On average over 5000 people enter “headache back of head” into Google each month, and this is THE list of causes.
Most people will have pain referred from the upper part of the neck – called cervicogenic headache – or a condition called Chronic Migraine.
If you are still not sure what is causing your pain, please read on – there are 38 different causes; Common, Serious and Rare.
The first step you must take if you are struggling with headaches is to know if you are safe.
1: Common Causes of “Headache Back of Head”
Cervicogenic Headache [1, 2]
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 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 should have an assessment by a physiotherapist to determine whether a neck structure, such as a stiffened facet joint, requires treatment.
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.
Migraine is not, in my experience, a common diagnosis in people who ask me for advice about their “headache back of head”.
However, many people with very typical migraine will describe pains in the back of the head that mean that they have not just migraine but also involvement of the upper cervical spine.
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  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.
To make things more complicated, there are people who have had neck injuries who will start to experience pain in the head that sounds exactly like migraine .
Many people with migraine will also have undetected dysfunction of the upper cervical spine  and may be helped by an assessment by a physiotherapist. 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.
You can read in detail about other migraine symptoms.
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 headaches are located, exclusively, in the neck or very back of the head, but most people with ice-pick headaches experience them in or around the eye.
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.
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. Temporal Arteritis requires immediate treatment with steroids .
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 tests 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 be diagnosed with a brain haemorrhage called Subarachnoid haemorrhage . If due to a ruptured berry aneurysm, prompt 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 this pain happens out of the blue it requires immediate medical attention.
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
The majority of these are experienced as sudden severe pains in the occipital (back of head) area. It is now thought that if you get these headaches they are often due to a condition called 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 found is a condition called 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 a 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 is a rare treatable headache that wakens from sleep almost every night, usually at about the same time. If you have this type of headache you go to bed pain free, and it is the onset of headache that compels you to get up from lying. 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 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 (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.
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 located headaches associated 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 – they get 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 epileptic seizures.
Sleep Apnoea Headaches
Sleep apnoea and heavy snoring may increase the risk of chronic headaches . 22% of headaches associated with sleep aponea in one series were located in the back of the head . Treating sleep apnoea will often help the 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.
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