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1 · SNAPSHOT

Cervicogenic Headache body chart — Illustrative, not diagnostic. Canva body chart for Cervicogenic Headache.

Who: Adults, female preponderance, often eight years into it before anyone names it. Post-traumatic necks, sustained-posture jobs, chronic neck stiffness.
What: A secondary headache. Pain generated at C1–C3 and referred to the head. That one word does the work — you are not treating a headache, you are treating a neck that is producing one.
How it behaves: Aggs: neck movement, sustained postures, external pressure over the upper cervical/occipital region. Eases: unloading, lying supine.

The one thing to take from this page:

Almost every headache patient has a neck that feels bad. That finding is not the diagnosis — it is the reason you have to test something else.

Finding	Figure
Neck pain in migraine vs non-headache controls	77.0% (95% CI 69.0–86.4) vs 23.2% (18.6–28.5)
Neck pain in chronic migraine	87.0% (77.0–93.0)
Prevalence, general population aged 30–44 (n = 30,000)	0.17%
Reported prevalence across 34 publications	0.17% – 69%
CGH patients who also have migraine · who also overuse medication	42% · 50%
Cervical flexion-rotation test, pooled	Se 83.0% · Sp 83.0% · +LR 5.0 (2.6–9.5)

[1][2][3][4]

⚠️ No Australian guideline exists for cervicogenic headache. There is no Australian headache standard at all — ACSQHC covers low back pain and knee osteoarthritis, not this. Anchored to the OPTIMa guideline ([5], Canada), with the IFOMPT Cervical Framework [6] for the vascular screen. The odd part: the guideline is foreign, and the strongest trial underneath it is Australian — 200 participants, multicentre, Queensland [7].

Pattern > Label. "Cervicogenic headache" names a source you cannot prove without a needle. A headache that behaves like a neck is the thing you can actually reason about.

⚠️ A correction, carried onto the page, not dropped. You will be taught that "reproduction of familiar headache = diagnostic key". It isn't. See §5.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

The five stages, in order. On a headache page the subjective does more than usual, because the objective cannot finish the job.

MAIN PROBLEM

"It starts at the base of my skull and comes over the top into my eye. Always the same side. It's worse on the days I'm at the desk."

Ask them to point to where it starts. Suboccipital start with frontal/temporal spread is the pattern. A headache that starts frontal and stays there is telling you something else.

BODY CHART

P1 suboccipital / upper cervical. P2 frontal, temporal, retro-orbital. Ipsilateral neck and shoulder ache is usual.
Side: unilateral without side-shift is a CHISG criterion [8] — and ICHD-3 does not require it [9]. ⚠️ Do not treat bilateral pain as excluding a cervical contribution. Across 59 RCTs, 49% used CHISG and 39% used IHS/ICHD criteria [10]. The field cannot agree; you are not going to settle it in a 40-minute S/E.
Mark any arm symptoms separately. Those change the exam, not the headache hypothesis.

BEHAVIOUR

Coding: usually In (intermittent, posture- and movement-linked), drifting toward P in the chronic ones. Morning stiffness >30 min codes In.
Aggs: end-range or sustained cervical rotation, desk and phone postures, sleeping position, external pressure over the occiput. Eases: unloading the neck, lying supine, changing position.
24-hr pattern: desk and phone postures and sustained rotation build it; unloading and lying supine ease it. Headache days per month is the count that matters.
Night: sleeping position is in the Aggs — ask which.
Severity: VAS 0–10 at best / at worst / right now.
Irritability, all three parts — resting symptoms present or not · how much provoking activity sets it off · how long it takes to settle. On this pattern it sets your dosage at C1–C3 and it decides whether you test the flexion-rotation test at all today.

HISTORY

Two questions carry more weight than the rest of the S/E combined. Together they explained 44% of the variance in flexion-rotation range — and migraine-associated factors explained none of it [11]:

Ask	Why
"Do neck movements or positions bring the headache on?"	one half of that 44%
"Does the neck start hurting before the head does?"	the other half

Then: onset, trauma (whiplash, a fall, a tackle), trajectory, previous episodes, imaging, what has been tried. Mean symptom duration in the general-population cohort was eight years (Knackstedt et al. 2010). This is rarely a fresh, clean, single problem.

SPECIAL / SCREENING QUESTIONS

On a headache, this stage is not the last thing you do. It is the thing you do first if anything in the story is new, sudden or strange. See §4 — free, always.

SNNOOP10 on every new headache patient [12].
Analgesic days per month, visit one, every time. 50% of the general-population CGH cohort had co-occurring medication overuse (Knackstedt et al. 2010).
Dizziness, light-headedness or visual symptoms are a screening trigger, not a supporting feature. ⚠️ A correction. They are usually taught as supporting features. Cranial and cervical artery dissection commonly presents as headache or neck pain and may mimic a primary headache disorder [13]. Run the IFOMPT Cervical Framework before any upper cervical technique (Rushton et al. 2023). Reasoning lives on the cervical arterial dysfunction page — don't re-derive it here.
General health, medications, sleep, mood, work and study load, caffeine.

Patterns > Labels. A neck-provoked, neck-preceded, suboccipital-to-frontal headache in a genuinely restricted neck is a pattern. Whether a pathologist would call it "cervicogenic" is a different question, and one you cannot answer.

Assessing this region? Download the Cervical Spine assessment template →

3 · HYPOTHESIS RANKING

Rank only after the dangerous ones are cleared. §4 comes first in the room, even though it comes second on the page.

Top three, one discriminating feature each.

Rank	Pattern	The one discriminating feature
1	Migraine — the commonest and hardest mimic	The flexion-rotation test, not the neck complaint. Neck pain does NOT separate them: 77.0% of migraine patients have it (Al-Khazali et al. 2022). What separates them is range — mean rotation to the most restricted side 25° in CGH vs 42° in migraine (Hall et al. 2010), pooled between-group difference 17.67° (95% CI 13.69–21.65) (Anarte-Lazo et al. 2021).
2	Tension-type headache	Bilateral, band-like, pressing — and not aggravated by routine physical activity. Tender pericranial muscles belong to TTH too; only reduced extensor strength reached significance versus controls, at very low certainty (Pensri et al. 2025). ⚠️ Management differs: OPTIMa says do not offer cervical manipulation as sole treatment for TTH (Côté et al. 2019).
3	Third occipital nerve / C2–3 PIV joint headache — the cervical alternative	It is a subtype you cannot separate clinically. Prevalence 27% (95% CI 18–36) in 100 chronic post-whiplash patients, 53% (37–68) where headache dominated — and no history or examination feature identified it before controlled diagnostic blocks [14]. Only C2–3 tenderness was associated (p = 0.01).

Also in the room, and worth naming out loud:

Cluster headache — strictly unilateral orbital/temporal, 15–180 minutes, ipsilateral autonomic features, a restless, agitated patient. Medical, not physio.
Occipital neuralgia — paroxysmal, stabbing (59%), unilateral (81%), greater occipital nerve territory (98%), with hypoaesthesia in that territory (73%). Shooting, not the dull ache of CGH [15]. No population-based data exists.
Medication-overuse headache — headache ≥15 days/month with regular acute-medication overuse. 50% of the population CGH cohort had it (Knackstedt et al. 2010).
TMJ — reproduced by mandibular loading, not cervical movement.

And the overlap that breaks the ranking: 42% of general-population CGH patients also have migraine (Knackstedt et al. 2010). It is not either/or. Every trial in this field recruited patients with one clean headache. Your patient may not have read them.

The ranking is a hypothesis order, not a verdict. Take it to your educator as a ranked list with the discriminator attached, never as an answer.

4 · RED FLAGS — DON'T MISS THIS

Free forever. Safety is never gated — not on this page, not on any page, not ever.

Most headaches are not cervical, and a few are emergencies wearing a neck complaint. This section runs before you rank anything.

The four that send someone out the door

Flag	What it means
Thunderclap — peak intensity within one hour	Emergency, today. Not a re-test next visit. The Ottawa SAH Rule was 100% sensitive (95% CI 94.6–100) at 13.6% specificity (13.1–15.8) in 1,153 alert, neurologically intact adults [16]. That is a hospital tool. It is not what you do — it is why you send.
New headache with onset after 50	Pattern change and new onset in an older adult are two of the three most sensitive items on the list (each 64.4%) [17].
Systemic features — fever, unexplained weight loss, night sweats, known neoplasm, immune pathology	Systemic symptoms and neoplasm history are among the most specific items (89% and 89.1%). Specific means: when they are there, take them seriously.
Cranial or cervical arterial dysfunction	New, unfamiliar, severe head or neck pain — often the only symptom initially — and it mimics primary headache [13]. Add any of the 5 D's and 3 N's, Horner's, pulsatile tinnitus, or recent minor neck trauma. A leading cause of stroke in younger adults. Full reasoning: cervical arterial dysfunction.

SNNOOP10 — run it on every new headache

Systemic symptoms including fever · Neoplasm history · Neurologic deficit including decreased consciousness · Onset sudden or abrupt · Older age at onset · Pattern change or recent-onset new headache · Positional headache · Precipitated by sneezing, coughing or exercise · Papilloedema · Progressive headache and atypical presentation · Pregnancy or puerperium · Painful eye with autonomic features · Post-traumatic onset · Pathology of the immune system such as HIV · Painkiller overuse or a new drug at onset [12].

And read the numbers honestly. Sensitivity 100% (95% CI 90.2–100) with AUC 0.66 (0.55–0.76) in a 100-patient emergency department cohort where 65% turned out to be secondary headaches (García-Azorín et al. 2022). It rules out. It does not rule in. And that setting is nothing like a physiotherapy caseload. The list's own authors note that prospective epidemiological data on red flags do not exist (Do et al. 2019).

Before any upper cervical technique

Work through the IFOMPT Cervical Framework [6]. Events are rare, and recognisable if the right history questions get asked and the physical examination is adapted to test that hypothesis. It is a reasoning framework, not a test battery — and it is not optional before you manipulate or end-range mobilise a C1–C2 segment.

The quiet one

Medication overuse. Not an emergency, but it changes everything you do and nothing you do will work around it. 50% of the Norwegian population CGH cohort had it. Ask analgesic days per month on visit one and refer to the GP if it is ≥15.

Rule: if the headache is new, sudden, progressive, systemic or neurological, you are not the right clinician today. Refer, and say why.

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Guideline anchor

No Australian guideline for this presentation.

Anchored to OPTIMa clinical practice guideline - non-pharmacological management of persistent headaches associated with neck pain (Côté et al. 2019, PMID 30707486, Canada), paired with the International IFOMPT Cervical Framework (Rushton et al. 2023, PMID 36099171) for the vascular screen.

PubMed

No Australian clinical practice guideline exists for cervicogenic headache, and no Australian standard covers headache at all. Searched live on 1 Sep 2026; nothing returned. ACSQHC publishes clinical care standards for low back pain and knee osteoarthritis, not headache. The nearest Australian document is the 2014 SIRA NSW whiplash guideline - a different pattern, eleven years old.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 32

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Every source on this page resolves and title-verifies against PubMed. Newest first.

2022Al-Khazali et al. (2022). Prevalence of neck pain in migraine: A systematic review and meta-analysis. Cephalalgia : an international journal of headache, 42(7), 663-673. https://doi.org/10.1177/03331024211068073
2010Knackstedt et al. (2010). Cervicogenic headache in the general population: the Akershus study of chronic headache. Cephalalgia : an international journal of headache, 30(12), 1468-76. https://doi.org/10.1177/0333102410368442
2025Mingels et al. (2025). The occurrence of cervicogenic headache: A mapping review. Musculoskeletal science & practice, 77, 103290. https://doi.org/10.1016/j.msksp.2025.103290
2022Demont et al. (2022). Cervicogenic headache, an easy diagnosis? A systematic review and meta-analysis of diagnostic studies. Musculoskeletal science & practice, 62, 102640. https://doi.org/10.1016/j.msksp.2022.102640
2019Côté et al. (2019). Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. European journal of pain (London, England), 23(6), 1051-1070. https://doi.org/10.1002/ejp.1374
2023Rushton et al. (2023). International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework. The Journal of orthopaedic and sports physical therapy, 53(1), 7-22. https://doi.org/10.2519/jospt.2022.11147
2002Jull et al. (2002). A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine, 27(17), 1835-43; discussion 1843. https://doi.org/10.1097/00007632-200209010-00004
1998Sjaastad et al. (1998). Cervicogenic headache: diagnostic criteria. The Cervicogenic Headache International Study Group. Headache, 38(6), 442-5. https://doi.org/10.1046/j.1526-4610.1998.3806442.x
2018Anon. (2018). Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia : an international journal of headache, 38(1), 1-211. https://doi.org/10.1177/0333102417738202
2026Iyer et al. (2026). Diagnostic Criteria and Outcome Measures for Cervicogenic Headache in Randomised Controlled Trials: An Updated Systematised Review With Age-Based Subgroup Analysis. Musculoskeletal care, 24(2), e70215. https://doi.org/10.1002/msc.70215
2010Hall et al. (2010). Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test. The journal of headache and pain, 11(5), 391-7. https://doi.org/10.1007/s10194-010-0222-3
2019Do et al. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology, 92(3), 134-144. https://doi.org/10.1212/WNL.0000000000006697
2025Doukhi et al. (2025). Headaches attributed to cranial and cervical artery dissections. The journal of headache and pain, 26(1), 28. https://doi.org/10.1186/s10194-025-01958-9
1994Lord et al. (1994). Third occipital nerve headache: a prevalence study. Journal of neurology, neurosurgery, and psychiatry, 57(10), 1187-90. https://doi.org/10.1136/jnnp.57.10.1187
2025Melchior et al. (2025). Epidemiology and clinical features of occipital neuralgia: A systematic review and meta-analysis. Cephalalgia : an international journal of headache, 45(2), 3331024251317595. https://doi.org/10.1177/03331024251317595
2017Perry et al. (2017). Validation of the Ottawa Subarachnoid Hemorrhage Rule in patients with acute headache. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 189(45), E1379-E1385. https://doi.org/10.1503/cmaj.170072
2022García-Azorín et al. (2022). Sensitivity of the SNNOOP10 list in the high-risk secondary headache detection. Cephalalgia : an international journal of headache, 42(14), 1521-1531. https://doi.org/10.1177/03331024221120249
2008Hall et al. (2008). Intertester reliability and diagnostic validity of the cervical flexion-rotation test. Journal of manipulative and physiological therapeutics, 31(4), 293-300. https://doi.org/10.1016/j.jmpt.2008.03.012
2016Rubio-Ochoa et al. (2016). Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review. Manual therapy, 21, 35-40. https://doi.org/10.1016/j.math.2015.09.008
2007Ogince et al. (2007). The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache. Manual therapy, 12(3), 256-62. https://doi.org/10.1016/j.math.2006.06.016
2019van der Meer et al. (2019). The diagnostic accuracy of headache measurement instruments: A systematic review and meta-analysis focusing on headaches associated with musculoskeletal symptoms. Cephalalgia : an international journal of headache, 39(10), 1313-1332. https://doi.org/10.1177/0333102419840777
2006Zito et al. (2006). Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual therapy, 11(2), 118-29. https://doi.org/10.1016/j.math.2005.04.007
2023Jull (2023). Cervicogenic headache. Musculoskeletal science & practice, 66, 102787. https://doi.org/10.1016/j.msksp.2023.102787
2007Jull et al. (2007). Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches. Cephalalgia : an international journal of headache, 27(7), 793-802. https://doi.org/10.1111/j.1468-2982.2007.01345.x
2025Pensri et al. (2025). Cervical musculoskeletal impairments in migraine and tension-type headache and relationship to pain related factors: An updated systematic review and meta-analysis. Musculoskeletal science & practice, 76, 103251. https://doi.org/10.1016/j.msksp.2024.103251
2009Bogduk & Govind (2009). Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. The Lancet. Neurology, 8(10), 959-68. https://doi.org/10.1016/S1474-4422(09)70209-1
2026Martins et al. (2026). Efficacy of nonsurgical interventions for the management of adults with cervicogenic headache: a systematic review and meta-analyses. Annals of physical and rehabilitation medicine, 69(4), 102070. https://doi.org/10.1016/j.rehab.2025.102070
2022Bini et al. (2022). The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: a systematic review and meta-analysis. Chiropractic & manual therapies, 30(1), 49. https://doi.org/10.1186/s12998-022-00459-9
2026Koonalinthip et al. (2026). The Comparative Efficacy of Treatments for Cervicogenic Headache: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials. European journal of pain (London, England), 30(2), e70219. https://doi.org/10.1002/ejp.70219
2016Dunning et al. (2016). Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC musculoskeletal disorders, 17, 64. https://doi.org/10.1186/s12891-016-0912-3
2018Haas et al. (2018). Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. The spine journal : official journal of the North American Spine Society, 18(10), 1741-1754. https://doi.org/10.1016/j.spinee.2018.02.019
2021Anarte-Lazo et al. (2021). Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis. BMC musculoskeletal disorders, 22(1), 755. https://doi.org/10.1186/s12891-021-04595-w

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