Headaches and cephalalgia: causes, types, and treatment

Headaches affect approximately 50% of the world's population each year^.1 They are one of the most common reasons for seeking medical advice. What many people don't know is that a large proportion of these headaches are caused by dysfunction in the neck. These cervicogenic headaches can be effectively treated with physical therapy, providing lasting relief.

Having recurring headaches can be exhausting and worrying. Here's the good news: serious causes are rare, accounting for less than 2% of cases.² Understanding your headaches better is the first step toward controlling them. Physical therapy can significantly reduce the frequency and intensity of your headaches if they originate in the cervical spine.

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 originate from blood vessels, nerves, muscles, or structures around the skull. Interestingly, the brain itself does not feel pain because it has no pain receptors.

The term "headache" encompasses more than 200 different types of headaches.⁵ Some originate inside the head with no 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 all the same thing.

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

These different names simply reflect different medical traditions:

• Cervicogenic headache: term used by neurologists and pain specialists
• Tension headache: a common term, often associated with stress
• Myofascial headache: a term used in physical therapy, emphasizing the involvement of muscles

In all three cases, physical therapy targeting the neck is effective. That's why these conditions can be treated in the same way.

What is a migraine?

Migraine is a type of headache with distinct characteristics: pain usually 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^.

Migraine is more than just an intense headache. It is a neurological condition with distinct phases. Some people experience an "aura" before the pain, with visual symptoms such as flashes of light or zigzag lines.

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

If you think you have migraines, check out our comprehensive 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 itself?

Cervicogenic headaches are headaches that originate in the structures of the neck, not in the head itself. Unlike classic migraines, this pain begins in the cervical region and radiates to the skull. It is a type of headache that responds particularly well to physical therapy.

Approximately 15 to 20% of chronic headaches are thought to be of cervical origin.² This is a significant proportion. However, this condition often remains unrecognized or misdiagnosed.

Which structures of 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 The C2-C3 joint is responsible for approximately 70% of cases. This joint is particularly stressed during head rotation and extension movements. The suboccipital muscles at the base of the skull frequently have trigger points that contribute to headaches.

How can neck dysfunction cause headaches?

The mechanism is called referred pain. The upper cervical nerves share connections with the trigeminal nerve in your brainstem. This is called the trigeminal-cervical nucleus.² This connection explains why irritation in the neck can produce pain that you feel in your head, around your eyes, or even in your forehead.

To better understand, think of a heart attack: the pain can be felt in the arm or jaw, even though the problem is in the heart. The principle is exactly the same for 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 are different. Cervicogenic headache always presents with pain on the same side, which starts in the neck and is dull and constant. Triggers are typically neck movements and prolonged positions. Nausea and sensitivity to light are rare or absent, and there is no visual aura. Neck stiffness is present.

Migraine, in comparison, can alternate sides. The pain starts in the head and is pulsating and throbbing. Triggers include light, stress, and certain foods. Nausea and sensitivity to light are common. Visual aura is sometimes present. The typical duration is 4 to 72 hours^.

• The pain begins after prolonged sitting (screen, driving).
• Turning or tilting the head triggers or worsens the headache.
• You have neck stiffness along with the headache.
• The pain is always on the same side.
• Anti-migraine medication does not work

A subtle point: migraines can also be accompanied by neck pain. That's why a professional evaluation is important for making the right diagnosis. Some people have both conditions simultaneously. For more information on migraines, see our comprehensive guide to migraines.

What are the causes and how is it diagnosed?

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

The most common triggers include prolonged postures (sitting in front of a screen, head forward), stress and tension (clenched jaw, tense shoulders), sleep problems (lack of sleep, poor pillow), and repetitive activities (prolonged driving, manual labor).

A sudden movement of the head or neck, such as when experiencing a stiff neck, can trigger headaches. Similarly, a car accident, a fall, or a blow to the head can traumatize the cervical structures and initiate a cycle of pain referred to the head.

A jaw problem, often associated with teeth clenching or nighttime bruxism, can also cause headaches. If you experience jaw clicking or pain when eating, consult our guide to jaw pain (TMJ).

How is the diagnosis made?

The diagnosis is based primarily on clinical examination and patient history. According to the International Classification of Headache Disorders (ICHD-3), diagnosis requires clinical evidence of a cervical source, a temporal relationship between the headache and the cervical problem, and improvement with improvement of the cervical problem or reduced range of motion.⁵

Imaging (CT scan or MRI) is not necessary for the vast majority of headaches. It is reserved for cases with red flags or when the diagnosis is uncertain.

How can physical therapy relieve your headaches?

Physical ^therapy is the first line of treatment for cervicogenic and tension headaches. Studies show that manual therapy combined with therapeutic exercises can significantly reduce the frequency and intensity of headaches.

How effective is physical therapy?

The results are encouraging. A benchmark study showed that 72% of patients treated with manual therapy and exercises had a significant reduction in their headaches after 12 months. Among these patients, 42% reported relief of 80% or more^.

With a combination of manual therapy and exercises, 81% of patients achieve an improvement of 50% or more, and 42% achieve a 100% improvement. With manual therapy alone, 71% achieve an improvement of 50% or more. With exercises alone, 76% achieve an improvement of 50% or more.⁴

What physical therapy can offer

How long does it take to see results?

Most patients notice improvement within 4 to 8 weeks of active treatment^. A typical program consists of 8 to 12 sessions spaced one to two times per week, combined with exercises to be done at home. Consistency in your home exercises greatly influences the speed of recovery.

For more information, see our guide to physical therapy for neck pain.

What can you do at home, and when should you seek medical attention?

Several strategies can reduce the frequency and intensity of your headaches.

Immediate relief

• Ice application: Ice wrapped in a wet towel on the upper neck, 15 to 20 minutes
• Move gently: Neck movements within pain-free limits
• Support your shoulders: Cushion under your armpits when sitting, armrests, hand in your pocket

Stress management and healthy lifestyle

• Relaxation and deep breathing techniques
• Regular and sufficient sleep (7-8 hours)
• Adequate hydration (6-8 glasses of water per day)
• Regular meals, without skipping meals
• Limit alcohol and caffeine

Posture and ergonomics

• Screen at eye level
• Take breaks to move around every 30-45 minutes
• Avoid staying in the same position for long periods of time.
• Pillow that fills the hollow of the neck at night
• Avoid sleeping on your stomach

Neck relaxation exercises

The important thing is consistency. A few minutes of exercise every day is better than one long session once a week: gentle, controlled neck rotations, cranio-cervical flexion exercises (gently tucking in the chin), shoulder muscle stretches, and posture exercises.

Note on medications

For occasional headaches, acetaminophen (Tylenol) or anti-inflammatory drugs (ibuprofen, naproxen) can help. Be careful of medication overuse headaches: Taking pain medication for more than 10 to 15 days per month can paradoxically cause rebound headaches.⁵ Medication is generally less effective for cervicogenic headaches than for migraines.

Red flags: when to seek emergency care?

Consult your doctor if your headaches are frequent (more than 15 days per month), if they change in nature, if they affect your quality of life, or if they do not respond to usual treatments.

• Sudden, intense headache that is "the worst of your life" (could indicate a brain hemorrhage)
• Headache with fever and severe neck stiffness (possible meningitis)
• Headache after a blow to the head (need to rule out injury)
• Personality change or confusion (neurological sign to be evaluated)
• Weakness or numbness on one side of the body (possible stroke)
• Double vision or loss of vision (urgent neurological symptom)
• Headache that gradually worsens (requires investigation)

When in doubt, consult a professional. In Quebec, you can consult a physical therapist directly, without a prescription. This is often a good place to start if your headaches are accompanied by tension in your neck or shoulders.

What conditions are associated with headaches?

Headaches frequently coexist with other conditions:

• Neck pain : treating the neck generally helps reduce headaches
• Jaw pain (TMJ) : up to 70% of people with TMJ disorders also have headaches
• Cervicobrachialgia : pain from the neck to the arm, often accompanied by headaches
• Cervical osteoarthritis : may contribute to headaches, particularly with age

To understand how headaches fit into a broader picture, see our guide to head and facial pain.

What are the most frequently asked questions about headaches?

Are headaches dangerous?

In the vast majority of cases, no. Over 98% of headaches are benign.² They are uncomfortable and can affect your quality of life, but they do not indicate 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?

This is not recommended. Taking painkillers for more than 10 to 15 days per month can cause medication overuse headaches.⁵ Your body becomes accustomed to the medication and you develop rebound headaches. If you need medication this often, consult your doctor to explore other options such as physical therapy.

Can physical therapy really help my headaches?

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

How can I tell if my headache is coming from my neck?

Your headache is probably coming from your neck if: it starts after prolonged positioning, it is triggered or aggravated by neck movements, it is accompanied by neck stiffness, it is always on the same side, and if migraine medication does not work. A physical therapist can perform specific tests to confirm this origin.

How long will 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 usually require 4 to 8 weeks of active treatment to see significant improvement.⁴ The key is consistency: doing your exercises, applying posture tips, and managing your triggers.

What is the difference between tension headache and cervicogenic headache?

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

If you suffer from recurring headaches, you don't have to endure them in silence. Solutions exist. Our physical therapists can assess whether your neck or posture is contributing to your headaches and offer you a personalized treatment plan.

Sources

• Stovner LJ, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007.

• Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. The Lancet Neurology. 2009.

• Page P. Cervicogenic headaches: an evidence-based approach to clinical management. International Journal of Sports Physical Therapy. 2011.

• Jull G, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002.

• Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018.