Cervicogenic Headache vs Migraine: Assessment Guide for Physios

Quick comparison

• Side: cervicogenic headache is side-locked, always the same side; migraine is often one-sided but can switch sides.
• Trigger: cervicogenic headache is provoked by neck movement or sustained postures; migraine by sleep change, hormones, stress or certain foods.
• Associated features: migraine brings nausea, sensitivity to light and sound, and sometimes aura; these are absent or mild in cervicogenic headache.
• Neck exam: cervicogenic headache shows reduced range, often a positive flexion-rotation test and reproduction of headache on upper cervical palpation.
• Character: migraine is often throbbing and worse with activity; cervicogenic headache is a non-throbbing ache spreading from the neck forwards.

What is happening in the nervous system

Cervicogenic headache is explained by convergence in the trigeminocervical nucleus in the upper spinal cord. Sensory fibres from the upper three cervical nerves meet fibres from the trigeminal nerve, which supplies the forehead and around the eye. Pain from the upper neck joints, muscles or ligaments can therefore be felt in the head, typically spreading from the back of the skull to the front on the same side.

Migraine is a primary brain disorder. It involves changes in how the brain processes sensory information and activation of the trigeminovascular system, which releases inflammatory messengers around the blood vessels of the meninges. Because the same trigeminocervical pathway is involved, neck pain and neck muscle tenderness are very common during migraine attacks. This shared pathway is why neck symptoms alone cannot tell the two conditions apart.

The flexion-rotation test

With the neck fully flexed, rotate the head passively each way. Rotation below about 32°, or a 10° side difference, suggests C1-C2 dysfunction and supports cervicogenic headache. A normal test does not rule it out but lowers its likelihood.

Worked mini-scenario

A 34-year-old reports headaches several times a month with neck tightness. During attacks she feels nauseous, prefers a dark room, and the pain switches sides.

Hypotheses: migraine without aura, cervicogenic headache, tension-type headache. Neck range is near full and the flexion-rotation test is symmetrical.

Reasoning: side-switching, nausea and light sensitivity point to migraine; neck pain is a common migraine feature. The plan includes a headache diary, checking painkiller use (medication overuse), and GP coordination for migraine care.

A contrasting case: the cervicogenic patient

A 46-year-old office worker has had right-sided headaches for four months, always on the right. They start at the base of the skull after long periods at the computer and spread to the right eye. There is no nausea, no light or sound sensitivity and no aura. She had a minor rear-end car accident a year ago.

Neck rotation to the right is reduced. The flexion-rotation test shows clearly less rotation to the right than to the left. Sustained pressure over the right upper cervical segments reproduces her usual headache, which eases as the pressure is held. Her deep neck flexor endurance is poor. The neurological screen is normal and there are no red flags.

Reasoning: a side-locked headache provoked by sustained posture, starting in the neck, reproduced by upper cervical pressure and with a positive flexion-rotation test supports cervicogenic headache. The plan is manual therapy to the upper cervical spine, deep neck flexor and scapular training, workstation and break advice, and a headache diary to measure change.

Compare this with the first case. Both patients have one-sided headache and neck pain. The difference is the pattern: one has migraine features, the other a reproducible neck source.

Subjective questions that separate them

A detailed headache history is the most powerful tool you have. Ask the patient to describe a typical attack from the first warning to recovery. Migraine often has a build-up phase, may include aura such as zigzag lines or tingling spreading over minutes, then a moderate to severe headache lasting hours to days with nausea and a need for a dark, quiet room. Cervicogenic headache usually starts in the neck and spreads forward to the forehead or eye on the same side, and it often comes on after sustained postures or particular neck movements.

Ask about patterns. Migraine is frequently linked to the menstrual cycle, missed sleep, missed meals, stress or the weekend after a busy week. Ask how often painkillers are taken, because frequent use can cause medication overuse headache. Ask about past neck injury, such as whiplash, and whether neck movement or pressure on the upper neck can bring on the familiar headache.

• Is the headache always on the same side?
• Does neck movement or a held posture bring it on?
• Do you feel sick, or bothered by light and sound, during an attack?
• Any visual or sensory changes before the headache?
• How many days a month do you take painkillers?

Examination sequence

Screen for red flags first and record a basic neurological examination: cranial nerves, coordination and limb neurology where indicated. Then assess cervical range of motion, the flexion-rotation test, and palpation of the upper cervical segments. In cervicogenic headache, sustained pressure on the upper neck can reproduce the usual headache, and that reproduction often eases as pressure is held.

Add the craniocervical flexion test to look at deep neck flexor control and endurance, which is often reduced in cervicogenic headache. Keep in mind that tender neck muscles and some loss of range are common in migraine as well, so the decision rests on the overall pattern rather than any single finding.

How management differs

Cervicogenic headache responds well to a combination of manual therapy and specific exercise, particularly deep neck flexor and scapular training, along with advice about postures and workload. Many patients see a reduction in headache frequency over several weeks when treatment is consistent.

Migraine needs medical diagnosis and, where appropriate, acute and preventive medication. Physiotherapists can help with associated neck pain, regular aerobic exercise, sleep and lifestyle routines, and a headache diary. It is important to explain to the patient that neck treatment alone is unlikely to stop migraine attacks, so that expectations stay realistic.

Common mistakes

• Assuming neck pain means the neck is the cause of the headache.
• Missing aura or nausea because the patient was not asked directly.
• Not checking painkiller frequency for medication overuse.
• Skipping red-flag screening in a 'familiar' headache that has changed.
• Treating the neck for months without a reduction in headache days.

Other headaches to keep on the list

Tension-type headache is the most common headache and is usually bilateral, pressing and mild to moderate, without nausea. Medication overuse headache develops when painkillers are taken on many days each month and often transforms an existing headache into a near-daily one. Occipital neuralgia causes brief, sharp, shooting pain in the back of the head. Temporomandibular disorders can also refer pain to the temple. Considering these alongside cervicogenic headache and migraine keeps your reasoning complete.

Outcome measures and reassessment

The headache diary is the most important outcome measure. Ask the patient to record headache days, peak intensity, duration, triggers and painkiller use. Compare four-week blocks rather than single weeks, because headaches naturally vary. A validated measure such as the Headache Impact Test (HIT-6) or the Neck Disability Index adds information about the overall burden.

In the clinic, retest the flexion-rotation test, cervical range and deep neck flexor performance every few sessions. If neck findings improve but headache days do not, reconsider whether the neck is really driving the headache.

Prognosis and what to tell the patient

Patients with cervicogenic headache can be told that their headache has a mechanical source that usually responds to treatment and exercise, and that consistency over several weeks matters. Patients with migraine need to understand that migraine is a common, real brain condition, not a sign of a damaged neck, and that effective medical treatments are available. Physiotherapy can still help by reducing neck pain, improving fitness and supporting healthy routines, but it works best alongside medical care.

Putting it together

Treat cervicogenic headache and migraine as competing hypotheses and look for the pattern that fits best. Side-locked pain, a neck movement or posture trigger, reproduction with upper cervical pressure and a positive flexion-rotation test all support a cervical source. Side-switching attacks, nausea, light and sound sensitivity, aura and links to sleep, hormones or stress all support migraine. Some patients have both, so be ready to share care with the GP or neurologist. Above all, re-screen for red flags whenever the pattern of headache changes, even in a patient you know well, and refer urgently if anything new appears.

How to present this differential in an exam or OSCE

Begin with safety. In any headache station, state that you would screen with SNNOOP10 before anything else, and give two or three examples, such as thunderclap onset, fever with neck stiffness or new neurological signs. Examiners look for this first.

Then name your hypotheses: cervicogenic headache, migraine, tension-type headache and medication overuse headache. Explain the history features that separate them, especially side-locking, neck triggers, nausea, light and sound sensitivity, aura and painkiller frequency. Describe your physical examination: neurological screen, cervical range, the flexion-rotation test, upper cervical palpation for headache reproduction and the craniocervical flexion test.

Close with management that matches the diagnosis. For cervicogenic headache, describe manual therapy and specific exercise. For migraine, describe referral for medical care and the supportive role of physiotherapy. Mention the headache diary as your outcome measure. Ending with shared care and reassessment shows the examiner that you understand the limits of physiotherapy as well as its strengths.

Rehearse the whole sequence with real patient stories so that the order becomes automatic under exam pressure.

Red flags not to miss (SNNOOP10)

• Sudden 'worst ever' thunderclap headache.
• Fever, neck stiffness, rash or immune suppression.
• New neurological signs, confusion or new headache after age 50.
• Headache after neck trauma or manipulation - consider vascular causes.

Key takeaways

• Neck pain alone does not mean cervicogenic headache.
• Side-locked headache provoked by neck movement, with a positive flexion-rotation test, supports cervicogenic headache.
• Nausea, light and sound sensitivity, and side-switching favour migraine.
• Screen every headache with SNNOOP10.

Frequently asked questions

Can physiotherapy help migraine?

It can help associated neck pain and support lifestyle management, but migraine generally needs medical assessment and treatment alongside.

What are the diagnostic criteria for cervicogenic headache?

The International Classification of Headache Disorders (ICHD-3) requires evidence of a cervical cause, a time link to the neck problem, and headache provoked by neck movement or relieved when the neck problem settles.

Is tension-type headache the same as cervicogenic headache?

No. Tension-type headache is usually a bilateral, pressing or tightening headache without a clear neck movement trigger. Cervicogenic headache is side-locked and linked to a cervical source.

How can I tell if physiotherapy is working?

Use a headache diary. Track headache days per month, intensity and painkiller use. A clear reduction over several weeks supports continuing; no change suggests reviewing the diagnosis.

Does poor posture cause cervicogenic headache?

Posture alone is a weak explanation. Sustained positions can provoke symptoms in a sensitive neck, so regular breaks and varied positions help, but there is no single correct posture that prevents headache.

What is the role of exercise in migraine?

Regular aerobic exercise is associated with fewer migraine days in some people and supports sleep and mood. Start gently, because sudden intense exercise can trigger an attack in some patients.

How many sessions does cervicogenic headache usually need?

Many patients show a meaningful reduction in headache frequency within about six to eight weeks of consistent manual therapy and exercise. If the diary shows no change by then, reassess the diagnosis and consider referral.

Should I refer every migraine patient to a doctor?

If the patient has never had a medical diagnosis, if attacks are changing, or if they rely on frequent painkillers, yes. Shared care gives them access to effective acute and preventive medication.

Is neck manipulation safe for headache patients?

Screen carefully for vascular and other red flags first. Many clinicians prefer mobilisation and exercise, which are effective for cervicogenic headache and carry lower risk.

Can migraine start after whiplash?

Headache after whiplash is common and may show cervicogenic or migraine-like features. A new headache after trauma always needs red-flag screening before treatment.

Clinical sources

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