Headache Back of Head
On average over 5000 people enter "headache back of head" into Google each month.
So here's over 30 different causes (please be patient!)
I've identified these causes from a search of medical journals to find cases where pain in the back of the head has been a prominent symptom.
I have hand searched the journals 'Cephalalgia' and "Headache - The Official Journal of the American Headache Society" to identify these causes of pain in the back of the head.
I would be confident that it is one of the most comprehensive lists of its type you will find.
I have seen many in my own practice, but some are rare and might appear just once in a neurologist's career.
If you have just written headache back of head into a search box, the most likely cause is pain coming form the the upper part of your neck - called cervicogenic headache.
Cervicogenic headache can be extremely painful and persistent, but is the most common severe headache that can be treated without resorting to medication - you need to see a qualified physiotherapist.
Please note : the time for concern is if a back of head pain hit you suddenly (time from onset to maximum pain within seconds) - thunderclap headache - which has a 10% risk of a serious cause being found, and requires immediate medical attention.
"Headache Back of Head"
5 Common Causes
- Cervicogenic Headache
The most common of these is a pain referred from the joints of the upper spine. This is called cervicogenic headache (cervic = neck, genic = caused by).
The classic cervicogenic headache causes a pain in the back of the head - on one side only.
The pain can spread up the back of the head and round the side towards the ear or over the top into the forehead.
Most people with cervicogenic headache will have previously injured their neck (a whiplash injury is typical).
Other people will have had minor injuries (often forgotten) or adopt postures or habits that contribute to poor posture, which can predispose to pain.
In my experience, most middle-aged/older people referred to me with a severe one-sided headache that's been going on for months will have cervicogenic headache.
In these older people there are restricted neck movements due to "wear and tear" of the joints of the upper spine (facet joints).
Cervicogenic headache is very common - as many as 4% of adults will have this pain at some point in their lives.
Fortunately Cervicogenic Headache Treatment can be effective, and is the most common headache that might respond to physical treatment, without resorting to medication.
- Occipital Neuralgia
This another severe, sharp "headache back of head" that spread up to the top of head or into the eye on the same side.
Nerve block, anti-inflammatories or Gabapentin are worth trying. Most people who are diagnosed with occipital neuralgia will actually be suffering from cervicogenic headache.
There is still controversy about whether cervicogenic headache and Occipital Neuralgia are the same or different conditions.
My own view is that most are better called cervicogenic headache. However, occipital neuralgia is a better description for people who have had soft tissue injury to the back of the head.
Migraine is not, in my experience, a common diagnosis in people who ask me for advice about their "headache back of head".
One survey from the 1970s (Olesen, Denmark) found that only 6% of people with acute migraine took pain in the back of the head.
A more recent survey in 2005 (Kelman, Atlanta) found that about 39% of people with migraine would report pain in the back of head or even in the neck.
The real figure, I think, is somewhere in between, probably more like 10-15%.
A "headache back of head" might be migraine if it is severe enough to make you want to lie down, and you feel nauseated with it.
People with migraine don't always have pain in one location.
Usually in migraine pain can be experienced in different locations during different migraine attacks.
- Ice-pick Headache
About 35% of all people will get these brief intense pains in the head lasting a few seconds (This information is from a large Norwegian Study called the Vaga Study).
They appear out of the blue, and may make you wince, or feel briefly weak at the knees if they are very intense.
In a small number of people, these ice-pick pains are located, exclusively, in the neck or very back of the head.
It can be very difficult to tell the difference between cervicogenic headache and ice-pick pains.
Usually ice-pick pains can occur anywhere in the head, whereas cervicogenic headache are locked to one side of the head only.
- Ice-cream headache
- This is felt in the temples in most cases, but about 6% of young people feel this pain exclusively in the back of the head!
Serious Causes of "Headache Back of Head"
Harm may occur if not treated promptly.
The occipital arteries run up the back of the head, and are often affected in temporal arteritis. As the occipital arteries lie right next to the greater occipital nerve, temporal arteritis can cause a "headache back of head".
(I've made this mistake once before, but the penny dropped at follow-up and a good recovery came on with steroid treatment!).
About 30 people per 100,000 will get temporal arteritis in any given year. The diagnosis requires an ESR blood test and a temporal artery biopsy procedure.
Vertebral Artery Dissection
This may present with a sudden severe "headache back of head", but is even more rare than arteritis at about 5 people per 100,000 each year.
Vertebral artery dissection is a cause of a stroke. The best way to distinguish vertebral artery dissection from cervicogenic headache is to listen to the onset of pain.
In dissection it is usually much more rapid - onset over seconds.
In cervicogenic there will usually have been a smaller amount of pain in the preceding months or years.
If your doctor considers a diagnosis of Vertebral Artery Dissection this is ruled out using an MRI scan.
It would be prudent to talk to your doctor before starting physiotherapy or spinal manipulation therapy for a "headache back of head" that came on abruptly.
Unfortunately there is no way to distinguish between cervicogenic headache and vertebral dissection with 100% certainty - it comes down to a clinical judgement, erring on the side of caution with investigations if symptoms are in any way unusual.
Statistically, cervicogenic headache is about 800 times more commonplace than dissection.
About 10% of people who come to hospital with a very sudden onset severe pain in the back of the head will be diagnosed with a brain haemorrhage (Subarachnoid haemorrhage).
This sudden severe headache is called "Thunderclap Headache".
If this pain happens out of the blue it requires immediate medical attention. If at the time of onset of pain there is vomiting or a faint, the risk of there being an underlying brain haemorrhage is higher than in those who had pain and no other symptom.
"Headache Back of Head"
Provoked by physical stimulus
Headache During Orgasm
High Altitude Headache
- The majority of these are experienced as sudden severe pains in the occipital area.
In one paper, 77% of 30 cases were occipital orgasmic pain, lasting an average of 30 minutes, occurring in >50% of intercourse in 93% of cases, and remitting after an average of 2 months.
It is now thought that these headaches are almost all due to a condition called reversible cerebral vasoconstriction syndrome.
- 4/98 mountain climbers at high altitude experienced their pain in the back of the head. Most of the headaches involved the entire head. and about half were made worse with exertion.
Pool Players Headache
- One series of 83 cases of headaches triggered by coughing found no cause in 74 cases. Of these 74 cases, 35% were in the back of the head.
In the 9 cases with a cause found, 4 had occipital pain (44%).
Cough Headache requires investigation. The most common cause found is a condition called Chiari malformation.
- People who play pool for prolonged periods of time may experience pain in the head and neck after playing for between 3-6 hours.
There is one report of this, and the problem is presumably from the joints of the neck, such as over extension at the atlanto-axial joint.
This is probably a form of cervicogenic headache.
Neck Tongue Syndrome
- Pain referred from the heart can be felt in the back of the head. 11/32 published cases, reviewed in 2008, had occipital pain during either an angina attack or heart attack proper.
This is one of the causes of an Exercise Induced Headache, although it can also cause a Thunderclap Headache
Treating the heart disease fixes the headaches.
- This is an unusual back of the head syndrome. It is provoked by rotation of the neck which irritates the C2 nerve and produces a sensory disturbance in the tongue.
Some will get a spasm of tongue muscle.
There are nerve fibres which run in the nerve to the tongue (hypoglossal nerve) which join with fibres from the upper neck (C2 nerve), so pain from the neck can produce symptoms in the tongue.
Low pressure headache, usually due to Spontaneous Intracranial Hypotension
- Pain in a low pressure headache can be experienced anywhere, but most commonly it is on both sides of the head.
Some people will report a severe dull ache in the back of the head that is worse while up and about, and is relieved by lying down flat for 15-30 minutes.
Low pressure headaches are often associated with a muffling of hearing or buzzing in the ears that is also better on lying down.
The common cause of low pressure is due to a spinal tap or lumbar puncture procedure. About 20-30% of post-lumbar puncture headaches in one large series were located at the back of the head.
Some people will get a spontaneous leak of spinal fluid within the spine. The spontaneous cases are called Spontaneous Intracranial Hypotension.
Low pressure headache that is very severe and incapacitating can be treated with a an epidural blood patch procedure, which has a 70-80% success rate in typical cases.
"Headache back of Head"
Due to a "trapped" nerve
C-2 Neuralgia, from Lateral Atlanto-axial joint disease
Occipital Condyle Syndrome
Hypoglossal Nerve Palsy
- Disease of this joint can irritate the C2 nerve and cause intense sharp pains going up the back of the head. They can even cause the eye to water.
Rheumatoid arthritis is the most common serious cause of this problem.
Other conditions that can affect this joint or the C2 nerve include a neuroma, meningioma or pressure from a nearby blood vessel. This condition will require specialist investigation and treatment.
Accessory Nerve Palsy
Vascular Loop Compression of Upper cervical nerve Roots
- Even without an occipital condyle syndrome hypoglossal nerve palsy can be painful. This may be due to compression of the inflamed nerve in the hypoglossal canal, but the exact mechanism is not certain.
- A low lying course of the posterior inferior cerebellar artery has been identified in persistent occipital neuralgia.
Headache Back of Head
Due to Structural Disease of the Junction Between Headache and Neck
Extra-bone connecting occiput to cervical spine
- The brain in this condition sits much lower within the skull and can block flow of spinal fluid causing bouts of bad headache.
Technically speaking, low lying cerebellar tonsils could stretch the upper cervical nerve roots and contribute to pain in the back of the head.
The classic pain of Chiari Malformation is in the back of the head and is provoked by coughing or exertion, so without these provoking factors a Chiari is less likely to be the cause.
- One case of a teenage girl with fixed, one sided severe pain due to an accessory bone joining head to neck, which was relieved when the accessory bone was removed surgically
- Single case of severe occipital pain associated with a vascular lesion in the upper spinal cord.
"Headache Back of Head"
Caused by Primary or "Idiopathic" Conditions
- This is a localised, fixed area of pain the size and shape of a coin. It is thought to be due to inflammation of one of the cutaneous nerves of the scalp, and is more a nuisance than a serious disorder.
- 26% of one series of 652 cases experienced cluster pains in the back of the head.
There are other features of cluster that must be present for this diagnosis - watery eye, nasal symptoms, agitation and strictly one-sided pain.
Oxygen and Sumatriptan injections work best for acute attacks. Verapamil is the best preventative drug
New Daily Persistent Headache
- This is a strictly one-sided headache and in most cases is at the front and side of the head. In one series 1/18 had the occiput as the main site of pain. In another 5/18 there was some pain there, but it was not the main site of pain.
- 80% of these people recall the onset of new headache several months earlier and the pain seems to persist, and no cause is found.
Some of these are associated with a viral infection.
64% have bilateral pain and 60% have occipital pain. In 55% the pain is described as throbbing at times and 54% report pressure symptoms at times, and some experience both throbbing and pressure
"Headache Back of Head"
Associated with other Diseases
This pain in the back of the head is severe to the point of preventing sleep. It has its onset over about 1-2 days and is associated with pain on swallowing.
Brain Tumour Headache
- 35% of people with previously known Parkinson's Disease in one survey had a non-descript bilateral posterior neck and head pain
Sleep Apnoea Headaches
- 11/51 people in one series of people with brain tumours reported pain in the back of the head.
However, occipital pain is not a distinctive feature of brain tumours.
Most brain tumours present with other neurological symptoms such as epileptic seizures
Idiopathic Intracranial Hypertension
Overactive Thyroid Gland
- One case of a relapse of Graves Disease (thyrotoxicosis) was associated with 2 months of severe occipital pain
Adult Aqueductal Stenosis
- Dengue Fever causes a febrile illness which is usually present for about a week before diagnosis.
97% of Dengue Fever cases will have a prominent headache, of which about one in five will be in the back of the head.
Headache is more pronounced in ordinary Dengue fever than in its more dangerous counterpart Dengue Haemorrhagic Fever.
- This is a cause of thunderclap headache, and like most thunderclap headache is experienced in the back of the head
References on Headache Back of Head
Sand T et al. Blink reflex R2 amplitudes in cervicogenic headache, chronic tension-type headache and migraine. Cephalalgia 2006; 26:1186–91 (Free Abstract only)
O Sjaastad et al. Extracephalic jabs/idiopathic stabs. Vågå study of headache epidemiology Cephalalgia;2003;23:50-54. (Free Abstract only)
Martins IP et al. Extratrigeminal Ice-Pick Status Headache 1995;35:107-110 (Free Abstract only)
Goadsby P. Cervicogenic headache: a pain in the neck for some neurologists? The Lancet Neurology 2009;8: 875-877 (Free Abstract only - but best recent technical paper)
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