It Take to See Results?

Most patients notice improvement within 4 to 8 weeks of active treatment.⁴ A typical program includes 8 to 12 sessions, scheduled once or twice a week, combined with home exercises. Being consistent with your home exercises significantly impacts how quickly you recover.

To learn more, consult our guide on physiotherapy for neck pain.

What can you do at home, and when should you seek professional help?

Several strategies can help reduce how often you get headaches and how severe they are.

Immediate relief

• Apply Ice: Wrap ice in a wet towel and place it on the upper neck for 15 to 20 minutes.
• Gentle Movement: Move your neck within pain-free limits.
• Support Your Shoulders: Use a cushion under your armpits when sitting, use armrests, or keep your hand in your pocket.

Stress Management and Lifestyle Habits

• Relaxation and Deep Breathing Techniques
• Regular and Sufficient Sleep (7-8 hours)
• Adequate Hydration (6-8 glasses of water per day)
• Eat regular meals, avoid skipping any.
• Limit Alcohol and Caffeine

Posture and Ergonomics

• Screen at Eye Level
• Take Breaks to Move Every 30-45 Minutes
• Avoid Staying in the Same Position for Too Long
• Use a pillow that supports the natural curve of your neck at night.
• Avoid Sleeping on Your Stomach

Neck Relaxation Exercises

Consistency is key. A few minutes of exercise every day is better than one long session once a week: gentle, controlled neck rotations, craniocervical flexion exercises (gently tucking the chin in), shoulder muscle stretches, and postural exercises. A self-administered neck mobilization exercise, performed twice a day, reduced the headache index by 54% at 12 months, compared with 13% in the control group.

Note on Medications

For occasional headaches, acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen) may help. Be aware of medication-overuse headaches: Taking pain relievers for more than 10 to 15 days a month can, paradoxically, cause rebound headaches.⁵ Medication is generally less effective for cervicogenic headaches than for migraines. Taking pain medication too often can, over time, perpetuate headaches. This is known as medication-overuse headache. Any patient with chronic headaches should be aware of this.

Red Flags: When to Seek Urgent Medical Attention?

See a healthcare professional if your headaches become frequent, if their nature changes, if they affect your quality of life, or if they do not respond to standard treatments. These are good reasons to have the situation evaluated, even if they are not emergencies. True signs of an emergency are different: neurological signs such as weakness on one side of the body or sudden difficulty speaking.

Emergency symptoms:

• A sudden, intense headache described as 'the worst of your life' (could indicate a brain bleed).
• Headache with fever and severe neck stiffness (possible meningitis)
• Headache after a head injury (needs to rule out a more serious injury)
• Personality changes or confusion (neurological sign that needs evaluation)
• Weakness or numbness on one side of the body (possible stroke)
• Double vision or vision loss (urgent neurological symptom)
• Headache that gradually worsens (requires investigation)

When in doubt, seek medical advice. In Quebec, you can consult a physiotherapist directly, without a prescription. This is often a good starting point if your headaches are accompanied by neck or shoulder tension.

What conditions are associated with headaches?

Headaches frequently coexist with other conditions:

• Neck Pain: treating the neck generally helps reduce headaches
• Jaw Pain (TMJ) : Jaw problems and headaches often go hand in hand. People with a serious TMJ disorder almost always have chronic headaches.
• Cervical Radiculopathy: pain extending from the neck to the arm, often accompanied by headaches
• Cervical Osteoarthritis: can contribute to headaches, especially with age

To understand how head pain fits into a broader picture, consult our guide on head and facial pain.

What are the most frequently asked questions about headaches?

Are headaches dangerous?

In the vast majority of cases, no. More than 98% of headaches are benign.² They are uncomfortable and can affect your quality of life, but they do not signal a dangerous condition. The red flags mentioned above help identify the rare cases that require attention.

Can I take medication every day for my headaches?

It's not recommended. Taking painkillers more than 10 to 15 days a month can lead to medication overuse headaches.⁵ Your body gets used to the medication, and you develop rebound headaches. If you need medication this often, consult a professional to explore other options like physiotherapy.

Can physiotherapy really help my headaches?

Yes, especially if your headaches are related to muscle tension, posture, or originate from the neck. Studies show that physiotherapy reduces the frequency and intensity of cervicogenic and tension headaches, with 72% of patients reporting significant improvement.⁴

How do I know if my headache is coming from my neck?

Your headache likely originates from your neck if: it starts after a prolonged position, it's triggered or worsened by neck movements, it's accompanied by neck stiffness, it's always on the same side, and if anti-migraine medications don't work. A physiotherapist can perform specific tests to confirm this origin.

How long does it take for my headaches to improve?

It depends on the type and cause. Occasional headaches can improve quickly with lifestyle changes. More chronic headaches generally require 4 to 8 weeks of active treatment to see significant improvement.⁴ Consistency is key: doing your exercises, applying postural advice, and managing your triggers.

What is the difference between a tension headache and a cervicogenic headache?

In practice, they essentially mean the same thing.^2,3 Both terms describe headaches in which the neck plays a significant role. Treatment is similar: physical therapy focused on the neck, exercises, and management of stress and posture. Whether your doctor uses one term or the other, the treatment approach will be the same.

Key points to remember: Headaches are very common and are usually benign. However, certain signs require urgent evaluation: a sudden, severe headache, or an unusual worsening of a previously experienced headache. Cervicogenic headache, tension-type headache, and myofascial headache are essentially the same condition: the neck is the source. In the most robust study on cervicogenic headache, 76% of patients had reduced the frequency of their headaches by at least 50% after 7 weeks of treatment, and 35% were headache-free. At 12 months, 72% of them still had a reduction in frequency of at least 50%. Migraine is different and requires a specific approach (see our guide on migraine). Lifestyle changes (posture, stress, sleep, hydration) significantly reduce the frequency of headaches.

If you suffer from recurrent headaches, you don't have to endure them in silence. Solutions are available. Our physiotherapists can assess whether your neck or posture contributes to your headaches and offer you a personalized treatment plan.

Sources

1. Stovner LJ, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007.
2. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. The Lancet Neurology. 2009.
3. Page P. Cervicogenic headaches: an evidence-led approach to clinical management. International Journal of Sports Physical Therapy. 2011.
4. Jull G, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002.
5. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018.