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Unraveling the Mystery of Headaches


Headaches are generally classified in one of six major categories including Sinus, Cluster, Tension, Migraine, TMJ and Cervicogenic (neck) type headaches. For the purposes of this article we will succinctly examine the mechanically mediated types of headaches that are described in the figure below. Mechanical Physical Therapy is particularly successful at treating Cervicogenic (neck), Tension type and TMJ type headaches. This article aims to give a brief overview of causes of mechanical headaches and an explanation on treatments as well as prognosis.


Examination of Headaches

The task of a mechanical examination, as in other areas of the spine, is first to determine those who are inappropriate for treatment. Further, the evaluation process identifies those with red flag” features that should be referred for further investigation. The history principally gives these features for differential diagnosis.

Included below are possible red flag indicators of serious pathology in headaches:

  • progressive worsening of headache
  • recent severe onset / ‘thunderclap’ headache
  • onset of headache after exertion
  • onset of headaches > 50 years old
  • history of major trauma
  • nausea / vomiting
  • temporal / occipital headache, with visual changes
  • preceding sore throat / respiratory infection
  • history of cancer
  • problems with speech / swallowing
  • visual changes – diploplia, ptosis, blurring
  • associated symptoms: progressive weakness,
  • convulsions, blackouts, mental changes, systemically unwell

Clues to mechanical nature of cervicogenic headache:

  • intermittent symptoms
  • symptoms associated with consistent activity
  • symptoms produced with sustained activity in one posture


Manual Therapy from mechanical physical therapists provides a good conservative option for the treatment of cervicogenic headache. The International Headache Society includes C1/C2 limited rotation manifested as impaired neck mobility as a diagnostic criterion of cervicogenic headache. In addition to limited range of motion (ROM), a forward head posture, weakness in the deep neck flexors (DNF) and weak cervical extensors are often present with cervicogenic headaches.

Manual treatment aimed at the upper cervical spine specifically to increase cervical rotation has been shown to be effective in reducing self-reported headache severity and increasing cervical rotation. Training the DNFs, postural alignment and neck extensor strengthening is important to this population of patients.
Patients with cervicogenic headache that are correctly diagnosed can significantly reduce their headache severity and increase their cervical spine range of motion with skilled manual physical therapy and a low-load exercise program directed to the upper cervical spine.


A solid customized rehabilitation program provided by a Doctor of Physical Therapy will include the following, based on current empirical evidence and clinical outcomes:

1. Patient education with a thorough Home Exercise Program (HEP) to include Self mobilization techniques.

2. Manual Physical Therapy including IASTM (see IASTM blog at www.wrightpt.com), soft tissue mobilization, directional preference training of the cervical spine, trigger point therapy, manipulative intervention.

3. Strengthening of deep neck flexors, cervicothoracic motor function and axioscapular muscles

4. Postural and proprioceptive exercises

5. Modalities including cryotherapy, moist heat, interferential electrical stimulation or others as needed.

6. Traction when warranted – the five variables that best predict the benefit of cervical traction are:

  • Age > 55
  • Pain relief with arm resting on top of head
  • Reproduction of symptoms with the upper limb tension test A
  • Symptoms that peripheralize with PAs at C4-7
  • Symptom relief with cervical distraction.

The presence of any 3 of these variables increases success of traction to 79% and presence of 4 variables increases success rates to 95%. The presence of only one variable decreases the probability of success with cervical traction to less than chance.

Referral Recommendation for Headache Disorders

Headache patients that would benefit most from mechanical cervicogenic treatment include those with the following:

1. Tender cervical paraspinal tissue
2. Visual deformity such as wry neck or forward head, side locked position
3. Headache symptoms with radiculopathy
4. Hemicranial symptoms in the oculo-frontal-temporal area
5. Restricted rotation from a flexed position

In particular, patients without a complaint of light-headedness have an elevated likelihood for success from mechanical treatment.

Please contact bryan@wrightpt.com for further questions about our effective headache treatments. You can also reach me as shown below at the TF Locust Grove location.