Why is my head hurting? What’s that all about?


Have you ever wondered why you have a headache that can be in different parts of your head at different times?   

 Why is it sometimes at the front of my head?  Why at other times is it only in the back of my head? 

 What can I do to keep the headaches from starting?

 How do I get rid of them once they’ve started?         


Primary Headaches

  1.   Tension
  2.   Migraine
  3.   Cluster


  1. Alcohol
  2. Hunger
  3. Over medication
  4. Sinus problems
  5. Dehydration


The Cervicogenic Headache is one of the most common types of headaches seen by physiotherapists (at least in my experience). The prevalence (occurrence) has been reported to be approximated 18 per cent of all headache types. 

What you might typically see with this type of headache is:

  1. Signs of neck involvement (typically the upper neck C1-2-3 levels).
    1. pain and tenderness in the neck area
    2. reduced range of motion in the neck
  2. Brought on by neck movement or positioning.
  3. Typically one-sided pain in the neck, head and shoulder.
  4. Possible history of neck trauma (whiplash).
  5. Moderate to severe, non-throbbing pain typically starting in the neck.
  6. Accompanied by dizziness, light sensitivity, nausea and blurred vision.


The trigeminal nerve is the fifth cranial nerve (comes out of the head). It supplies feeling to the face and also has a motor supply to the muscle of the jaw area.

In the upper part of the neck, the nerves from the neck and the trigeminal nerve converge. When there’s dysfunction in the upper part of the neck, the trigeminal nerve can get facilitated (gets improper input and over active).This can create tension in the jaw muscles and the headache sensation that’s often felt on one side of the face. Treating the jaw often is needed when treating neck problems and headaches.


Tension in the muscles is thought to be the contributing factor to what are called tension headaches. One of the key muscles involved seems to be the upper part of the trapezius (traps). The other key muscles that I have noted clinically are the longissimus cervicus and the intercostalis cervicus. If you have ever experienced tightness in the upper back part of the shoulder and just slightly between the shoulder blades, this is the area where these muscles start.   

Trigger points are the area of the muscle that when pressed on reproduces the symptom that you are having. Trigger points have been shown to be areas of peripheral sensitization (have release of alogenic substances). Peripheral (spinal part of the nervous system) sensitization has been connected with central sensitization (central is the brain part of the nervous system). It is thought that the release of the trigger point will affect the pattern of the headache in the brain and thereby reduce the headaches. 


There is research that has shown a correlation between weakness or dysfunction of the deeper neck muscles at the front of the neck (look back to the April 15 blog on neck stabilization). Headache sufferers may also have a smaller bulk of muscles at the upper part of the neck at the back. 


So we already discussed reducing headaches by releasing the trigger points. The other way to reduce headaches is through exercise. This occurs by activating the parts of our spinal cord that come down from the brain (descending pathways). This helps to block the pain signal. Cardiovascular-type exercise releases endorphins which are a neuropeptid that acts like a morphine.


Manipulation:  Spinal manipulation has been shown to be effective in reducing headache symptoms. In recent years there has been a lot of controversy about manipulation of the neck area. Some research has indicated that manipulation of the thoracic spine (mid-back) can be effective for management of neck pain and headaches. A recent study by GA Jull indicated that we cannot yet predict who will or won’t benefit from this treatment. Although, if the pain starts in the neck before the headache and you don’t have associated light-headedness, there is a good chance you will benefit. 

Exercise:  For people who have associated light-headedness with their headaches, there are some specific exercises that target the proprioceptors in the upper neck. (Proprioception is the awareness of where our body is positioned through receptors in our joints and ligaments. There is a high concentration of these in the upper neck). 

The benefit of cardiovascular exercise was mentioned previously. 

Manual Therapy: I consider manual therapy to include acupressure, massage, joint mobilizations (moving the joints but not doing a high velocity manipulation  thrust). 

Craniosacral Therapy: This is considered an alternative therapy technique, but I have seen it employed clinically to help with reducing headache tension. 

IMS (intramuscular stimulation):  IMS works on the principle of peripheral sensitization caused by pressure to the nerves that exit from the spinal canal. When there is pressure on the nerve, the muscle becomes overly sensitive and overactive to environmental stimuli. The muscles that are tense and ropy along with the spinal segment area are released using an acupuncture needle. I personally have been using IMS quite successfully for management of tension headaches.  For more information on IMS, go to www.istop.org


So where you feel your headache, may actually have to do with the type of headache that it is. When there’s tension just at the upper back of the neck, you might start to eventually experience the headache at the front of the face on one side (trigeminal nerve involvement).

When you get the headache at the base of the skull area and the back of the head, it is most likely from tension in the muscles in that area located there, and pinching of the occipital nerve, which supplies that area. 

A throbbing headache may be vascular (true migraine), which I did not talk about. Basically what I know about vascular-type headaches is that the blood vessels dilate allowing more blood into the brain area. 

Keeping the headaches from starting involves knowing what triggers them. Working on proper posture when sitting (especially working on the computer) and standing (slouching puts more pressure on the areas where the nerves come out and creates muscle imbalances). I do know that once the headache moves from the back of the neck to the front, it is much more difficult to get rid of. The best time to take your medication is at the first sign of tension. Heat is also often effective for muscle relaxation as is regular stretching.

If you are plagued with chronic headaches that have not responded to other treatments (manual therapy, massage, manipulation) I would recommend reading up on IMS to see if it is something you would like to try. 


K Aaseth, RB Grande, KJ Kværner, P Gulbrandsen, C Lundqvist & MB Russell.   Prevalence of secondary chronic headaches in a population-based sample of 30–44-year-old persons. The Akershus study of chronic headache. Blackwell Publishing Ltd Cephalalgia, 2008, 28, 705–713

C Fernández-de-las-Peñas1. Physical therapy and exercise in headache. Blackwell Publishing Ltd Cephalalgia, 2008, 28 (Suppl. 1), 36–38

S Evers. Comparison of cervicogenic headache with migraine. Blackwell Publishing Ltd Cephalalgia, 2008, 28 (Suppl. 1), 16–17

GA Jull & WR Stanton. Predictors of responsiveness to physiotherapy management of cervicogenic headache. Blackwell Publishing Ltd Cephalalgia,2004, 25, 101–108

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