Cervicogenic headaches: Migraines, tension headaches and cervical spine instability

Ross Hauser, MD

Patients with migraines and chronic headache have a cervical neck instability problem

At Caring Medical, we have been seeing headache patients for a long time. In 2009, our research team lead by Ross Hauser, MD., published our findings and recommendations for the treatment of chronic headaches and migraines in patients where clear cervical neck instability was suspected. This was based on already 15 years of clinic observation.

“I have these headaches no one can figure out”

A person may contact our office with an email or a phone call which they describe something like this:

I get these bad headaches, they started about a year ago. No one can figure out what is causing them. I have had brain scans, sinus scans, I had my teeth checked. I have been sent to ENTs who have requested lots of different blood workups. Everything comes back normal. My headaches start at the back of my head, eventually, it moves behind my eyes and sinus area. I am not getting any answers except medications.

I have been to several neurologists. They were are at a loss. Each one recommended treatments that I had already tried with the previous doctors that did not help me. Pain medications, physical therapy, mostly. Then I started to develop terrible neck pain as well. When I had the neck pain checked out the pain doctor told me I had cervical disc degenerative disease. I had cortisone and nerve blocks for my neck and my headaches went away. I was told that the relief would likely be temporary and it was. My neck pain and headaches are back. At least now I know that my headaches are Cervicogenic headaches.

For many people, physical therapy, medications, nerve blocks, can be helpful and provide long-term relief for their headaches. These are not the people we see in our office. We see the people who these treatments did not help.

Cervicogenic headaches – Migraines, tension headaches, and cervical neck instability

Above we gave two examples of the type of patient we can see who is confused about the cause and onset of their back of the head headaches. When someone comes into our clinic and we suspect Cervicogenic headaches we look for:

In our research, we discussed at the beginning of this article, published in the journal Practical Pain Management, (1) we described the problems of patients with headaches that were not being helped by traditional drug-based medicine and stress management. Not much has changed in the last ten-plus years.

Treatments that do not work, do not work because they do not address the problems of cervical spine instability from cervical ligament damage.

Among some of the reasons that patients do not get a headache or migraine relief is that pharmaceutical-based management of the patient’s headaches does not address the problem of headaches coming from neck pain caused by weakened or damaged cervical ligaments.

In our 2014 research led by Danielle R. Steilen-Matias, MMS, PA-C, and published in The Open Orthopaedics Journal (2) our research team was able to demonstrate that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.

A brief note on vertebrobasilar insufficiency. Typically this describes a narrowing of the arteries that is usually treated with blood thinners and cholesterol medication. In this context, vertebrobasilar insufficiency is describing a situation where hypermobility of the neck vertebrae is causing a “squeezing,” of the arteries by pinching movement.

Our research was cited in an April 2018 study in the International Journal of Environmental Research and Public Health. (3) Here researchers wrote:

The management of common recurrent headaches

We are going to explore research that will give evidence that your chronic headache and migraine are not being resolved because no one is talking to you about ligaments, perhaps except those health care providers who cannot offer injection treatment or cannot prescribe pharmaceutical management: chiropractors. We will also discuss physical therapy below.

Above we wrote that someone who is suspected of having cervical neck instability as the cause of their headaches is:

An October 2018 study published in the journal BioMed Central Neurology, (4) describes the challenges faced by patients and chiropractors in helping patients with a tension headache, migraine, and cervicogenic headache.

Here are the learning points from that research.

Number of chiropractic visits

For headache suffers with less than 3 months duration:

How do chiropractors treat by headache type?

Why are so many visiting the chiropractor? The researchers suggest:


What are we to make of this?

Chiropractors understand that there is a neck component to headache management, they may not have all the tools they need in their treatments to offer satisfactory relief for some patients. If you are reading this article you are likely one of these patients. We are pleased to be able to combine our treatments with chiropractic under the guidance of Ross Hauser, MD, and Brian R. Hutcheson, D.C.

In this video, Ross Hauser, MD explains and demonstrates the use of Digital Motion X-ray (DMX) to help identify cervical neck and spine instability in the C1-C2 region in a patient with severe migraines.

The summary transcript of this video, with explanatory notes, is below the video.

One of the more common conditions we see at Caring Medical is severe migraine headaches. I am going to demonstrate how we diagnosis and plan treatments for a patient we suspect of upper cervical spine instability as the cause of migraine headaches. In this video Digital Motion X-ray DMX is utilized to demonstrate the clues and signs of cervical spine instability, especially that surrounding the Dens or the C2 vertebrae.

At the 1:00 mark of the video, the Digital Motion X-ray DMX of the patient’s cervical spine instability is demonstrated.

More instability

This patient had 4 Prolotherapy treatments, his headaches are at a minimum. He will need a few more treatments to stabilize his cervical spine and further reduce eliminate his migraines.

Ross Hauser, MD. Cause of occipital neuralgia and migraines seen on DMX and resolved with Prolotherapy

In this video, Ross Hauser, MD offers a brief introduction to causes and the diagnosis of occipital neuralgia and migraines and treated with the aid of DMX (Digital Motion X-Ray and simple dextrose Prolotherapy cervical spine injections.

Summary highlights of the video:

Digital motion X-Ray C1 – C2

The digital motion x-ray is explained and demonstrated below

Headache researchers are understanding that patients with migraines and chronic headache have a neck pain/instability problem and it is more common than thought

Let’s look at five recent research studies.

Researchers representing Lund University in Sweden and the University of Copenhagen in Denmark published a December 2017 study in The Journal of Headache and Pain (5) showing that the prevalence of migraines with co-existing tension-type headache and neck pain is high in the general population.

They also acknowledge the problem that there is very little literature on the characteristics of these combined conditions.

The aim of their study was to investigate:

Here are the results which give evidence to the neck pain connection to headaches:

The researchers were able to conclude that migraine with co-existing tension-type headache and neck pain was highly prevalent and that persons with migraine and co-existing tension-type headache and neck pain may require more individually tailored interventions to increase the level of physical activity and to improve psychological well-being, perceived stress, and self-rated health.

Now let’s examine the second study from a diverse team of Canadian researchers from medical universities and hospitals throughout Canada. Here doctors writing in the European Spine Journal explored treatments for managing patients who suffered from chronic tension-type headaches with constant neck pain and muscle spasm. The muscle spasms should have been a clue that the headaches were being caused by cervical neck instability. Muscles spasm in unstable joints because they are being overworked trying to help or replace the function of damaged ligaments and tendons in stabilizing the joint. 

Chiropractors found headaches have a neck instability component and the treatments offered were symptom management techniques

This is shown by researchers at the Canadian Memorial Chiropractic College who wrote of the effectiveness or non-effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain. In the European Spine Journal (6) they suggested that treatments should include exercise (to help stabilize), relaxation training with stress coping therapy (to reduce spasm), and perhaps manual therapy (chiropractic) to help get the neck back in its natural position.

The connection and problems of headache and neck pain in the workplace have also found recommendations from the University of Turin doctors for relaxation techniques to help manage muscle spasms and tension. The doctors noted a muscle relaxation program could significantly reduce the high rate of work disability. (7)

Again, the researchers point to system suppression, at least in these papers attempts are made to get away from pharmaceutical management of chronic headaches and do seek to find the problems of headaches routed in neck pain and instability, and muscle spasm.

In the fourth study from doctors at the University of São Paulo in Brazil, researchers concluded: “We cannot assume that physical therapy promotes additional improvement in migraine treatment; however, it can increase the cervical pressure pain threshold, anticipate clinically relevant changes, and enhance patient satisfaction.”(8)

Lastly, in the fifth paper doctors examined the 4th phase of a migraine cycle – The migraine postdrome – that is the physical aftermath after the migraine episode has dissipated. In this study of 120 patients, 81% reported at least one non-headache symptom in the postdrome.

Postdrome symptoms, in order of frequency, included feeling tired/weary and having difficulty concentrating, and stiff neck. Many patients also reported mild residual head discomfort. (9)

One notable characteristic of the patients was noted by the doctors:

There is a striking underestimation of the frequency of neck stiffness and sensitivity to light and noise.

“Emerging evidence of occipital nerve compression in unremitting head and neck pain”

That is the title of recent research that appears in the July 2019 issue of The Journal of Headache and Pain (10) It comes from researchers at the University of Texas and Harvard Medical School

The cause of Unremitting head and neck pain in some patients may be compression of the lesser and greater occipital nerves by the posterior cervical muscles and their fascial attachments at the occipital ridge (where the base of the skull meets the spine) with subsequent local perineural inflammation (nerve inflammation). The resulting pain is typically in the sub-occipital and occipital location, and, via anatomic connections between extracranial and intracranial nerves, may radiate frontally to trigeminal-innervated areas of the head. Migraine-like features of photophobia (light sensitivity) and nausea may occur with frontal radiation.

Occipital allodynia (a super sensitivity to pain) is common, as is a spasm of the cervical muscles. Patients with Unremitting head and neck pain may comprise a subgroup of Chronic Migraine, as well as Chronic Tension-Type Headache, New Daily Persistent Headache, and Cervicogenic Headache.

Centrally acting membrane-stabilizing agents (local anesthetics), which are often ineffective for Chronic Migraine, are similarly generally ineffective for Unremitting head and neck pain.”

The researchers suggest extracranially-directed treatments such as occipital nerve blocks, cervical trigger point injections, botulinum toxin, and monoclonal antibodies may provide more substantial relief for unremitting head and neck pain; additionally, decompression of the occipital nerves from muscular and fascial compression is effective for some patients and may result in enduring pain relief.

A brief explanation of cervical ligament injury and headaches

In this video, Ross Hauser, MD, explains the mechanisms of cervical ligament injury and headaches.

Transcript summary:

The back up of cerebrospinal fluid in perimenopausal or in menopause. The cause of the pressure is the pressure headache.

A 2018 paper in the Journal of Women’s Health (11) titled: “A New Subtype of Chronic Daily Headache Presenting in Older Women,” found a new classification for perimenopausal or menopausal women suffering from headache suspected of being caused by intracranial pressure. While this research suggests that obesity or weight may play a role, of the eight patients they examined, two were not overweight, reflecting 25% of the study group. Let’s look at the research:

The conclusion of this study: “This newly defined subtype of chronic daily headache appears to be caused by a state of elevated CSF pressure. It is hypothesized that a combination of an elevated BMI and the presence of cerebral venous insufficiency leads to this form of daily headache.” Elevated CSF pressure is also characteristic in cervical instability patients.

Prolotherapy and the neck element in headaches

Do weakened ligaments in the neck causes an unnatural head posture which can cause headaches? Can strengthening these neck ligaments resolve the problem of chronic headaches and migraines by resolving the problem of cervical instability?

We are going to return to our research published in the journal Practical Pain Management, (1)

Prolotherapy is based on the theory that the cause of most chronic musculoskeletal pain is ligament and/or tendon weakness (or laxity). This retrospective pilot study was undertaken to evaluate the effectiveness of dextrose prolotherapy on tension and migraine headache pain and its associated symptoms.

Typical areas treated during Prolotherapy sessions for chronic headaches and neck pain are the base of the skull, cervical vertebral ligaments, posterior-lateral clavicle, where the trapezius muscle attaches, as well as the attachments of the levator scapulae muscles. Because there is an anesthetic in the solution, generally the neck or headache pain is immediately relieved. This again, confirms the diagnosis both for the patient and the physician.

Study highlights:

Light sensitivity in the study patients

Sensitivity to light is a common complaint associated with tension or migraine headaches. Study participants reported on light sensitivity both prior to and following completion of the
Prolotherapy treatments, rating them on a scale of 1 to 10 (with 10 being the most severe).

Our study followed patients, on average, 22 months after their last Prolotherapy treatment and all 100% still had benefits.

Clinically significant improvements were reported including:

Further reading: Cervical Spine Realignment and restoring loss of cervical lordosis

In our article Cervical Spine Realignment and restoring loss of cervical lordosis, Dr. Hauser presents the case that cervical spine, upper cervical spine, and lower cervical spine instability may be an unexplored cause of your neurologic-like, vascular-like and psychiatric-like conditions and symptoms.

Further reading: Symptoms and conditions of Craniocervical Instability

In this article, Symptoms and conditions of Craniocervical Instability, Dr. Hauser has put together a summary of some of the symptoms and conditions that we have seen in our patients either previously diagnosed or recently diagnosed with Craniocervical Instability, upper cervical spine instability, cervical spine instability, or simply problems related to neck pain.

For many of these people, symptoms, and conditions extended far beyond the neck pain, radiating pain of cervical radiculopathy, headaches, TMJ, and possibly dizziness usually associated with problems in the neck. These people’s symptoms and conditions extend into neurologic-type problems that may include digestion, irregular cardiovascular problems, hallucinogenic sensations, vision problems, hearing problems, swallowing problems, excessive sweating, and a myriad of others.

I want to point out that the symptoms and conditions you will see described below can be caused by many problems. This article demonstrates that craniocervical instability and cervical neck instability can be one of them.

If this article has helped you understand the problems of chronic headaches and migraines and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

1 Hauser RA, McCullough H. Dextrose Prolotherapy for recurring headache and migraine pain. Practical Pain Management. 2009:58-65. [Google Scholar]
2 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
3 Lin WS, Huang TF, Chuang TY, Lin CL, Kao CH. Association between cervical spondylosis and migraine: a nationwide retrospective cohort study. International journal of environmental research and public health. 2018 Apr;15(4):587. [Google Scholar]
4 Moore C, Leaver A, Sibbritt D, Adams J. The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey. BMC Neurol. 2018;18(1):171. Published 2018 Oct 17. doi:10.1186/s12883-018-1173-6 [Google Scholar]
5 Krøll LS, Hammarlund CS, Westergaard ML, Nielsen T, Sloth LB, Jensen RH, Gard G. Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain. The journal of headache and pain. 2017 Dec 1;18(1):46. [Google Scholar]
6 Varatharajan S, Ferguson B, Chrobak K, Shergill Y, Côté P, Wong JJ, Yu H, Shearer HM, Southerst D, Sutton D, Randhawa K. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Spine Journal. 2016 Jul 1;25(7):1971-99. [Google Scholar]
7 Rota E, Evangelista A, Ceccarelli M, Ferrero L, Milani C, Ugolini A, Mongini F. Efficacy of a workplace relaxation exercise program on muscle tenderness in a working community with headache and neck pain: a longitudinal, controlled study. Eur J Phys Rehabil Med. 2016 Jan 8.PubMed PMID: 26745361.  [Google Scholar]
8. Bevilaqua-Grossi D, Gonçalves MC, Carvalho GF, Florencio LL, Dach F, Speciali JG, Bigal ME, Chaves TC. Additional Effects of a Physical Therapy Protocol on Headache Frequency, Pressure Pain Threshold, and Improvement Perception in Patients With Migraine and Associated Neck Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2015 Dec 21. [Google Scholar]
9. Giffin NJ, Lipton RB, Silberstein SD, Olesen J, Goadsby PJ. The migraine postdrome: An electronic diary study. Neurology. 2016;87(3):309-313 [Google Scholar]
10. Blake P, Burstein R. Emerging evidence of occipital nerve compression in unremitting head and neck pain. The journal of headache and pain. 2019 Dec;20(1):76. [Google Scholar]
11 Rozen TD. A new subtype of chronic daily headache presenting in older women. Journal of Women’s Health. 2018 Feb 1;27(2):203-8. [Google Scholar]
12 Rozen T, Swidan S, Hamel R, Saper J. Trendelenburg position: a tool to screen for the presence of a low CSF pressure syndrome in daily headache patients. Headache: The Journal of Head and Face Pain. 2008 Oct;48(9):1366-71. [Google Scholar]

This article was updated March 7, 2021

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