Headache

Written by Dr Steven Hewitt — Chiropractor · AHPRA: CHI0001115420 · Last reviewed: May 2026

Headache is among the most prevalent and most undertreated musculoskeletal presentations in clinical practice. The dominant treatment approach — analgesic medication — addresses the pain signal but not the mechanical input that is generating or amplifying it. For a significant proportion of people with recurrent tension-type headache and migraine, cervical musculoskeletal impairments are present, measurable, and responsive to treatment.

Important note: New, sudden, or unusually severe headache — particularly headache described as "the worst of my life", headache with fever, neck stiffness, or neurological symptoms — requires urgent medical assessment to exclude serious pathology. The conditions described on this page are musculoskeletal in nature and are appropriate for conservative management after medical exclusion.

Tension-Type Headache: The Cervical Spine's Role

Tension-type headache (TTH) is the most prevalent headache type globally, characterised by bilateral pressing or tightening pain, typically of mild to moderate intensity and without the nausea or photophobia of migraine. Its pathophysiology is less well understood than migraine — but what is increasingly clear is that the suboccipital muscles and cervical joints play a central role in both generating and perpetuating it.

The convergence of cervical afferents and trigeminal afferents at the trigeminocervical nucleus (TCN) in the upper spinal cord creates a pathway through which cervical nociception is referred into the head. The suboccipital muscles — rectus capitis posterior major and minor, obliquus capitis superior and inferior — have a direct fascial connection to the cervical spinal dura via the myodural bridge. Tension in these muscles is transmitted directly to the dura, and dural sensitisation is a well-recognised contributor to headache. [1]

A 2023 systematic review confirmed that manual therapy — including suboccipital soft tissue release, cervical mobilisation, and cervicothoracic manipulation — significantly reduces both headache frequency and intensity in tension-type headache. [2] A clinical practice guideline published in 2026 recommends cervical and thoracic manual therapy as appropriate management for tension-type headache in the absence of contraindications. [3] The treatment targets are the upper cervical joints, the suboccipital muscle group, and the cervicothoracic junction — the same structures involved in cervicogenic headache and, to a significant degree, in migraine. → Tension-Type Headache

Migraine: Why the Cervical Spine Matters

The traditional framing of migraine as a purely neurological or vascular event has been substantially revised. Cervical musculoskeletal impairments — reduced cervical range of motion, upper cervical joint tenderness, deep cervical flexor weakness, and forward head posture — are consistently more prevalent in people with migraine than in headache-free controls. [4]

The mechanism is the same trigeminocervical convergence that operates in tension-type headache and cervicogenic headache: cervical afferent input, particularly from the upper three cervical segments, reaches the TCN and amplifies trigeminal sensitisation. In a nervous system already sensitised by migraine pathophysiology, the cervical contribution may lower the threshold at which attacks are triggered and increase attack frequency.

A 2019 systematic review and meta-analysis of spinal manipulation for migraine — across six randomised controlled trials — found significant reductions in migraine days, attack frequency, and disability. [5] The effect was not trivial. The authors concluded that spinal manipulation is a reasonable option for migraine prophylaxis, particularly in patients who prefer to avoid or reduce pharmacological management. The cervical spine is not the cause of migraine — but in many people it is a modifiable contributor to its frequency and severity. → Migraine — Musculoskeletal Contribution

The Suboccipital Region: A Common Thread

Both tension-type headache and migraine involve impairments in the suboccipital region — the muscles, joints, and fascial structures at the base of the skull. The rectus capitis posterior minor has a direct connective tissue bridge to the posterior atlanto-occipital membrane and the cervical dura. [1] Contraction or densification of this muscle group generates dural tension that can produce or amplify headache pain — a mechanism that is independent of the central sensitisation pathways of migraine, though the two interact.

Assessment and treatment of the suboccipital region — through soft tissue mobilisation, upper cervical joint assessment, and deep cervical flexor retraining — is a component of management for both headache types described here. It is also relevant to cervicogenic headache (covered in the Cervicogenic Headache page in the neck section) and to dizziness (covered in the Dizziness section) — regions that share the same anatomical substrate.

What Can You Do Right Now?

Track your headache pattern carefully. The cervical contribution to headache is most apparent when headaches correlate with periods of sustained posture — prolonged desk work, driving, reading — and when neck stiffness or suboccipital tenderness precede or accompany the headache. Keeping a simple diary of headache onset, preceding activity, and associated neck symptoms for two to three weeks provides the information that makes clinical assessment significantly more targeted.

Address forward head posture. Forward head posture loads the suboccipital extensors disproportionately — for every inch the head moves forward of its balanced position, the load on the cervical extensors approximately doubles. Chin tucks, deep cervical flexor exercises, and sustained attention to screen height and sitting position reduce this chronic loading. These are the same exercises used in clinical management of cervicogenic headache and TTH.

Reduce sustained tension in the suboccipital muscles. Gentle self-massage at the base of the skull — applying sustained gentle pressure to the suboccipital muscles with the fingertips in a supported lying position — can reduce local muscle tension and provide temporary relief. This is not a substitute for clinical assessment of the joint and fascial contributors, but it is a practical self-management tool.

Consider the sleep position. Sleeping with an inappropriately high or low pillow sustains upper cervical flexion or extension for hours at a time, loading the suboccipital structures during the period when the system should be recovering. A pillow that maintains neutral cervical alignment in your predominant sleep position is worth assessing.

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