Do we have a role in managing chronic headaches?

Headaches are frequent causes for presentations at most manual therapy clinics.  Headaches can be debilitating, annoying and all encompassing, be they migraine, tension type headaches, cervicogenic  or the less common autonomic cephalgias such as cluster headaches (sometimes called suicide headaches). People will frequently seek out manual therapy because when their head hurts, they also will tend to have neck pain.  Studies tell us that 64-70% of people with headache and migraine will also have neck pain 1.

Is the neck the cause of the headache?

In some cases, yes.  In reality though, cervicogenic headaches actually make up a fairly small proportion (18%) of the headache sufferer population 2.  To be classified as a cervicogenic headache (and be therefore most likely to respond to manual therapy) the headache must be precipitated by neck movements or postures and/or pressure over the upper cervical/ occipital regions, have restriction in neck ROM and have weakness in the deep cervical flexors.  Cervicogenic headaches are also typically side dominant and don’t throb3.

Typically, manual therapists tend to place a lot of emphasis for diagnosis of a cervicogenic headache on the ability to reproduce the headache with palpation of the upper cervical region.  However this is a bit of an erroneous test because we know that almost 100% of patients with either a tension type headache or a migraine will also get reproduction of their headache with palpation of the upper cervicals4.   This is most likely due to the phenomenon of convergence at the Trigeminocervical nucleus(TCN) , where information from both the upper three cervical vertebra and the trigeminal nerve feed into the same region in the brain.  Like other types of convergence or referred pain, the brain can’t figure out where the pain is coming from and so both can tend to be painful.  In the chronic headache sufferer, the TCN undergoes central sensitisation processes, making it more likely to interpret and pass on information of a painful nature.

The literature tells us that physical treatment for headaches tends to only give sustained benefit to those people who genuinely fall into the cervicogenic headache category 5 .  However, as practitioners we have all seen instances when some level of relief from manual therapy has been achieved for a headache that falls outside of these categories, including for those suffering from tension type headaches.  In these instances, we are probably having a modulatory effect on the TCN.

As an occasional tension headache sufferer, I would argue that any benefit that can be achieved from manual therapy for a non cervicogenic headache  is  fantastic and is worth pursuing – with the caveat that both the practitioner and patient understand the context of use – to provide temporary relief as part of a bigger picture of treatment.  We should not be suggesting that we can comprehensively treat all types of headaches using manual therapy alone.  As in all chronic conditions, passive approaches such as this are not the answer.

The literature is very good at telling us what doesn’t work for a particular condition, and headaches are no different in this instance.  In the next blog post we will look at some of the approaches that are known to have an effect on headache frequency, intensity and medication use.  Surely all this research has to be good for something!


  1. Blau, J., MacGregor, E. (1994). Headache and the neck.  Headache, 35(2), 104-106.
  2. Nilsson, N. (1995). The prevalence of cervicogenic headache in a random population sample of 20-59 year olds. Spine, 1:20 (17) 1884-1888.
  3. Hall, T., Briffa, K., & Hoppa, D. (2008). Clinical evaluation of cervicogenic headache: A clinical perspective. The Journal of Manual and Manipulative Therapy, 16(2) 73-80.
  4. Watson, D., & Drummond, D. (2012). Headache pain referral during examination of the neck in migraine and tension-type headache. Headache, 52(8), 1226-35
  5. Bronfort,G., Haas, M., Evans, R., Leininger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Journal of Chiropractic and Osteopathy. 25, 18.