Cervicogenic Headache: The Diagnosis Hiding in Plain Sight

Still Disputed, Still Dismissed

In clinics worldwide, patients with persistent, disabling headache continue to fall through the cracks, which is a frustrating reality. Despite our increasing understanding of pain science, brainstem sensitisation, and the role of convergence in the trigeminocervical complex (TCC), the idea that a headache could originate from cervical afferents remains somewhat controversial. And yet, it occurs. We see it. Reproduce it. Treat it. Resolve it.

Why Is This Diagnosis So Politely Ignored?

So why does cervicogenic headache (CGH) remain the diagnosis that dares not speak its name?

The answer isn’t just in evidence but in perception. In the medical approach, a headache is considered neurological until proven otherwise. If it responds to triptans, it’s a migraine. If it occurs during stress, it’s tension-type. But what if the real cause is the neck? What if the answer is less mysterious, but much more tangible?

We’re Not Guessing – We’re Testing

For decades, physiotherapists and manual therapists have observed what others dismiss: one-sided, persistent head pain that can be reliably reproduced by palpating C1 and/or C2. Not referred shoulder pain. Not vague tenderness. The actual headache. Reproduced, resolved, and changed in real time. This is not a philosophical debate. It is a diagnostic issue phenomenon.

The Patient Pathway That Misses the Neck

And yet, patients continue to be medicated, scanned, and dismissed (told it’s “stress,” “hormonal,” or “in their head”) without their cervical spine ever being assessed. Many have seen half a dozen practitioners before anyone even touches their neck. It is not an education problem. It’s a belief system problem. For instance, a patient with persistent, one-sided headache might be diagnosed with migraine or tension-type headache without a thorough assessment of their cervical spine, leading to ineffective treatment and prolonged suffering.

The Anatomy Already Makes the Case

The irony? We already know that the upper cervical spinal nerves project directly into the TCC, alongside the trigeminal nerve. We accept that input from the neck can exacerbate migraine. But we stop short of saying it can cause a headache. Why? Because that would challenge the tidy division between “primary” headache, which are not associated with any underlying medical condition, and “secondary” headache, which are. Because if a headache can arise from a joint, nerve root, or mechanical dysfunction, then maybe it’s not all “idiopathic” after all.

What You See, You Can’t Un-See

But CGH doesn’t need approval to exist. It already exists in our clinics, in our patients, and in the hands of any clinician trained to look. You can’t un-see a headache as it resolves when a C2-3 segment is mobilised or retraction is sustained. You can’t forget the patient who says, “That’s the exact pain I get in my head,” when you apply sustained pressure to C1 and/or C2.

It’s Not Rare. It’s Rarely Recognised

The question is not whether CGH is real, it’s how much longer we’re going to pretend it’s rare. Because it’s not rare; it’s rarely recognised. Instead, it’s misdiagnosed – rolled up in the migraine umbrella or buried under catch-all labels like “chronic daily headache.” In fact, studies show that up to 30% of patients with persistent headache may actually have cervicogenic headache.[1] And all the while, their headache begins (and ends) in the neck.

Diagnosis Is Power

There is immense power in giving this pain a name. In showing the patient that their experience is valid. In explaining that it’s not “just stress”. Rather it’s C1-C3 afferents driving input into and effectively increasing the volume of the TCC. And perhaps most importantly, there is power in recognising that this isn’t new. It’s just ignored. Your recognition is crucial.

Let’s Stop Whispering What We Know

It’s time to shift the narrative. To urgently make assessing the upper cervical spine a routine part of every patient with persistent headache. To stop fearing the word cervicogenic, as if it’s just a diagnosis of exclusion.

It’s not. It’s a diagnosis of precision. We owe it to our patients and to ourselves, to move beyond the indefensible perspective that “it cannot come from the neck.” It can. It does. And we can do something about it.

Reference:

1. Fishbain, D.A., Cervicogenic headache. Cephalalgia, 2002. 22(10): p. 829; discussion 829-30.