Feeling safe means understanding what is happening to you – which means that knowing the cause will help.
In most people with pain in the back of the head, the pain comes from the upper part of the neck – called cervicogenic headache – or is due to Chronic Migraine.
1: Common Causes of “Headache Back of Head”
- Cervicogenic Headache [1, 2]This is pain that originates in joints and muscles of the neck. This is called Cervicogenic Headache (cervic = neck, genic = caused by). The strange thing is that neck pain is often absent – the pain signal is sent up and forward into the head.Usually Cervicogenic Headache causes pain in the back of the head – on one side only.Cervicogenic Headache can spread up the back of the head, 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 have had a head injury. Most people who get concussion or severe head injury will have also had trauma to the neck.
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 abnormal function of the joints of the upper spine (facet joints). The test performed to identify abnormal neck movements is called the Flexion-Rotation Test .
Cervicogenic Headache is very common – as many as 4% of adults will have this pain at some point in their lives .
Fortunately physiotherapy alone can be effective , and this is the most common headache that might respond to physical treatment, without resorting to medication.
It is also very common to see people with neck related headaches describe symptoms that sound more like Migraine (feeling sick or not liking light when the head is sore) , or symptoms like tension-type headache (pressure or weight or band-like feelings) on or around the head .
For this reason, anyone who has recurrent or persistent headaches – even if they sound like Migraine or Tension-Type Headache – should see a physiotherapist or osteopath. Neck problems are a ‘modifiable’ risk factor for headaches.
This another severe, sharp “headache back of head” that spreads up to the top of head or into the eye on the same side.
Most people who have this label will actually have abnormal neck examinations, and the term Cervicogenic Headache is probably more appropriate. There is more on Occipital Neuralgia here.
- MigraineMigraine is not, in my experience, a common diagnosis in people who ask me for advice about their “headache back of head”.Many people with Migraine will describe pains in the back of the head.In the 1970s Jes Olesen of Denmark found that 6% of people with acute migraine took pain in the back of the head . A more recent survey in 2005  found that about 39% of people with migraine would report pain in the back of head or even in the neck.The more severe your migraine pain is the more likely it is that you will experience neck pain as part of your migraine. Up to 75% of people with severe migraine attacks will experience neck pain during a severe migraine.
People who have had neck injuries can also develop headaches that sound just like Migraine .
SO if you think you have Migraine in the back of your head, you may have an unidentified, treatable problem with the upper part of your cervical spine or neck muscles . Treating the neck can be beneficial in people who describe migraine, especially if it is a “headache back of head” as well as more typical migraine symptoms. Having your neck examined and treated is part of the Headache Friendly Lifestyle™.
Ice-pick Headaches are brief intense pains in the head lasting a few seconds. 35% of people report these occasionally and about 2% of people regularly suffer .
Ice-pick Headaches appear out of the blue. You may wince or feel briefly weak at the knees if they are very intense.
Most Ice-pick Headaches occur in and around the eye, but do happen in the neck or very back of the head. Ice-pick Headache is a cause of a sharp pain in the back of the head.
This is felt in the temples in most cases, but about 5% of people feel this pain exclusively in the back of the head [13, 14].
2: Serious Causes of “Headache Back of Head”
Harm may occur if not treated promptly.
Giant Cell Arteritis – also called Temporal Arteritis
The occipital arteries run up the back of the head, and are often affected in Giant Cell Arteritis.
As the occipital arteries lie right next to the greater occipital nerve, so Giant Cell Arteritis can cause a “headache back of head”.
About 30 people per 100,000 will get Giant Cell Arteritis in a year. The diagnosis requires an ESR blood test and a temporal artery biopsy procedure. Giant Cell Arteritis or Temporal Arteritis requires immediate treatment with steroids . It is possible that Giant Cell Arteritis is a vascular form of Shingles (Herpes Zoster Reactivation).
Vertebral Artery Dissection
This may present with a sudden severe “headache back of head”, but is even more rare than arteritis at about 1 to 2 people per 100,000 each year [16, 17] .
Statistically, Cervicogenic Headache is about 800 times more common than vertebral dissection.
It can be very difficult to tell the difference between a first episode of cervicogenic headache and a vertebral artery dissection. Sudden sharp head pains can present as a medical emergency  A history of recurrent episode strongly favours cervicogenic headache. With a first episode there may be not option other than doing CT or MR Angiography to rule out a vertebral artery dissection.
About 10% of people who come to hospital with a very sudden onset severe pain in the back of the head will have Subarachnoid haemorrhage . Most are due to a ruptured berry aneurysm, and require immediate diagnosis and treatment is essential. If a ruptured aneurysm is missed, the second bleed can be devastating .
This sudden severe headache is called “Thunderclap Headache”.
If at the time of onset of pain there is a witnessed loss of consciousness or if a thunderclap pain occurred during exertion, then there is a higher risk that such a pain is due to a serious cause like subarachnoid haemorrhage  compared to those who had pain and no other symptoms.
3. Headache Back of Head Due to Physical Stimulus
Headache During Orgasm
Sexual Activity Headache is usually a sudden severe pain in the occipital (back of head) area. These headaches may be due to Reversible Cerebral Vasoconstriction Syndrome..
High Altitude Headache
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 .
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 is Chiari Malformation . Most people with Cough Headache do not have a cause – called Primary Cough Headache. Muscular problems or stiff neck joints can also cause cough induced headache.
About 50% of people on dialysis for kidney failure will get a headache after dialysis sessions. People with higher blood pressure before dialysis are more likely to get headache, and in 27% of people, the headache is located at the back of the head 
Pool Players Headache
People who play pool for prolonged periods of time may experience pain in the head and neck after playing for between 3-6 hours . The problem is presumably from the joints of the neck, such as over extension at the atlanto-axial joint. This is probably an occupational form of Cervicogenic Headache.
Headache referred from the heart can be felt in the back of the head. In 11/32 published cases, reviewed in 2008, pain in the back of the head occurred during either an angina attack or heart attack proper . Treating the heart disease resolves the headaches.
This rare, treatable headache wakens you from sleep almost every night at about the same time. If you have hypnic headache you go to bed pain free, and it is the onset of headache that compels you to get up. A drug called Lithium Carbonate helps about 70% , although a survey of people with Hypnic Headache conducted through this website found that caffeine was the most helpful treatment.
Neck Tongue Syndrome
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 as well as sharp pain int eh neck and back of the head .
Low pressure headache, usually due to Spontaneous Intracranial Hypotension
Pain in a low pressure headache can be experienced in any part of the head. Most commonly it is on both sides of the head. Some people will report a severe dull ache in the back of the head (eg 7 out of 30 cases reported in 2000 ).
The classic feature of a low pressure headache is that is worse while up and about, and is relieved by lying down flat for several 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 most effective treatment is an epidural blood patch.
4. Headache Back of Head Due to a ‘Trapped Nerve’
C-2 Neuralgia, from Lateral Atlanto-axial joint disease
Thickening of the ligaments between the C1 and C2 vertebra (atlanto-epistrophic ligament), or disease of the joint capsule between C1 and C2 vertebrae (lateral atlanto-axial joints) or compression of the C2 nerve root by a small vein may all cause intense sharp pains going up the back of the head .
If the C2 nerve root is irritated it can even cause the eye to water . Other conditions that can affect this joint or the C2 nerve include a neuroma , meningioma  or neurofibroma . These conditions all require specialist assessment and treatment and are really, really rare.
Occipital Condyle Syndrome
Almost everyone who gets occipital condyle syndrome will have a known history of cancer elsewhere eg prostrate or breast . This causes a severe occipital pain due to spread of cancer into the occipital bone at the base of the skull.
The hypoglossal (XIIth) cranial nerve passes through this bit of bone and supplies the muscles of the tongue. Severe headache usually comes on a few weeks before the tongue movements start to cause speech or swallowing difficulty. If you stick the tongue out it deviates to the weak side – which is also usually the side of most pain.
Hypoglossal Nerve Palsy
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.
In 3 reported cases, one had occipital headaches with weakness of the tongue . The classic cause of a hypoglossal nerve palsy and headache is internal carotid artery dissection .
Accessory Nerve Palsy
Pain in the neck and shoulder are common if the Accesory Nerve is damaged – the usual cause is surgery in the neck to biopsy or remove a lymph gland. The pain can spread into the back of the head . The shoulder on the affected side loses its contour compared to the other and drops down.
Vascular Loop Compression of Upper Cervical Nerve Roots
A low lying course of the posterior inferior cerebellar artery has been identified in persistent pain in the back of the head . When surgeons have operated on people with suspected C2 nerve root compression, they very often find a vein causing compression of the C2 nerve root .
5. Headache Back of Head Due to Structural Disease of the Junction Between Head and Neck
The classic pain of Chiari Malformation is in the back of the head  and is provoked by coughing, exertion, laughter or sneezing, so without these provoking factors a Chiari is less likely to be the cause.
Single case of severe pain in the back of the head associated with a vascular lesion in the upper spinal cord .
6: Headache Back of Head Caused by Primary or “Idiopathic” Conditions
Epicrania Fugax is a variant of ice-pick pains . What is different is that these are even shorter in duration and seem to “zig-zag” through the head. 4 out of 10 cases in one series had pain starting at the back of the head and zig-zag their way through to the front of the head.
No serious cause is found.
My personal view is that these sort of pains could easily be referred pain from the upper cervical spine (see maps of referred pain from Cooper  or Aprill ).
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, and another series noted that 10% of people with cluster headache had neck pain .
It is still not known if trauma causes cluster headache in some cases or whether people with cluster headache are more likely to report trauma or subsequently experience head trauma . Oxygen and Sumatriptan injections work best for acute attacks, and Verapamil is the best preventative drug .
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 back of the head as the main site of pain  . In another 5/18 there was some pain there, but it was not the main site of pain. It is possible that Hemicrania Continua is a manifestation of cervicogenic headache .
New Daily Persistent Headache
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 headache in the back of the head. In 55% the pain is described as throbbing at times and 54% report pressure symptoms at times, and some experience both throbbing and pressure.
7: 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 the clinical clue to diagnosis is that there is pain on swallowing . It is usually relieved by a course of anti-inflammatory medicines. A scan of the neck may show calcification of the longus colli muscle.
“Coat-hanger Pain” is described in people with low blood pressure related to known Parkinsons Disease or a related condition called Multiple System Atrophy.
The patient experiences a pain in the neck and back of head that feels like they are being suspended on a coat-hanger. This is a potential mechanism for headache in people with Parkinsons Disease and would cause pain extending from the neck into the back of the head .
Brain Tumour Headache
11/51 people in one series of people with brain tumours reported pain in the back of the head . However, headache in the back of the head is not a distinctive feature of brain tumours . Most brain tumours present with other neurological symptoms such as progressive neurological deficits or epileptic seizures.
Sleep Apnoea Headaches
Sleep apnoea and heavy snoring increase the risk of chronic headaches . 22% of headaches associated with sleep aponea in one series are in the back of the head . Treating sleep apnoea will reduce the risk of headache, but this is still an area of active research .
Idiopathic Intracranial Hypertension
In about 1 in 6 cases, headaches were in the back of the head . The quality of pain is pulsatile or throbbing in 83% and assoc with nausea in 57% and a feeling of stiff neck in 59%.
The biggest risk for developing this condition is obesity and weight reduction through a properly directed exercise and diet programme can be curative . Surgery, in the form of a ventriculo-peritoneal shunt is a last resort to try and preserve visual function .
Overactive Thyroid Gland
One case of a relapse of Graves Disease (over active thyroid disease) was associated with 2 months of severe headache in the back of the head .
Dengue Fever causes a fever and headache . 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 .
Adult Aqueductal Stenosis
This is a cause of thunderclap headache, and like most thunderclap headache is experienced in the back of the head .
This is an ‘evidence-based’ list – gleaned from a systematic search of medical literature.
Bibliography 1. Bogduk, N. and J. Govind, Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol, 2009. 8(10): p. 959-68. 2. Cooper, G., B. Bailey, and N. Bogduk, Cervical zygapophysial joint pain maps. Pain Med, 2007. 8(4): p. 344-53. 3. Drottning, M., P.H. Staff, and O. Sjaastad, Cervicogenic headache (CEH) after whiplash injury. Cephalalgia, 2002. 22(3): p. 165-71. 4. Hall, T.M., et al., Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test. J Headache Pain, 2010. 11(5): p. 391-7. 5. Sjaastad, O. and L.S. Bakketeig, Prevalence of cervicogenic headache: Vaga study of headache epidemiology. Acta Neurol Scand, 2008. 117(3): p. 173-80. 6. Jull, G., et al., A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976), 2002. 27(17): p. 1835-43; discussion 1843. 7. Fredriksen, T.A., H. Hovdal, and O. Sjaastad, "Cervicogenic headache": clinical manifestation. Cephalalgia, 1987. 7(2): p. 147-60. 8. Watson, D.H. and P.D. Drummond, Head pain referral during examination of the neck in migraine and tension-type headache. Headache, 2012. 52(8): p. 1226-35. 9. Olesen, J., Some clinical features of the acute migraine attack. An analysis of 750 patients. Headache, 1978. 18(5): p. 268-71. 10. Kelman, L., Migraine pain location: a tertiary care study of 1283 migraineurs. Headache, 2005. 45(8): p. 1038-47. 11. Weiss, H.D., B.J. Stern, and J. Goldberg, Post-traumatic migraine: chronic migraine precipitated by minor head or neck trauma. Headache, 1991. 31(7): p. 451-6. 12. Sjaastad, O., H. Pettersen, and L.S. Bakketeig, The Vaga study; epidemiology of headache I: the prevalence of ultrashort paroxysms. Cephalalgia, 2001. 21(3): p. 207-15. 13. de Oliveira, D.A. and M.M. Valenca, The characteristics of head pain in response to an experimental cold stimulus to the palate: An observational study of 414 volunteers. Cephalalgia, 2012. 32(15): p. 1123-30. 14. Bird, N., E.A. MacGregor, and M.I. Wilkinson, Ice cream headache--site, duration, and relationship to migraine. Headache, 1992. 32(1): p. 35-8. 15. Dasgupta, B., et al., BSR and BHPR guidelines for the management of giant cell arteritis. Rheumatology (Oxford), 2010. 49(8): p. 1594-7. 16. Metso, T.M., et al., Adult cervicocerebral artery dissection: a single-center study of 301 Finnish patients. Eur J Neurol, 2009. 16(6): p. 656-61. 17. Lee, V.H., et al., Incidence and outcome of cervical artery dissection: a population-based study. Neurology, 2006. 67(10): p. 1809-12. 18. Pascual-Leone, A. and P. Pascual-Leone, Occipital neuralgia: another benign cause of "thunderclap headache". Journal of Neurology, Neurosurgery & Psychiatry, 1992. 55: p. 411. 19. Landtblom, A.-M., et al., Sudden onset headache: A prospective study of features, incidence and causes. Cephalalgia, 2002. 22: p. 354-360. 20. Edlow, J.A. and L.R. Caplan, Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage.[see comment]. New England Journal of Medicine, 2000. 342: p. 29-36. 21. Perry, J.J., et al., Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. Jama, 2013. 310(12): p. 1248-55. 22. Yeh, Y.C., et al., Clinical features, imaging findings and outcomes of headache associated with sexual activity. Cephalalgia, 2010. 30(11): p. 1329-35. 23. Serrano-Duenas, M., High altitude headache. A prospective study of its clinical characteristics. Cephalalgia, 2005. 25(12): p. 1110-6. 24. Chen, P.K., J.L. Fuh, and S.J. Wang, Cough headache: a study of 83 consecutive patients. Cephalalgia, 2009. 29(10): p. 1079-85. 25. Stovner, L.J., Headache associated with the Chiari type I malformation. Headache, 1993. 33: p. 175-181. 26. Goksan, B., et al., Haemodialysis-related headache. Cephalalgia, 2004. 24(4): p. 284-7. 27. Lim, E.C., B.K. Ong, and E.P. Wilder-Smith, Pool players' headache. Cephalalgia, 2005. 25(4): p. 312-3. 28. Wei, J.H. and H.F. Wang, Cardiac cephalalgia: case reports and review. Cephalalgia, 2008. 28(8): p. 892-6. 29. Evers, S. and P.J. Goadsby, Hypnic headache: clinical features, pathophysiology, and treatment. Neurology, 2003. 60(6): p. 905-9. 30. Lance, J.W. and M. Anthony, Neck-tongue syndrome on sudden turning of the head. J Neurol Neurosurg Psychiatry, 1980. 43(2): p. 97-101. 31. Chung, S.J., J.S. Kim, and M.C. Lee, Syndrome of cerebral spinal fluid hypovolemia: clinical and imaging features and outcome. Neurology, 2000. 55(9): p. 1321-7. 32. Schievink, W.I., Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. Jama, 2006. 295(19): p. 2286-96. 33. Pikus, H.J. and J.M. Phillips, Characteristics of patients successfully treated for cervicogenic headache by surgical decompression of the second cervical root. Headache, 1995. 35(10): p. 621-9. 34. Keith, W.S., "Whiplash"-injury of the 2nd cervical ganglion and nerve. Can J Neurol Sci, 1986. 13(2): p. 133-7. 35. Chowdhury, F.H., M.R. Haque, and M.H. Sarker, High cervical spinal schwannoma; microneurosurgical management: an experience of 15 cases. Acta Neurol Taiwan, 2013. 22(2): p. 59-66. 36. Kuritzky, A., Cluster headache-like pain caused by an upper cervical meningioma. Cephalalgia, 1984. 4(3): p. 185-6. 37. Goldhammer, L., Second cervical root neurofibroma and ipsilateral migraine headache. Cephalalgia, 1993. 13(2): p. 132-4. 38. Loevner, L.A. and D.M. Yousem, Overlooked metastatic lesions of the occipital condyle: a missed case treasure trove. Radiographics, 1997. 17(5): p. 1111-21. 39. Mateen, F.J., C.J. Boes, and N. Kumar, Unilateral headache and hypoglossal nerve palsy: a report of three cases. Cephalalgia, 2007. 27(7): p. 840-2. 40. Marin, L.F., et al., Hypoglossal nerve palsy as the sole manifestation of spontaneous internal carotid artery dissection. Arq Neuropsiquiatr, 2009. 67(1): p. 107-8. 41. Cherington, M., R. Hendee, and R. Roland, Accessory nerve palsy--a painful cranial neuropathy: surgical cure. Headache, 1978. 18(5): p. 274-5. 42. White, J.B., et al., Vascular compression as a potential cause of occipital neuralgia: a case report. Cephalalgia, 2008. 28(1): p. 78-82. 43. Bruti, G., et al., Neurovascular headache and occipital neuralgia secondary to bleeding of bulbocervical cavernoma. Cephalalgia, 2007. 27(9): p. 1074-9. 44. Pareja, J.A., et al., Epicrania fugax: an ultrabrief paroxysmal epicranial pain. Cephalalgia, 2008. 28(3): p. 257-63. 45. Aprill, C., M.J. Axinn, and N. Bogduk, Occipital headaches stemming from the lateral atlanto-axial (C1-2) joint. Cephalalgia, 2002. 22(1): p. 15-22. 46. Guerrero, A.L., et al., Nummular headache with and without exacerbations: comparative characteristics in a series of 72 patients. Cephalalgia, 2012. 32(8): p. 649-53. 47. Solomon, S., R.B. Lipton, and L.C. Newman, Nuchal features of cluster headache. Headache, 1990. 30(6): p. 347-9. 48. Lambru, G. and M. Matharu, Traumatic head injury in cluster headache: cause or effect? Curr Pain Headache Rep, 2012. 16(2): p. 162-9. 49. Carville, S., et al., Diagnosis and management of headaches in young people and adults: summary of NICE guidance. Bmj, 2012. 345: p. e5765. 50. Bordini, C., et al., "Hemicrania continua": a clinical review. Headache, 1991. 31(1): p. 20-6. 51. Sjaastad, O., et al., Hemicrania continua and cervicogenic headache. Separate headaches or two faces of the same headache? Funct Neurol, 1993. 8(2): p. 79-83. 52. Vanast, W., New daily persistent headaches: definition of a benign syndrome. . Headache, 1986. 26: p. 317-20. 53. Ekbom, K., Retropharyngeal tendonitis. Headache, 2009. 49(10): p. 1549-50. 54. Khurana, R.K., Coat-hanger ache in orthostatic hypotension. Cephalalgia, 2012. 32(10): p. 731-7. 55. Schankin, C.J., et al., Characteristics of brain tumour-associated headache. Cephalalgia, 2007. 27(8): p. 904-11. 56. Neau, J.P., et al., Relationship between sleep apnoea syndrome, snoring and headaches. Cephalalgia, 2002. 22(5): p. 333-9. 57. Sand, T., K. Hagen, and H. Schrader, Sleep apnoea and chronic headache. Cephalalgia, 2003. 23(2): p. 90-5. 58. Russell, M.B., H.A. Kristiansen, and K.J. Kvaerner, Headache in sleep apnea syndrome: epidemiology and pathophysiology. Cephalalgia, 2014. 34(10): p. 752-5. 59. Wall, M. and D. George, Idiopathic intracranial hypertension. A prospective study of 50 patients. Brain, 1991. 114 ( Pt 1A): p. 155-80. 60. Sinclair, A.J., et al., Low energy diet and intracranial pressure in women with idiopathic intracranial hypertension: prospective cohort study. Bmj, 2010. 341: p. c2701. 61. Sinclair, A.J., et al., Is cerebrospinal fluid shunting in idiopathic intracranial hypertension worthwhile? A 10-year review. Cephalalgia, 2011. 31(16): p. 1627-33. 62. Stone, J., et al., Thyrotoxicosis presenting with headache. Cephalalgia, 2007. 27(6): p. 561-2. 63. Domingues, R.B., et al., Headache features in patients with dengue virus infection. Cephalalgia, 2006. 26(7): p. 879-82. 64. Basilio-de-Oliveira, C.A., et al., Pathologic study of a fatal case of dengue-3 virus infection in Rio de Janeiro, Brazil. Brazilian Journal of Infectious Diseases, 2005. 9: p. 341-347. 65. Mucchiut, M., et al., Adult aqueductal stenosis presenting as a thunderclap headache: a case report. Cephalalgia, 2007. 27: p. 1171-3.
Is Your Headache Dangerous?
Get your FREE copy
by Dr Raeburn Forbes MD(Hons)
Get Control of Headaches
Feeling safe is your first step