November 2, 2016

How Do I Rule In or Out a Cervicogenic Headache?

Author: Maggie Henjum


A quick review of these are listed as follows: diplopia, dysphagia, dysarthria, dizziness, drop attacks, ataxia, numbness, nystagmus, nausea. Take time to review Kerry et al article for a thorough and excellent understanding of therapist considerations in a manual practice.3 Once we have cleared patient for safe examination, a few tools are validated as being extremely useful in differentiating between cervicogenic headache and migraine headaches. A clear subjective exam is our second stop asking clear questions including location of symptoms, unilateral vs. bilateral, aggravating positions, and patient ability to reproduce their symptoms in clinic for you.

The following examination items have been validated:

The first three have 100% sensitivity when clustered: Therefore, if the first three tests are negative, then the patient most likely does not have cervicogenic headaches.6

1)      Decreased AROM extension

2)      Tender at OA and C3/4

3)      Weakness at DNF: this can be saved for a whole weeks discussion on current literature to support the use of DNF assessment and weakness, I will save that discussion for a later date. The two tests validated for assessment are as follows:

  1. Cranial Cervical Flexor Test (CCFT): Patient is in supine, use of a pressure cuff for feedback is utilized. A normal test is Patient able to generate 26-30mmHg pressure for 10 seconds without compensations4
  2. Neck Flexor Muscle Endurance Test: Patient tucks their chin and lifts head approximately 1 inch off of the table maintaining the chin tuck throughout. Normal: >38 seconds.5

4) Cervical flexion rotation testing (CFRT): This test is performed by pulling the patient into full cervical flexion and rotating the upper cervical spine and assessing ROM deficits. A positive test is found to be reduced by 10 degrees or more compared to unaffected side, with P<.01.7 Few clinical pearls about this test include:

  • Per Hall et al, average ROM < 11.5 degrees in subjects with cervicogenic headaches.7
  • For the statistically minded: Sensitivity: .75, Specificity: .92 for cervicogenic headaches
  • To track our patient change: MDIC = 7 degrees

5) Assessment of tissue restriction4

  • Upper trapezius p = .003
  • Levator scapulae p = .001
  • Scalenes p = .001
  • Suboccipital extensors p = .035

Manual testing as described above has been described to have a sensitivity of 80-100%, therefore leaving us confident that these tests with a subjective examination leave us with the appropriate patient to treat out.


Original post: August 5, 2013



1) Mintken, Paul. Cervicogenic Headaches: Diagnosis and Treatment.  Lecture conducted at: University of Colorado Denver. 2010.

2) Zito, G., Jull, G., & Story, I. (2006). Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual therapy,11(2), 118–29. doi:10.1016/j.math.2005.04.007

3) Kerry, R., & Taylor, A. J. (2009). Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. The Journal of orthopaedic and sports physical therapy, 39(5), 378–87. doi:10.2519/jospt.2009.2926

4) Zito, G., Jull, G., & Story, I. (2006). Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual therapy,11(2), 118–29. doi:10.1016/j.math.2005.04.007

5) Childs, J. D. (2008). Neck Pain. Journal of Orthopaedic and Sports Physical Therapy. doi:10.2519/jospt.2008.0303

6) Jull G, Amiri M, Bullock-Saxton J, Darnell R, Lander C. Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: subjects with single headaches. Cephalgia. 2007; 27:793-802.

7) Hall, T., Briffa, K., & Hopper, D. (2010). The influence of lower cervical joint pain on range of motion and interpretation of the flexion-rotation test.The Journal of manual & manipulative therapy, 18(3), 126–31. doi:10.1179/106698110X12640740712293