Headache Back of Head

On average 5400 people enter "headache back of head" into Google each month. So here's the causes of pain in the back of the head.

Most of these are not serious.

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) or will have restricted neck movements due to "wear and tear" of the joints of the upper neck bones.

Cervicogenic headache is very common - as many as 4% of adults will have this pain.

Here's a full list of causes of a headache located in the back of head starting with the least serious:

1. Cervicogenic Headache
2. Occipital Neuralgia
Severe, sharp "headache back of head" that spread up to the top of head or into the eye on the same side. Nerve block or Gabapentin worth trying. Most people who are diagnosed with occipital neuralgia will actually be suffering from cervicogenic headache.
3. Retropharyngeal Tendinitis
This pain is severe, onset over about 1-2 days and is associated with pain on swallowing. ESR may be slightly elevated. treat with NSAIDS e.g. Diclofenac or Indomethacin
4. 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). 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.
5. Lateral Atlanto-axial joint disease. Rheumatoid arthritis is the most common serious cause of this problem.
6. Neck-tongue syndrome
This is an unusual pain syndrome. Rotation of the neck produces sensory disturbance in the tongue, some patients 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 ther neck can produce symptoms in the tongue.

The more serious causes include:

7. Temporal Arteritis / Giant Cell arteritis
Please recall that the occipital arteries are frequently involved in temporal arteritis, and as they lie right next to the greater occipital nerve, temporal arteritis can be confused with occipital neuralgia (I've done it, but the penny dropped at follow-up and a good recovery ensued on prednisolone!). About 30 people per 100,000 will get temporal arteritis in any given year.
8. 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 with this rare condition.
9. Chiari Malformation
The 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 provoked by coughing.
10. Low pressure headache - Intracranial Hypotension
Pain in this low pressure headache can be experienced anywhere, but would be worse with upright posture in classic cases. Can be relieved by epidural blood patch procedure. The typical pain of intracranial hypotension is in the side of the head.
11. Subarachnoid haemorrhage may cause a thunderclap headache pain of sudden onset in the back of the head.

Some people remain sceptical about the existence of cervicogenic headaches, i.e. headaches that originate in the neck. In US and Australian pain practice, it is commonplace to use diagnostic joint injection anaesthetic blocks to try and localise the source of pain in the cervical spine. These specialists argue that you actually prove where the pain is coming from. If you can prove that a specific neck joint is the source of a headache from a local anaesthetic injection, you could then do a more permanent procedure called a neurolysis.

In Europe, it is more common to rely on clinical criteria, such as the location and characteristics of the pain. While I am generally in favour of a simplistic approach i.e. the European one, on this occasion the US/Australian one probably makes more sense. However, other than in specialist pain practices, I do not know of anyone who routinely uses nerve block injections routinely in the UK for the evaluation of cervicogenic headaches i.e. "headache back of head".

One interesting study looked at the blink reflex. The speed of the blink reflex is reduced in people whose greater occipital nerve (the main sensory nerve at the back of the head) is anaesthetised with local anaesthetic. This, in many ways, proves that there are nerves connecting the neck to the main headache nerve - the trigeminal nerve.

In the 1960's studies in cats proved that mammals do have connections between the nerves in the neck and those of the trigeminal system. This evidence is regarded as important proof that disease of structures in the neck could result in pain in the front of the head.

In fact, many of the conditions listed will not just produce pain in the back of the head, but also will spread through to the front of the head too.

Some of my patients will say they think their headaches come from their neck. By this they may mean that their neck gets sore, before they take a proper headache - neck ache is a common warning symptom before a proper migraine for example.

Other people would mean that between headaches they are aware of a pain or "crick" in the neck, and that if they could resolve the neck pain the headache would improve.

Treatment for Headache in Back of Head

By far the most common cause is cervicogenic headache.

Non-steroidal anti-inflammatory tablets are probably best. If a short course of these does not help, then treatment from a physiotherapist can relieve the pain.

If Non-steroidals and physiotherapy do not provide relief, then a facet joint injection by a pain specialist may give longer term relief.

Occipital nerve block can give temporary relief in some cases. I have used thes in people who have been admitted to hospital with severe cervicogenic headache in an attempt to provide temporary relief - with some degree of success (5ml of 1% lidocaine).

References on Headache Back of Head

O Sjaastad et al. Extracephalic jabs/idiopathic stabs. Vågå study of headache epidemiologyCephalalgia;2003;23:50-54. (Free Abstract only)

Martins IP et al. Extratrigeminal Ice-Pick StatusHeadache 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

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