The headache starts at the back of your neck and finishes behind your eye.

CERVICOGENIC HEADACHE

A headache that starts in the neck and is felt in the head. It is not migraine, it responds to different things, and the most common reason it goes untreated for years is that nobody examined the neck of somebody complaining of headache.

What distinguishes it

• Side-locked. Almost always the same side every time, without switching.
• Starts at the back. Occipital or suboccipital onset, spreading forward to the temple, the forehead and behind the eye.
• Provoked by neck movement or posture, and by sustained positions rather than by the classical migraine triggers.
• Restricted neck movement on examination, usually rotation, on the symptomatic side.
• Reduced or absent nausea, photophobia and phonophobia compared with migraine — though mild versions occur and their presence does not exclude it.
• Relieved by anesthetising a cervical structure, which is the confirmatory step.

Where it comes from

The trigeminocervical nucleus is the anatomical explanation and it is worth understanding, because it makes the whole thing make sense. Sensory input from the upper three cervical nerve roots converges with input from the trigeminal nerve in the same region of the brainstem.

The nervous system cannot fully distinguish the source once those signals converge. So a problem at C2-3 is perceived in territory served by the trigeminal nerve — the forehead, the eye, the temple. The pain is genuinely felt in the head and genuinely generated in the neck.

The usual generators

The C2-3 facet joint is the most common, and its referral pattern reaches the back and top of the head. The C1-2 lateral atlantoaxial joint is next and is a distinct target requiring a distinct technique — see atlanto-axial injection. The upper cervical discs and the greater occipital nerve contribute in some people.

The C2 dorsal root ganglion has been described as a central hub for this problem, which is a useful way to think about why several different structures at that level all produce a similar headache.

Why it gets treated as migraine for years

Because it is treated by whoever the patient reaches, and a headache complaint goes to headache services. Preventives get tried, they partly work because most things partly work, and the neck is never examined.

The tell is a headache that has not responded well to two or three adequate preventive trials, is reliably one-sided, and is worse after a long drive or a day at a desk. That combination deserves a neck examination before a fourth medication.

How it is confirmed and treated

Confirmation is by anesthetising the suspected structure — a medial branch block at C2-3, an atlantoaxial injection, or a greater occipital nerve block depending on the pattern. A headache that goes when a specific structure is anesthetised has been located.

Where blocks confirm a facet source, radiofrequency neurotomy is the durable option. Where the occipital nerve carries it, blocks and the upstream segment are addressed. Physical therapy directed at the upper cervical segments has a genuine role and is not an afterthought.

What we will not do is treat this with botulinum toxin, which is a chronic migraine indication rather than a cervicogenic one.

What the first appointment looks for

Range of movement measured properly, with attention to rotation in flexion — the position that isolates C1-2. Palpation of the upper cervical segments for reproduction of the headache. The sternocleidomastoid and the suboccipital muscles, because both refer into the head. And the greater occipital nerve where it crosses the skull base.

None of that requires equipment and all of it is more informative for this diagnosis than imaging. If your headache workup has never included someone examining your neck, the workup is incomplete regardless of how thorough it was otherwise.

Why it responds so poorly to what has been tried

Migraine preventives target a mechanism that is not the one generating this pain. Analgesia works briefly and encourages overuse. Massage helps the secondary muscle component and not the joint underneath it.

That pattern — partial, temporary responses to several reasonable treatments — is itself diagnostic information. It usually means the actual generator has not been addressed rather than that the headache is refractory.

The features that separate it from migraine

It is side-locked and stays on the same side. It starts in the neck or the back of the head and moves forward, not the other way round. It is provoked by neck position and by pressure over the upper cervical segments. And it is usually not accompanied by the full migrainous package — the nausea, the light and sound sensitivity, the aura.

Where those features are present alongside it, both diagnoses can be true at once, and treating only the one that was recognized first is why some people improve halfway and stop.

Why the neck gets skipped

Headache pathways are built around primary headache disorders, and the neck examination is not part of most of them. A patient can complete a full headache workup — imaging, bloods, preventive trials — without anybody having put a hand on the upper cervical spine.

What the treatment sequence looks like

Address the muscular layer first, because it is quick, low-risk and frequently a large share of the problem. Then test the joint layer: if the upper cervical segments reproduce the headache, a diagnostic block answers whether they are generating it.

A positive block opens the door to radiofrequency ablation, which gives months rather than weeks and can be repeated. Where the picture points higher, at C1-2, an atlantoaxial injection is the test that reaches a level nothing else does.

What to bring to the first appointment

A headache diary covering a month, the list of preventives already tried and at what doses, and any imaging you have. The diary matters more than the imaging — side-locking, the relationship to neck position, and the pattern across a week are the information that drives the diagnosis.

If you have had partial relief from something, say so and say how much. Partial responses are diagnostic information rather than failures, and they usually indicate that one of two contributing problems has been treated.

What people ask about headache coming from the neck

Can neck arthritis cause headaches?

Yes, specifically at the upper segments. C2-3 is the most common generator and its referral pattern reaches the back and top of the head and behind the eye. Botox for neck and headache.

How do I know it is not migraine?

Side-locked, starts at the back, provoked by neck position, with restricted rotation on examination. And it responds to anesthetising a cervical structure, which migraine does not. What the facet joints actually do.

Can I have both?

Frequently, and that is why the history is taken carefully. Treating the cervicogenic component often reduces overall headache burden even where a primary headache disorder is also present. The occipital nerve block.

Will an MRI show it?

No. Upper cervical degenerative change is common and does not establish the source. This is diagnosed by examination and confirmed by block. The atlantoaxial joint.

Related reading

• Cervical facet syndrome
• Atlanto-axial injection
• Occipital nerve block
• Cervical medial branch block
• Temporal arteritis
• Sternocleidomastoid spasm

Headache that begins in the neck is usually a sustained ache. Pain that arrives and passes in seconds is a different mechanism.