Is your headache coming from your neck?

If your headache is reliably brought on by neck position or sustained desk posture, stays on the same side, and lacks nausea and throbbing, the generator may be in your neck rather than your head.

This matters because treating the head does not fix a neck problem. People cycle through migraine medications for years without touching the actual source.

How cervicogenic headache presents

• Pain that starts in the neck or at the base of the skull and is referred forward — over the back of the head, behind the ear, sometimes to the forehead or around the eye
• Usually one-sided, and it stays on that side — it does not alternate the way migraine can
• Provoked by neck movement or position, or by pressure over the upper cervical joints
• Reduced range of neck motion on the affected side
• A deep ache rather than electric jolts, and without the marked scalp tenderness of occipital neuralgia

ICHD-3 requires evidence that the headache is attributable to a disorder of the cervical spine or soft tissues of the neck, and lists two ways of showing it: the headache develops in temporal relation to the neck disorder, or the headache is abolished by a diagnostic blockade of a cervical structure or its nerve supply.¹

That second criterion is the important one, and it is the whole reason diagnostic blocks exist for this condition.

Which structures refer pain into the head

The atlanto-axial joint (C1–C2)

The joint that lets you shake your head “no” carries more rotation than any other in the neck, and it refers pain to the back of the head and behind the ear. It is frequently missed, because it sits above the levels most cervical imaging and most injections address. An atlanto-axial injection reaches it, under fluoroscopy with contrast confirmation — the vertebral artery and the C2 nerve root are immediately adjacent, so this one is never done blind.

The upper cervical facet joints

C2–C3 in particular refers into the occipital region. Diagnostic medial branch blocks establish whether these joints are the source.

The occipital nerves

Not a joint, but the pathway. An occipital nerve block is often the first step because it is quick, low-risk under ultrasound, and immediately informative.

Why whiplash shows up years later

Cervicogenic headache frequently follows a neck injury, and the gap between the injury and the headache can be months. People do not connect the two, and neither does the clinician who was not told about the accident. If you have had whiplash at any point, mention it even if it seems ancient history.

What the treatment plan looks like

An image-guided block first, to establish the source. If the block abolishes the pain, you have a target and the longer-term options become reasonable. If it does not, the diagnosis moves and you have not wasted months.

Physical therapy directed at the upper cervical spine does much of the durable work. Injections buy the window in which that becomes possible — treating a neck that hurts too much to move is not productive.

Everything here is placed under ultrasound or fluoroscopic guidance. With a diagnostic block, guidance is not a refinement: an unguided block that fails tells you nothing, because it may simply have missed.

Common questions

Can neck arthritis on an X-ray prove my headache is cervicogenic?

No. Degenerative changes are extremely common in people with no headache at all. ICHD-3 requires either a temporal relationship or abolition by a diagnostic block — imaging findings alone are not sufficient. See cervicogenic headache treatment.

I get neck pain with my migraines. Does that make them cervicogenic?

Usually not. Neck symptoms are very common during migraine attacks and are part of the migraine itself. The distinguishing feature is whether neck movement provokes the headache rather than accompanying it. See migraine treatment.

What if the block only helps a little?

A partial response is genuinely ambiguous and we treat it that way. It may mean more than one structure is contributing, or that the targeted structure is not the main generator. See image guidance for why a guided block makes a negative result trustworthy.

Is this the same as occipital neuralgia?

No. Occipital neuralgia is electric, shooting pain with marked scalp tenderness; cervicogenic headache is a deeper referred ache provoked by neck position. They overlap and a block often separates them — see occipital neuralgia treatment.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 11.2.1 Cervicogenic headache. ichd-3.org