Cervicogenic Headache: Three Tests Every PT Should Master

Cervicogenic headaches are a common yet often misdiagnosed condition originating from the upper cervical spine.

They frequently resemble migraines or tension-type headaches, which can complicate diagnosis and treatment. In this guide, we will explore key clinical insights, classification, diagnostic criteria, essential tests, interventions, and common pitfalls in managing cervicogenic headaches. By mastering these elements, healthcare professionals can enhance their assessment and treatment strategies, leading to improved patient outcomes.

1. Clinical Insight

Cervicogenic headaches are referred from the upper cervical spine, often misdiagnosed as migraines or tension-type headaches. Mastering three key tests can clarify the source and guide effective intervention.

2. Classification

Neck Pain with Headache (AOPT Cervical Spine CPG) — commonly linked to dysfunction at C1–C3, particularly affecting the C2–3 zygapophyseal joint and associated musculature.

3. Key Diagnostic Criteria

• Unilateral headache, starting in the neck/suboccipital region

• Aggravated by neck movements or sustained postures

• Restricted cervical ROM, especially upper cervical rotation

• Tenderness of suboccipital or upper cervical muscles/joints

• Often accompanied by dizziness or light sensitivity

Three Tests Every PT Should Master:

• Flexion-Rotation Test (FRT): Assesses C1–C2 rotation mobility

• Cervical Joint Position Error Test: Identifies proprioceptive deficits

• Craniocervical Flexion Test (CCFT): Detects deep neck flexor dysfunction

4. Top Interventions

Early Phase (Weeks 0–2)

• Manual therapy to upper cervical spine (mobilization or manipulation)

• Suboccipital release and soft tissue mobilization

• Postural education and load reduction (ergonomics)

• Begin CCFT training with low load

Mid Phase (Weeks 2–6)

• Progress deep cervical flexor motor control training

• Add proprioceptive retraining (laser, head repositioning tasks)

• Integrate thoracic spine mobilization for regional influence

• Gentle FRT mobilization if restricted

Late Phase (Weeks 6–10+)

• Return to higher load postural tasks (computer work, overhead tasks)

• Dynamic head control exercises (e.g., perturbations, ball toss)

• Sport or work-specific reintegration if relevant

Progression Criteria:

Decreased frequency/intensity of headaches, normalized FRT, improved CCFT performance, and symptom-free cervical AROM.

5. What to Avoid

• Overlooking the upper cervical spine in recurrent headaches

• Passive-only approaches without neuromuscular retraining

• Treating the headache region rather than the neck dysfunction

6. Clinical Takeaway

If you’re not using the Flexion-Rotation Test, you’re guessing. Accurate assessment of upper cervical mobility, position sense, and motor control is essential for treating cervicogenic headaches effectively.