Cervicogenic Headache Page

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:     Frankp@chiro.org

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Cervicogenic headache originates from disorders of the neck and is recognized as a referred pain in the head. Primary sensory afferents from the cervical nerve roots C1–C3 converge with afferents from the occiput and trigeminal afferents on the same second order neuron in the upper cervical Spine. Consequently, the anatomical structures innervated by the cervical roots C1–C3 are potential sources of cervicogenic headache. Cervical headache is often precipitated by neck movement and/or sustained awkward head positioning (such as painting the ceiling, or washing the floor) and can reproduced with pressure over the upper cervical or occipital region on the symptomatic side. It is often accompained by restricted cervical range of motion, ipsilateral neck, shoulder, or arm pain of a rather vague non-radicular nature or, occasionally, arm pain of a radicular nature.

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	The Effectiveness of Manual and Exercise Therapy on Headache Intensity and Frequency Among Patients with Cervicogenic Headache: A Systematic Review and Meta-analysis Chiropractic & Manual Therapies 2022 (Nov 23); 30 (1): 49 Manual therapy (with or without exercise therapy) appears to be a safe and effective intervention for Cervicogenic Headache (CGH), and should be considered in the management of this condition, as already proposed by the latest guidelines. [6] The main body of evidence favours the use of spinal manipulation to reduce headache intensity, frequency and disability, but other forms of manual therapy and exercise therapy were found to be consistently beneficial for other outcomes across the trials.
	Spinal Manipulation for the Management of Cervicogenic Headache: A Systematic Review and Meta-analysis European Journal of Pain 2020 (Oct); 24 (9): 1687–1702 Cervicogenic Headache (CGHA) is a common headache disorder. SMT can be considered an effective treatment modality, with this review suggesting it providing superior, small, short-term effects for pain intensity, frequency and disability when compared with other manual therapies. These findings may help clinicians in practice better understand the treatment effects of SMT alone for CGHA.
	Dose-Response and Efficacy of Spinal Manipulation for Care of Cervicogenic Headache: A Dual-Center Randomized Controlled Trial   NCT01530321 Spine J. 2018 (Oct); 18 (10): 1741–1754 ~ FULL TEXT A linear dose-response was observed for all follow-ups, a reduction of approximately 1 CGH day/4 weeks per additional 6 SMT visits (p<.05); a maximal effective dose could not be determined. CGH days/4 weeks were reduced from about 16 to 8 for the highest and most effective dose of 18 SMT visits. Mean differences in CGH days/4 weeks between 18 SMT visits and control were -3.3 (p=.004) and -2.9 (p=.017) at the primary endpoints, and similar in magnitude at the remaining endpoints (p<.05). Differences between other SMT doses and control were smaller in magnitude (p > .05). CGH intensity showed no important improvement nor differed by dose. Other secondary outcomes were generally supportive of the primary.
	Chiropractic Spinal Manipulative Therapy for Cervicogenic Headache: A Single-blinded, Placebo, Randomized Controlled Trial   NCT01687881 BMC Res Notes. 2017 (Jul 24); 10 (1): 310 ~ FULL TEXT Nineteen participants were equally randomized into the three groups, and 12 participants completed the randomized controlled trial. Headache frequency improved at all time points in the chiropractic spinal manipulative therapy and the placebo group. Headache index improved in the chiropractic spinal manipulative therapy group at all time points, while it improved at 6 and 12 months' follow-up in the placebo group. The control group remained unchanged during the whole study period. Adverse events were few, mild and transient. Blinding was concealed throughout the RCT. Thus, our results suggest that manual-therapy might be a safe treatment option for participants with cervicogenic headache, but data need to be confirmed in a randomized controlled trial with sufficient sample size and statistical power.
	Dose-response of Spinal Manipulation for Cervicogenic Headache: Study Protocol for a Randomized Controlled Trial   NCT01530321 Chiropractic & Manual Therapies 2016 (Jun 8); 24: 23 ~ FULL TEXT With growing concerns regarding the costs and side effects of commonly used conventional treatments, greater numbers of headache sufferers are seeking other approaches to care. This is the first full-scale randomized controlled trial assessing the dose-response of spinal manipulation therapy on outcomes for cervicogenic headache. The results of this study will provide important evidence for the management of cervicogenic headache in adults.
	Diagnostic Testing Considerations in Pediatric Cervicogenic Headache ACA News ~ May 23, 2016 ~ FULL TEXT Cervicogenic headache is common in pediatric patients and is defined by the International Headache Society as a condition caused by cervical Spine dysfunction that is usually accompanied by neck pain. We chose this type of headache because it is commonly seen in chiropractic offices. With these thoughts in mind, we performed a search for office-based tests to help substantiate a diagnosis of cervicogenic headache diagnosis in a pediatric patient.
	Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence? Front Neurol. 2016 (Mar 21); 7: 40 ~ FULL TEXT Seven of the 10 studies had statistically significant findings that subjects who received mobilization or manipulation interventions experienced improved outcomes or reported fewer symptoms than control subjects. These results suggest that mobilization or manipulation of the cervical Spine may be beneficial for individuals who suffer from cervicogenic headache (CEH), although heterogeneity of the studies makes it difficult to generalize the findings.
	Upper Cervical and Upper Thoracic Manipulation Versus Mobilization and Exercise in Patients with Cervicogenic Headache: A Multi-center Randomized Clinical Trial BMC Musculoskelet Disord. 2016 (Feb 6); 17 (1): 64 ~ FULL TEXT The 2X4 ANOVA demonstrated that individuals with cervicogenic headache (CH) who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up.
	Chiropractic Spinal Manipulative Therapy for Cervicogenic Headache: A Study Protocol of a Single-blinded Placebo-controlled Randomized Clinical Trial   NCT01687881 Springerplus. 2015 (Dec 16); 4: 779 ~ FULL TEXT Cervicogenic headache (CEH) is a secondary headache which affects 1.0–4.6 % of the population. Although the costs are unknown, the health consequences are substantial for the individual; especially considering that they often suffers chronicity. Pharmacological management has no or only minor effect on CEH. Thus, we aim to assess the efficacy of chiropractic spinal manipulative therapy (CSMT) for CEH in a single-blinded placebo-controlled randomized clinical trial (RCT).
	Manual Treatment For Cervicogenic Headache and Active Trigger Point In the Sternocleidomastoid Muscle: A Pilot Randomized Clinical Trial J Manipulative Physiol Ther. 2013 (Sep); 36 (7): 403–411 ~ FULL TEXT The purpose of this preliminary study was to determine feasibility of a clinical trial to measure the effects of manual therapy on sternocleidomastoid active trigger points (TrPs) in patients with cervicogenic headache (CeH).
	Manual Therapies for Cervicogenic Headache: A Systematic Review J Headache Pain. 2012 (Jul); 13 (5): 351–359 ~ FULL TEXT Current RCTs suggest that physiotherapy and SMT might be an effective treatment in the management of cervicogenic headache (CEH). However, the RCTs mostly included participant with infrequent CEH. Future challenges regarding CEH are substantial both from a diagnostic and management point of view.
	Cervicogenic Headache in the General Population: The Akershus Study of Chronic Headache Cephalalgia. 2010 (Dec); 30 (12): 1468–1476 The questionnaire response rate was 71% and the participation rate of the interview was 74%. The prevalence of CEH was 0.17% in the general population, with a female preponderance. Fifty per cent had co-occurrence of medication overuse and 42% had co-occurrence of migraine. The pericranial muscle tenderness score was significantly higher on the pain than non-pain side (p < .005). The cervical range of motion was significantly reduced compared to healthy controls (p < .005). The mean duration of cervicogenic headache (CEH) was eight years.
	A Preliminary Path Analysis of Expectancy and Patient-Provider Encounter in an Open-Label Randomized Controlled Trial of Spinal Manipulation for Cervicogenic Headache J Manipulative Physiol Ther 2010 (Jan); 33 (1): 5–13 ~ FULL TEXT Clearly, blinding is often not possible in efficacy and relative efficacy studies seeking to evaluate the independent effects of a single component of care (such as SMT). It is therefore important to control the effects of the patient-provider interaction on study outcomes to help optimize study internal validity. It appears that equipoise by the same providers across intervention types can be accomplished. It also appears that it is possible to reduce the confounding effect of the PPE to a relatively small proportion of the treatment effect found for the interventions under study. A challenging methodological issue that remains is determining to what extent equipoise in the PPE across treatment arms can serve as a surrogate for double blinding in randomized controlled trials.
	Cervicogenic Headache: An Assessment of the Evidence on Clinical Diagnosis, Invasive Tests, and Treatment Lancet Neurol. 2009 (Oct); 8 (10): 959–968 ~ FULL TEXT Cervicogenic headache is characterised by pain referred to the head from the cervical Spine. Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical. Laboratory and clinical studies have shown that pain from upper cervical joints and muscles can be referred to the head. Clinical diagnostic criteria have not proved valid, but a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks. In this Review, we outline the basic science and clinical evidence for cervicogenic headache and indicate how opposing approaches to its definition and diagnosis affect the evidence for its clinical management. We provide recommendations that enable a pragmatic approach to the diagnosis and management of probable cervicogenic headache, as well as a rigorous approach to the diagnosis and management of definite cervical headache.
	Dose Response and Efficacy of Spinal Manipulation for Chronic Cervicogenic Headache: A Pilot Randomized Controlled Trial The Spine Journal 2010 (Feb): 10 (2): 117–128 ~ FULL TEXT Eighty patients with chronic cervicogenic headache (CGH) were randomized to receive either 8 or 16 treatment sessions with either chiropractic care (Spinal Manipulation or SMT) or a minimal light massage (LM) as the control group. Both SMT groups improved much more than the control groups, with greater improvements in the group that received more care. You may also enjoy this PowerPoint Presentation by the authors of this study.
	Intertester Reliability and Diagnostic Validity of the Cervical Flexion-Rotation Test J Manipulative Physiol Ther 2008 (May); 31 (4): 293–300 ~ FULL TEXT Cervicogenic headache (CeH) has been classified by the International Headache Society (IHS) [1] and is said to account for 15% to 20% of all chronic and recurrent headaches. [2] Individuals report reduced quality of life [3] and experience considerable restriction of daily function and emotional distress. [4] There is encouraging evidence that CeH can be successfully managed by physical treatment. [5, 6]
	Clinical Test of Musculoskeletal Dysfunction in the Diagnosis of Cervicogenic Headache Manual Therapy 2006 (May); 11 (2): 91–166 The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension (P=0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.
	Spinal Manipulative Therapy in the Management of Cervicogenic Headache Headache. 2005 (Oct); 45 (9): 1260–1263 Patients suffering from cervicogenic headache (CeH) are commonly treated with spinal manipulative therapy. We have analyzed the quality and the outcomes of published, randomized, controlled trials assessing the effectiveness of spinal manipulation in CeH. Among 121 relevant articles, only two met all the inclusion criteria. Methodological quality scores were 8/10 and 7/10 points. Only one of the trials made use of a headache diary. Both the trials reported positive (+) results on headache intensity, headache duration, and medication intake, so that spinal manipulative therapy obtained strong evidence of effectiveness (level 1) with regard to these outcomes.
	Cervicogenic Head and Neck Pain in the ENT Clinic HNO 2005 (Sep); 53 (9): 804–809 It is discussed controversially whether cervicogenic pain in the head and/or neck is a pathogenic entity. The good results obtained with manual therapy in patients with head and neck pain contradict the refusal of the majority of the neurologists to accept the diagnosis "cervicogenic headache." Complaints about headache are frequently encountered in the general ENT clinic. The versatile picture of the cervicogenic headache is caused by the complex neural connections in the region of the upper cervical Spine. The differential diagnosis of the cervicogenic headache is described.
	Non-invasive Physical Treatments for Chronic/Recurrent Headache Cochrane Database Syst Review 2004; (3): CD001878 For the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). For the prophylactic treatment of chronic tension-type headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior in the short term after cessation of both treatments. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization.
	Dose Response for Chiropractic Care of Chronic Cervicogenic Headache and Associated Neck Pain: A Randomized Pilot Study J Manipulative Physiol Ther 2004 (Nov); 27 (9): 547–553 ~ FULL TEXT Patients were randomly allocated to 1, 3, or 4 visits per week for 3 weeks. All patients received high-velocity low-amplitude spinal manipulation. Doctor of Chiropractics could apply up to 2 physical modalities at each visit from among heat and soft tissue therapy. They could also recommend modification of daily activities and rehabilitative exercises. A large clinical trial on the relationship between pain relief and the number of chiropractic treatments is feasible. Findings give preliminary support for the benefit of larger doses, 9 to 12 treatments, of chiropractic care for the treatment of cervicogenic headache.
	Upper Crossed Syndrome and Its Relationship to Cervicogenic Headache J Manipulative Physiol Ther 2004 (Jul); 27 (6): 414–420 ~ FULL TEXT The principles of upper crossed syndrome and the use of exercise, chiropractic care, and myofascial release in the treatment of cervicogenic headache are discussed. A review of the literature indicates that analyzing muscle imbalance as well as vertebral subluxation may increase the effectiveness of chiropractic treatment for cervicogenic headache. There are more articles on this topic at our Rehabilitation Diplomate Information Page
	Cervicogenic Headache: The True Pain in the Neck   Foundation for Chiropractic Education and Research ~ 2004 For decades, Doctors of Chiropractic have successfully treated headaches. Success was so quick and profound in some instances that chiropractors theorized that some headaches are caused by dysfunction in the neck and cervical Spine. This theory was largely over-looked by the scientific community as they knew of no biological or physiological link. But the chiropractors were right! In 1995, a team of researchers at the University of Maryland in Baltimore were intricately dissecting cadavers and discovered the biological link–a connective tissue bridge from a muscle in the head to the membrane covering the brain and the spinal cord (the dura mater). [1]
	A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache Spine (Phila Pa 1976) 2002 (Sep 1); 27 (17): 1835–1843 Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained.
	Chiropractic Spinal Manipulation for Cervicogenic Headache in an 8-Year-Old J Neuromusculoskeletal System 2002 (Fall); 10 (3): 98–103 A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. A significant decrease in headache frequency as reported by the patient and parent was seen after the first treatment. After four treatments the headache frequency decreased to approximately one per month. The patient was followed for 2 months after termination of care and reported headache frequency of approximately two per month. There is evidence that spinal manipulation is effective in the treatment of CEH in adults.
	Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache Duke University Evidence-based Practice Center ~ 2001 In 1996, the Agency for Health Care Policy and Research (AHCPR) was scheduled to produce a set of clinical practice guidelines on available treatment alternatives for headache. This headache project was based on the systematic evaluation of the literature by a multidisciplinary panel of experts. Due to largely political circumstances, however, their efforts never came to fruition. The work was never released as guidelines, but was instead transformed with modifications and budget cuts into a set of evidence reports on only migraine headache. Thanks to FCER funding, the evidence reports have now been updated on both cervicogenic and tension-type headaches. You might also enjoy Dr. Anthony Rosner's discussion You may download the full 10-page Adobe Acrobat (PDF) version.   You will also enjoy FCER's announcement on the initial publication of the Duke Report.
	Cervicogenic Headache: Diagnostic Evaluation and Treatment Strategies Curr Pain Headache Rep 2001 (Aug); 5 (4): 361–368 The clinical presentation of cervicogenic headache suggests that there is an activation of the trigeminovascular neuroinflammatory cascade, which is thought to be one of the important pathophysiologic mechanisms of migraine. Another convergence of sensorimotor fibers has been described involving intercommunication between the spinal accessory nerve (CN XI), the upper cervical nerve roots, and ultimately the descending tract of the trigeminal nerve. This neural network may be the basis for the well- recognized patterns of referred pain from the trapezius and sternocleidomastoid muscles to the face and head.
	Cervicogenic Headaches: A Critical Review Spine J 2001 (Jan); 1 (1): 31–46 Despite a growing body of literature on CGH and an increasing acceptance that headaches can originate from the cervical spine, there remains considerable controversy and confusion concerning all aspects of this topic. However, a number of comments on CGH appear quite reasonable. The concept that headaches can originate from the neck is not new. The pain appears to be generated by irritation of nociceptors from structures in the cervical spine and may accompany injury and pathology in the neck. These headaches are difficult to differentiate from MH and TTH, although they possess the distinguishing characteristics of being triggered by neck movements, pain spreading to the occipital region, tenderness in the suboccipital tissues, decreased cervical range of motion, and unresponsiveness to typical headache medication. The significance of radiological findings and advanced diagnostic testing is unclear. Evidence to support treatment with surgery and injections consists mainly of case series without controls or standardized follow-up. The only treatment approach supported by a reasonable body of controlled trials is cervical manipulation, but this is by no means conclusive. Until additional research and improved consensus on the topic of CGH becomes available, it is essential that any clinician maintain an open, cautious, and critical approach to the literature. At this point, the clinician must be wary of enthusiastic and dogmatic claims concerning CGH. As the literature on this topic grows in volume and quality, the debate will intensify and hopefully result in the clarification of the cause, diagnosis, and treatment of CGH.
	Cervicogenic Headache: Anatomic Basis and Pathophysiologic Mechanisms Curr Pain Headache Rep 2001 (Aug); 5 (4): 382–386 Cervicogenic headache is pain perceived in the head but referred from a primary source in the cervical Spine. The physiologic basis for this pain is convergence between trigeminal afferents and afferents from the upper three cervical spinal nerves.
	Cervicogenic Headache: Manual and Manipulative Therapies Curr Pain Headache Rep 2001 (Aug); 5 (4): 369–375 This article reviews current literature on the role of manual medicine in the diagnosis and treatment of cervicogenic headache. Manual diagnostic procedures and treatment procedures are described for the cervical Spine. Emphasis is placed on accurate diagnosis using a biomechanical model and precise localization of forces.
	Clinical Study on Manipulative Treatment of Derangement of the Atlantoaxial Joint J Tradit Chin Med 1999 (Dec); 19 (4): 273–278 The clinical diagnosis of derangement consists of: dizziness, headache, prominence and tenderness on one side of the affected vertebra, deviation of the dens for 1 mm–4 mm on the open-mouth X-ray film, abnormal movement of the atlantoaxial joint on head-rotated open-mouth X-ray film. An accurate and delicate adjustment is the most effective treatment.
	A Proposed Etiology of Cervicogenic Headache: The Neurophysiologic Basis and Anatomic Relationship Between the Dura Mater and the Rectus Posterior Capitis Minor Muscle J Manipulative Physiol Ther 1999 (Oct); 22 (8): 534–539 ~ FULL TEXT A sizable body of clinical studies note the effect of manipulation on headache. These results support its effectiveness. The dura-mascular, dura-ligamentous connections in the upper cervical Spine and occipital areas may provide anatomic and physiologic answers to the cause of the cervicogenic headache.
	Systematic Review of Randomized Clinical Trials of Complementary/Alternative Therapies in the Treatment of Tension-type and Cervicogenic Headache Complementary Therapies in Medicine 1999 (Sep); 7 (3): 142–155 Twenty-four RCTs were identified in the categories of acupuncture, spinal manipulation, electrotherapy, physiotherapy, homeopathy and other therapies. Headache categories included tension-type (under various names pre-1988), cervicogenic and post-traumatic. Quality scores for the RCT reports ranged from approximately 30 to 80 on a 100 point scale.
	Further Clinical Clarification of the Muscle Dysfunction in Cervical Headache Cephalalgia 1999 (Apr); 19 (3): 179–185 From the perspective of physical characterization of cervical headache, it appears that response from passive stretch of muscle may not be a strong criterion for cervical headache but deep neck flexor performance may have potential to identify musculoskeletal involvement in headache. The finding may also provide positive directions for conservative treatment of cervical headache.
	The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache J Manipulative Physiol Ther 1997 (Jun); 20 (5): 326–330 The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group. The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group. Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group. You might also enjoy this sidebar article Chiropractic Effective for Cervicogenic Headache.
	Headache in Cervical Syndrome Ther Umsch 1997 (Feb); 54 (2): 94–97 Headache is a common symptom in patients suffering from cervical Spine disorders. The percentage of headaches in association with degenerative changes of the cervical Spine ranges from 13 to 79% and that in association with indirect trauma of the cervical Spine from 48 to 82%. Based on neuroanatomical and neurophysiological studies, the relationship of the upper cervical Spine and the trigeminal nuclei has been demonstrated and serves as an explanation for perceived head pain in cervical Spine disorders. As a source of pain, tension in the suboccipital muscles, irritation of the third occipital nerve, and degenerative changes of the C2/C3 joints have been discussed. Bogduk, in his studies, asserts a direct causative role of mechanical derangement of the cervical Spine in the pathogenesis of cervicogenic headaches.
	Manipulation and Mobilization of the Cervical Spine. A Systematic Review of the Literature Spine (Phila Pa 1976) 1996 (Aug 1); 21 (15): 1746–1760 The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (93% confidence interval, –0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical Spine manipulation is estimated to be between 5 and 10 per 10 million manipulations.
	A Randomized Controlled Trial of the Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache J Manipulative Physiol Ther. 1995 (Sep); 18 (7): 435–440 Thirty-nine subjects suffering from frequent headaches who fulfilled the IHS criteria for cervicogenic headache received high-velocity, low-amplitude cervical manipulation twice/wk for 3 wk. The other half received low-level laser in the upper cervical region and deep friction massage (including trigger points) in the lower cervical/upper thoracic region, also twice/wk for 3 wk. Despite a significant reduction in the manipulation group on all three outcome measures, differences between the two treatment groups failed to reach statistical significance. Editor's Comment: This study suffered from the affliction I refer to as The Problem with Placebos/Shams. Although there may not have been any pre-1995 literature in English regarding low-level laser or deep friction massage as palliative treatments, this study certainly demonstrates that both groups actually improved. However, there was no significant difference between both groups because BOTH groups received (some form of) active treatment.
	The Prevalence of Cervicogenic Headache in a Random Population Sample of 20-59 Year Olds Spine (Phila Pa 1976) 1995 (Sep 1); 20 (17): 1884–1888 A short questionnaire on headaches was mailed to 826 randomly selected residents of a midsized Danish town. A group of 57 individuals in the age range 20-59 years who reported having headache episodes on 5 or more days in the previous month were identified. Forty-five of the 57 were eventually interviewed and examined with respect to the IHS criteria for cervicogenic headache (the radiological criteria were omitted on ethical grounds). Of the 45 persons examined, eight fulfilled the diagnostic criteria for cervicogenic headache, equivalent to a prevalence in the headache group of 17.8%
	The Effect of Manipulation (Toggle Recoil Technique) fir Headaches With Upper Cervical Joint Dysfunction: A Pilot Study J Manipulative Physiol Ther 1994 (Jul); 17 (6): 369–375 Since the results of this pilot study were not adequately controlled they cannot be seen as proof supporting the clinical efficacy of manipulation for chronic headaches. However, as a group for duration, severity and frequency all measures were significant. These findings would suggest that further study of upper cervical manipulation for the treatment of chronic headaches with upper cervical joint dysfunction in a randomized, controlled clinical trial is needed.
	Cervical Headache: An Investigation of Natural Head Posture and Upper Cervical Flexor Muscle Performance Cephalalgia 1993 (Aug); 13 (4): 272–284 In this study, 60 female subjects, aged between 25 and 40 years, were divided into two equal groups on the basis of absence or presence of headache. A passive accessory intervertebral mobility (PAIVM) examination was performed to confirm an upper cervical articular cause of the subjects' headache and a questionnaire was used to establish a profile of the headache population. Measurements of cranio-cervical posture and isometric strength and endurance of the upper cervical flexor muscles were compared between the two groups of subjects. The headache group was found to be significantly different from the non-headache group in respect to forward head posture (FHP) (t = -5.98, p < 0.00005), less isometric strength (t = 3.43, p < 0.001) and less endurance (t = 8.71, p < 0.0005) of the upper cervical flexors.
	Cervicogenic Dysfunction in Muscle Contraction Headache and Migraine: A Descriptive Study J Manipulative Physiol Ther 1992 (Sep); 15 (7): 418–429 A case of cervicogenic headache (CEH) in an 8-year-old boy that improved after chiropractic spinal manipulation is reported. Both muscle contraction/tension-type headache (MCH) and common migraine without aura (CM) subjects demonstrate high occurrences of: a) occipital and neck pain during headaches; b) tender points in the upper cervical region; c) greatly reduced or absent cervical curve; and d) X-ray evidence of joint dysfunction in the upper and lower cervical Spine. These findings support the premise that the neck plays an important, but largely ignored role in the manifestation of adult benign headaches. A case-control study should be conducted to confirm the greater prevalence of cervicogenic dysfunction in headache as compared to nonheadache subjects.
	Spinal Manipulation and Headaches of Cervical Origin J Manipulative Physiol Ther 1989 (Dec); 12 (6): 455–468 This article reviews the published clinical studies of manipulation in the treatment of tension and migraine headaches. The topic of cervical headaches in general is reviewed and the current model of cervicogenic headache is critiqued. A representative case history is used to illustrate the thesis that the current model of cervicogenic headache may be too restrictive. The role of spinal manipulation as a trial of therapy in individual patients is also discussed. a retrospective diagnosis of cervical headache can often be confirmed by a successful outcome.

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