All posts in Conditions

How Pain Works Part 1. All pain comes from your Brain


Over the last 5-10 years we have learned A LOT about pain and how it works, but a lot of this is completely foreign to most people, so we’ve decided to produce a series of articles to help people actually understand their pain and what is going on… Firstly because KNOWLEDGE IS POWER! And secondly because understanding why you feel how you feel is empowering and dethreatening (as they say – just knowing is half the battle)

This is part one of a 5-part series on learning how pain works!


Now intuitively we all understand that pain comes from receptors in our body. We have nerve endings all over our body that pick-up pain signals and signal to our brain that we are in pain, right?

Sorry but that’s actually wrong!

All pain (and all sensory experience for that matter) comes from our brain. Our body is providing millions of sensory input signal to our brain at all times, but our brain computes everything and then works out what to experience.

Then the OUTPUT from our brain is what we experience.

This makes sense when we compare what we may know about our other senses.

Our ears don’t hear sound. There are receptors in our ears that are sensitive to vibration of air particles, and when it picks up vibration of air particles those receptors then turn that into electrical information that is transmitted to our brain. Our brain then interprets that electrical signal and works out what we are hearing. What we hear is an output of our brain computing the signals.

Now we don’t hear everything the same. If you’re doing something else you might not hear at all, even though the vibrations coming into the ear are the same. So just having the receptors stimulated doesn’t mean we actually hear. It’s what the brain chooses to do with the input it receives that determines what we actually experience.

The same as our eyes don’t see – our brain sees from the information provided by our eyes. Our eyes bring in light and focus it on the parts of the back of our eyes. Light hitting those parts of the eye then stimulates electrical signals to the brain. (If you’ve read into this before you know that the brain actually receives the information upside down). Your brain has to interpret this information to then give you an experience of what you are actually seeing. If you’ve ever seen an optical illusion, noticed a blind spot or realise you can’t actually see your nose (even though it’s always in your field of view) you can understand that your brain interpreting the information it has available to it is what allows us to see.

(I bet you all just looked at your nose right now)

The same happens with pain as an input. Your brain is provided input from all over your body and it decides what you feel based on its own priorities (which we’ll cover in the coming articles).

So because of this, we know that pain isn’t just fixed or static, and more pain doesn’t necessarily mean more damage. It also means you can have a lot of pain with very little damage at all (have you ever seen someone scared of needles scream in pain before the needle even touched them??)

Knowing that pain is an output of your brain means that we can understand how we experience pain, and then help us to control our experience of pain.

Coming up in part 2, we’ll learn about pain as a warning system, rather than pain being an indicator of damage.


Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries.


8 (and a half) Biggest Myths about Low Back Pain

8 (and a half) Biggest Myths about Low Back Pain

Despite information being abundant and easy to find nowadays, we find there are still many myths (and downright lies) that still seem to persist when it comes to pain and injury. Unfortunately poor understanding or unhelpful beliefs about your injury tend to lead to prolonged recovery of failure to recover at all.

Here are some of the biggest low back pain myths, and what you should really believe.


1. Once you hurt your back it never gets better

This is a myth that has persisted for a long time. It’s funny, because patients seem to think about their back differently to the rest of their body. If you pull your hamstring playing soccer, you wouldn’t automatically expect that it will never get better. It’s really no different with your back. By and large everyone gets better – your body is a fantastic healing machine! Research does show that there is a high-ish rate of recurrence with low back pain, but this has more to do with poor management and proper rehabilitation. Injuries heal! Your back is strong and designed to move. Injuries are very rarely permanent.

2. If I hurt my back I need to rest it/stay in bed

Bed rest has actually been shown to be worse for back pain than active recovery. It prolongs the time to recover, and increases the chances of recurrence. You also end up stiffer, weaker and more sensitized to your pain. The best advice is to try and stay active (even if you can only tolerate a little bit of activity) and try to move normally. This promotes good healing, reduces sensitivity and normalises movement.

3. Your back is weak/fragile – that’s why you get hurt

Your back/spine is actually very strong. There are lots and lots of connective tissue and ligaments, as well as muscles around your spine to keep it functioning well. You can transmit and tolerate significant amounts of weight through your spine. Your back is strong and designed to move.

if you have recurring low back pain, you may be suffering from deconditioning of the muscles around your back, or loss of functional movement control. You may also be avoiding certain movements and actually aggravating your pain by doing so. People need rehabilitation to ensure they get back to 100% strength and function after any injury, and back injuries are no different. Your spine itself, however, will heal and recover.

lumbar ligaments-BB

4. The worse my pain is, the more my back is damaged

Actually pain and damage are very poorly related. If you’ve ever stubbed your toe when it’s cold you will know that you can experience very high pain levels without any damage at all. Pain is very complex, but remember that it is a warning system. In acute injuries, you will often feel pain well before you suffer any damage. I often use the example of touching something hot – you feel pain and pull away automatically, but you don’t get burned. This is because you experienced pain to warn you of potential danger and you behaved accordingly.

When it comes to ongoing pain, our mental state, attitudes, beliefs, past experiences (etc. etc.) all contribute to our pain experience. High pain levels often don’t correlate with high levels of damage on scans.

5. I need an x-ray/scan for my back

Studies have shown that early imaging for acute low back pain is actually associated with slower recovery and increased health care costs. It’s very common for people who have NEVER had back pain to have findings that people might interpret as ‘damage’ on scans. Early scans (and poor understanding of what those scans actually represent) medicalises patients, convincing them that there is something ‘wrong’ or ‘damaged’ when in fact they probably had exactly the same findings before they suffered from pain. Numerous studies have shown that findings on MRI/CT/x-ray do not correlate to pain or loss of function. See the graphs below as an indication of just how common this is:

neck mri normal findingsLx mri findings graph

And while we’re at it:

5 1/2. My spine is damaged so there’s nothing I can do

See the images above and tell me your spine is still damaged. These findings are NORMAL, and gradually increase over time. I like to describe these as ‘time-related changes’. Much like wrinkles on your skin or grey hairs. Many people start to develop grey hairs or wrinkles – some much earlier than others. this does not mean that your hair is ‘painful’ or ‘damaged’. The wrinkles in your skin will not stop you from playing soccer ever again. They are just normal changes that occur in your body as time goes on.

(Obviously sometimes people do suffer injuries that are serious, and CT/MRI is very important when it is indicated. The point is that just because you are in pain doesn’t mean a scan will help, or the incidental findings on your scan are that important to your injury or recovery)

6. Something is ‘out’ and that’s why my back hurts

While the description of something going ‘out’ in your spine is an easy way to describe and understand a complex problem, it is actually physiologically incorrect. As you saw in the image earlier, there are significant ligament and soft tissue structures stabilising your spine. Your joints simply cannot go ‘out’ and ‘back in’. Not without dislocating them (which would hurt a lot more).

” but what about when I have my back cracked?” I hear you ask. “doesn’t that mean it is going back in?”

Well, no. Think about another part of your body – your knuckles. Chances are you, or someone you know, cracks their knuckles regularly. Were their knuckles ‘out’? Or subluxed/dislocated before you cracked them? Are they ‘back in’ now?

No. Cavitation (the technical term for cracking) occurs when you stretch two synovial joint surfaces apart quickly. It affects the surface tension between the two joint surfaces, and the pressure and volume within the joint. This results in a ‘crack’.

(And before any of you get too picky, yes sometimes something in your body could possibly be dislocated/subluxed, and will crack when it is enlocated. But that’s not what we’re talking about with back pain though).

7. Bending your back is bad for you

Your body is a fantastic machine capable of amazing feats of strength, endurance and skill. Do you really think that you would be able to bend your back if you weren’t supposed to? There are certainly more or less ideal ways to move depending on the task you are completing and the load you are under, but to think that you should never bend (as some people seem to) is ludicrous. I have certainly treated many people who have been told that bending is bad for them, and literally never bend at their spine EVER! This fear of movement is usually contributing to their ongoing problems, and they need to relearn how to move ‘normally’.

Try telling these guys that bending their spine is bad for them.

gymnast floor hurdles

8. There’s nothing I can do about it

If you’ve read this far (and congratulations that you did) you will hopefully have guessed that there is a lot we can do to address low back pain and dysfunction.

In general, the best advice for acute spinal pain is to try and stay active and do normal activities. It’s true that most low back injuries will resolve on their own within 6-12 weeks, regardless of how bad it was to start with. As I mentioned, the rate of recurrence is quite high, which has a lot to do with good management and proper rehabilitation following the initial injury.

If you are markedly restricted, it is a good idea to see your physiotherapist to get an idea of what you’ve done and what needs to be done to get better. We can also help to speed up that recovery time, and ensure you aren’t one of the unlucky ones with ongoing low back pain (or recurrent pain).

The key to good management and the fastest recovery is accurate assessment and diagnosis. You can then identify the optimal management for your individual situation to recover as fast as possible and reduce the risk of recurrence as much as possible.

Unfortunately, too many people either just take pain killers and do nothing about it. Or you get caught up in the myths and end up taking longer to get better. A back injury is really no different to any other injury. People often just don’t get looked after properly (or get bad advice from well meaning people).


If back pain is slowing you down – feel free to get in touch and see how we can help you get back to normal faster.


Happy Mythbusting!


Julian Bowen

Julian is the Director and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors; to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 


The Ultimate Guide to Ankle Sprain Treatment

ankle injury high heelsAnkle injuries are extremely common in sports, particularly netball, basketball, soccer, AFL and volleyball.  (As you can see, they can occur almost anywhere). Studies estimate that 1 sprain occurs in every 10,000 people every day.  In a  town like Perth where we are – that is equivalent to 202 people every day or over 73,000 ankle sprains per year. Ankle sprains also account for up to 25% of all sporting injuries! Studies show that 40% of people can be left with persistent instability of the ankle.  Considering what a big problem this is, it is high time that we provide you with the best, evidence based guidelines for the treatment and management of ankle sprains.

What is an Ankle Sprain?

Ligaments of the ankle

Ligaments of the ankle

Over 90 % of ankle sprains are injuries to the Anterior Talo-fibular Ligament (ATFL for short).  This is due to an inversion injury, where the ankle is twisted inwards.  There are three major ligaments on the outside of the ankle – the ATFL, the Calcaneofibular ligament and the Posterior Talo-fibular Ligament.  Generally – the worse the injury the more of these ligaments are damaged.

We use the term “sprain” to describe an injury of a ligament (remember a ligament connects a bone to another bone).  Sometimes the ankle can twist outwards, injuring the ligament on the inside of the ankle.  This guide will focus on lateral ligament sprains, but the same rules generally apply.

So What Should You Do?

First Aid

So you’ve landed on some defender’s foot at netball and twisted your ankle. It hurts….. bad.  Your team mates help you limp off the court, then what do you do? Good early management can significantly improve recovery times following ankle injury, so looking after it well now will get you back on the court quicker.

This immediate phase is where the good old RICE protocol (rest, ice, compression, elevation) is the most effective. (It has actually been expanded up to SPRICEMM, but we’ll get to that later).  When we say rest, we mean relative rest. Like stop playing netball and go look after your now rapidly swelling ankle.  It doesn’t mean hop around for two weeks being afraid to put your foot down. The S and P stand for support and protect. Support means keep the ankle in a nice neutral position (like the 90 degree position it would be in if you were standing on it).  This keeps the ligament in a shortened range and will help with the initial healing process.  Protect means prevention from further injury (like don’t go back and limp on to the court).ankle bruising 1

Anytime you have a soft tissue injury, you have bleeding. Bruising from a bad ankle sprain is bleeding from the damaged ligament and other tissue into the surrounding space.  You also develop an acute inflammatory response very quickly following the injury. Inflammation is a normal part of healing, as it bring lots of cells and chemicals rushing to the injured area to begin healing. This is normal and helps initiate the healing process. Inflammation also contains lots of chemicals that are irritants to your nerves and pain receptors in the surrounding tissues – this increases your pain levels and makes sure you know that you’ve had an injury.  There is an evolutionary theory that this helps to let you know that you have suffered an injury and to adjust your behaviour accordingly (like don’t fight that mammoth as you might have trouble running away).

Along with all this bleeding comes damage and death of the injured cells of the ligament. Bleeding also means a loss of normal blood supply to the surrounding cells. Ice is very beneficial in the very early stages to reduce secondary injury due to hypoxia (lack of oxygen to the cells) caused by disruption of the normal blood supply.  Secondary injury can also occur due to enzymatic mechanisms – the damaged and dying cells can release enzymes (chemicals) that damage the surrounding cells.

(For a deeper understanding of how inflammation works and the effects of ice, stay tuned for my upcoming article on the use of ice for soft tissue injuries)

If you don't have any icepacks, frozen peas work pretty well

If you don’t have any icepacks, frozen peas work pretty well

Ice reduces this secondary injury by:

Reducing metabolic requirements of the surrounding cells thus increasing the number of cells that survive. This obviously means less injury and quicker recovery. It was originally thought that ice also can reduce bleeding and reduce total inflammation, but the jury now seems to be out on this. It is still wise to use ice in the early stages to not only reduce the metabolic load but also to provide pain relief – you will generally feel better with some ice on your ankle.

Compression is probably the most effective tool we have at reducing excessive inflammation.  Now remember I said that inflammation is normal and important for healing to occur – so we don’t want to completely halt the inflammation process (I don’t actually think it is even possible to completely stop inflammation with these measures). However, excessive inflammation means that too much inflammatory exudate (inflammatory fluid that collects outside of the injured cells) can gather in the interstitial space (between all the other structures). This creates greater pressure within the space between the tissues and can reduce how much other chemicals and cells can get in to the area to help with healing. It’s a bit technical, but changes to the osmotic pressures and perfusion gradients mean that too much pressure from excess inflammation will stop some of the cells and chemicals required for healing even getting to the site of the injury.

Elevation may also be beneficial in reducing swelling, by using gravity to encourage the flow of fluid (and lymph, etc) away from the ankle. The research isn’t strong in this area, but if you’re resting in a neutral ankle position or icing your ankle, it’s not going to hurt to elevate it as well.

The initial bleeding can continue for up to 24 hours, so it is wise to continue icing regularly for at least the first day. There are lots of different protocols out there with varying levels of evidence, so there probably isn’t a perfect amount of time to ice (or have on/off) but keeping ice on regularly will be highly beneficial.

What about anti-inflammatories?

There is conflicting evidence for the use of anti-inflammatory medications in the early stages of injury.  We know that excess inflammation can inhibit optimal healing times and we also know that high pain levels make it hard to move on to the next phases of rehabilitation.  BUT, we also know that inflammation is a necessary part of the healing process. Most over the counter anti-inflammatory medications are aspirin substrates, (aspirin is a low grade blood thinner) so this type of medication could also potentially increase bleeding in that first day or so.

Generally we would take this on a case-by-case basis. We have to weigh up the benefits of pain relief with the potential for increased bleeding. Remember over the counter anti-inflammatory medications aren’t exactly wonder drugs.  I have never come across anyone who has ever sprained their ankle badly, taken 2 nurofen and then their swelling has magically disappeared. Pain relief is usually beneficial (paracetamol, etc) as controlling your pain levels better allows you to complete all your rehabilitation. If in doubt you should always discuss medication with your local pharmacist – they are experts in medications and their advice is completely free!

Anti-inflammatory medication is widely recommended by doctors for acute injuries, so should be considered generally safe to use. In most cases it is probably more helpful than not.

Early Stages

The next step is to work out if there is any serious damage that requires more medical attention. We follow a set of criteria called the Ottawa Rules to determine if you require an x-ray or might have a fracture.  There’s a lot to it, but in general if you:

Can’t walk more than a couple of steps, and

are quite sore to touch on any of the bones of the ankle or lateral foot

it would be wise to see a qualified health professional (such as ourselves) quickly to determine if you need an x-ray or might have broken ankle sprain diagram 1something. Generally I wouldn’t recommend going straight to emergency (unless there is obviously a bone sticking out in the wrong place) as usually you will just sit in a waiting room for 6 hours, get an x-ray then get sent home on crutches without adequate  management advice or treatment. It is usually much easier to get to your physio or GP within the next 24 hours (we usually try to ensure we have same day appointments available). If you need any other immediate treatment we can organise that for you. If you’re not sure, there are always after hours GPs that you won’t have to wait 6 hours in an emergency room to see.

While we’re at it, you should remember that whether you heard a “pop” or “crack” has no bearing on whether you have broken a bone or not – studies show it actually makes no difference at all.

The severity of the injury will dictate how long it will take to get back to full activity (including sport). A grade I injury (minor ligament injury) should be back to sport within a week or two (with proper management). Grade II might be 2-4 weeks.  Grade III (greater than 50% rupture) could be 6 weeks or more. A complete ligament rupture could be looking at 12 weeks on the bench, and might need input from a surgeon if there is persistent instability.

Keeping some sort of compression on at this stage usually helps to reduce excessive inflammation, and may also make it easier to weight bear. Icing may not be as important after the first day or two, but it does provide pain relief and doesn’t do any harm (and might possibly help to reduce inflammation) so if it feels good with ice – you should keep using ice. Assuming there is no fracture, then this brings us to the next important point:

Functional treatment is far superior to prolonged rest and immobilization!

Functional Treatment

While RICE is excellent first aid, it was only ever intended to be first aid.  It is not an effective complete treatment plan. There is a lot of information on the internet that will tell you that RICE doesn’t work at all, and this is because they are using it as a complete treatment. Once you are out of the initial first aid phase  RICE is not enough –  you need functional treatment.


This is actually what the M stood for in SPRICEMM – mobilise! You should start weight bearing (trying to walk on the ankle) as soon as it is comfortable to do so. You will not damage it any further by putting weight on the foot. Sometimes we will tape or brace your ankle to stabilise it better – this usually makes it easier to start walking on it sooner. The sooner you start walking and moving normally, the better you start to regain functional capacity and movement; and the quicker you will get back to sport.

In the old days many people were sent home on crutches and told not to put the foot down for 2 weeks. This is actually terrible advice, and leads to slower recovery, potential secondary complications (like complex regional pain syndrome) and increased risk of recurrence. It also tends to rest the ankle ligaments in a lengthened position, meaning the ligament will heal with more laxity and can suffer from ongoing instability.

We also want to begin some gentle movement of the foot and ankle to restore function and encourage normal healing of the tissues. At this stage we will often start some manual treatment to help restore normal mobility of the foot and ankle. You can also do some mobilisation work yourself at home – particularly working on your dorsiflexion mobility (see below).  Keep your heel down and try and bend your knee towards the wall (increasing the angle at the ankle)

Ankle-Dorsiflexion-Mobilty-             dorsiflexion stretch 1

When you are able it is best to begin exercise to also work on your balance and stability of the ankle. The ankle is critical for good balance and stability of the lower limb, and this is generally impaired following ankle injury.  Rehabilitation and restoration of this stability is critical to avoid persistent “weak ankles” and instability.


Appropriate rehabilitation is the key to avoiding persistent ankle pain and instability. We see patients in the clinic all the time who report having a “weak ankle” following a previous ankle injury. This means they continue to suffer from recurrent ankle sprains once they return to sport. It is completely unnecessary to settle for having a weak ankle after injury. All this means is that you never did the right rehabilitation to get the ankle strong again after the initial injury.

There are literally thousands of different exercises that you can do – for the best rehabilitation you should always be assessed by a competent physiotherapist who can identify your exact problems and design the perfect rehabilitation program specifically for you. Here are some safe places to start:

Balance and stability.single-leg-balance-level-one

As simple an exercise as standing on one leg is a very good place to start.  This will train the reactions you use to correct you balance, and all the little muscles around your ankle.  If this is too easy, you can make it harder by closing your eyes (please do it somewhere safe) or by standing on an unstable surface (like a cushion). Strengthening of the eversion muscles (see below) is also important to resist the forces when you twist your ankle inwards.

ankle strength 7

ankle eversion rehab physioadvisor


Neuromuscular Rehabilitation

Neuromuscular rehabilitation takes these static balance tasks and integrates them into functional movements and dynamic retraining. This is the real difference between just being ok to do normal daily activities and being 100% recovered for full sport. This end stage rehabilitation phase is also the most commonly skipped step. Being able to jump, hop, side-step while changing direction and throwing, and looking over your shoulder are all things that you would do all the time while playing sport. So it makes sense that you should actually retrain these movements. (Remember one of the top keys to any rehabilitation is SPECIFICITY of training).

Studies show that our balance and stability reactions can be impaired for up to a year following ankle injury, so it is essential to regain and retrain those stability mechanisms. Failure to do so is the number 1 reason 40% of people can end up with persistent instability or “weak ankles”.

There is an infinite combination of possibilities with this kind of rehabilitation (far beyond the scope of this article). Suffice to say, the retraining should be specific to your sport or activity. Do you do a lot of jumping and landing in your sport? Then you should probably include jumping and landing activities in your rehabilitation. Do you do a lot of changing direction? Then this should also be included.

We can design specific rehabilitation programs to get you back to 100% that are uniquely individual to your requirements and chosen sport. Even if you are one of those people that has “weak ankles” from previous injuries, then this type of strengthening and neuromuscular rehabilitation will be invaluable to get those ankles stable again and get you back to playing.

Take Home Messages:

1. Ice and compression as soon as possible will give you the best possible start to recover as quickly as possible.  Try to keep the ankle in a neutral position.

2. Get your ankle assessed to ensure there is no serious damage. Accurate diagnosis will put you on the right path from the beginning.

3. Start weight bearing as soon as you are comfortable to do so. Even partial weight bearing with crutches is better than no weight bearing.  Use tape or a brace if you need to reduce pain and stabilise your ankle.

4. Keep the ankle moving. Normal movement will encourage good healing and get you back to activity quicker.

5. Functional rehabilitation is the best approach to complete recovery.

6. Ensure that you complete your rehabilitation to avoid persistent problems. Most people should not have to put up with ongoing ankle issues – as long as the do the right thing.


As always, if you have any questions about this or anything else, we are always happy to hear from you.

Happy Rehab.

Julian Bowen

Julian is the owner and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 40,000 individual treatments in that time. He has worked with everyone from Paralympians, elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 



Petersen W, et al. (2013) Treatment of acute ankle ligament injuries: a systematic review. Archives of Orthopaedic and TRauma Surgery, Volume 133, Issue 8, pp 1129-1141

Kerkhoffs G, et al. (2012) Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med 2012;46:854-860 doi:10.1136/bjsports-2011-090490

Michel P.J. van den Bekerom, Peter A.A. Struijs, Leendert Blankevoort, Lieke Welling, C. Niek van Dijk, and Gino M.M.J. Kerkhoffs (2012) What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?. Journal of Athletic Training: Jul/Aug 2012, Vol. 47, No. 4, pp. 435-443

Bleakley C, et al. (2004) The Use of Ice in the Treatment of Acute Soft-Tissue Injury: A Systematic Review of Randomized Controlled Trials. Am J Sports Med January 2004 vol. 32 no. 1 251-261

Grey J & Rawlinson G (2013) The Physiotherapy Management of Inflammation, Healing and Repair. in S Porter (Eds) Tidy’s Physiotherapy. Elsevier Health Sciences pp 253-271


Cervicogenic Headache

cervicogenic headache


Cervicogenic headache refers to pain felt in the head that is referred from the neck.  This is because nerves that supply the neck (or originate from the neck) also supply sensation the the head, jaw and face.  The headache is usually unilateral (only on one side of the head), but in clinical practice we do often see other headache patterns (such as pain on both sides of the head) that can be related to the neck.  The key feature of cervicogenic headache is that we can reproduce the headache with some findings related to the neck. Often, palpation of one of the joints or muscles in your neck (but sometimes even your upper back/shoulders, jaw or muscles in your head) will bring on the exact headache you have been experiencing.  This shows a relationship between your headache and the symptomatic area of the neck – meaning that your headache will likely respond to treatment of this area.  Studies have estimated that cervicogenic headaches account for up to 18% of all headaches. (Although some other studies have reported incidence around 2.2 -4%. In clinical practice, however, we believe this to be much higher based on the presentations we see every day).

Cervicogenic headache should be differentiated from other types of headache. There are over 100 types of headaches described in the literature (although many are very rare). These can include conditions as interestingly named as “thunderclap” headache and orgasm headache (yes these really do exist). The most common are Migraine, Tension-type headache and Cervicogenic headache.

Migraine is a very specific condition (or group of conditions) that is usually a neurological issue.  This should not be confused with a “bad headache” that people will often refer to as a migraine.  Migraine is usually diagnosed by a GP or neurologist, and can be well managed with a team approach and appropriate medication.

Tension type headache is a primary headache, usually of unknown cause that causes tightness/tension feelings around the head.  In clinical practice, we often see patients who have been diagnosed with “tension-type” headaches who have many clinical signs of neck involvement and postural involvement

cervicogenic headache chart1


In reality, there is often a great overlap between the different types of headache and their symptoms and contributing factors.  Studies have shown that over 50% of migraine sufferers had signs of neck dysfunction, and neck pain was often a contributing factor to their migraine.  Similarly, Tension-type headache sufferers often have significant postural issues and neck issues that contribute to their symptoms.  Because of this, people who suffer with migraines or tension type headaches will often benefit from physiotherapy treatment to address these contributing issues. At the very least we can reduce the severity of the headache symptoms.

I personally believe that many sufferers of “tension-type” headaches also have a strong postural component, myofascial (muscle) component or are in fact suffering from cervicogenic headaches and have been mis-diagnosed. Tension-type headache appears to be the “go-to” diagnosis when no serious pathologies are found by GPs, but further assessment often indicates these other contributing factors play a part. This can unfortunately lead to ongoing pain and disability as the underlying causes have not been properly identified, so the proper treatment has not been provided.

On a side note, those with TMJ (jaw) pain or those who grind their teeth will also often complain of neck pain and headaches. This is also very treatable with physiotherapy management.

Management of cervicogenic headache is usually quite straightforward once the underlying causes have been identified.  Your physiotherapist will perform a thorough assessment of your neck and upper back, including: movement, posture, palpation, functional testing, strength testing and specific pain provocation tests to identify where exactly your headaches are coming from and what is causing them.  If we suspect that the cause of your headaches is not appropriate for physiotherapy treatment (such as Migraine without cervicogenic component) we will refer you onto the appropriate medical professional to get this further investigated.

Treatment usually involved addressing the underlying issues (often postural) and restoring the structural and musculoskeletal function of the neck and upper back.  This will often involve specific manual therapy treatments (when the physio will use their hands, or other appropriate tools, to perform safe and appropriate treatment techniques), soft tissue techniques and exercises.  For example, If you are getting headaches due to referred pain from a stiff C2/3 facet joint (a joint in your upper neck) – treatment to restore the movement and reduce irritation of that joint will also resolve your headaches. Now if that joint was getting stiff/irritated because your posture at the computer all day is poorly managed, then providing postural exercises and retraining would also be required to stop the headaches coming back. Simple really.

Take Home Messages:

  1. Headaches can often be caused by issues with the neck, upper back and posture.
  2. Other types of headaches can often have a cervicogenic component (be related to the neck) so treatment of the neck will often help to manage the headaches.
  3. Cervicogenic headaches are easily manageable with appropriate physiotherapy treatment, which will involve treating the symptoms as well as the underlying causes.

As always if you have any queries regarding this or any other issue you  may have, please do not hesitate to contact us. We are always happy to hear form you.


Julian Bowen


Julian is the owner and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 35,000 individual treatments in that time. He has worked with everyone from paralympians,  elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues and exercise rehabilitation for the prevention and treatment of injuries.  



Bogduk N. The anatomical basis for cervicogenic headache. J Manipulative Physiol Ther. 1992;15:67-70

Blau JN, MacGregor EA. Migraine and the neck. Headache. 1994;34:88-90

Kaniecki RG. Migraine and tension-type headache: an assessment of challenges in diagnosis. Neurology. 2002;58 (9 Suppl 16):S15-S20

Marcus D, Scharff L, Mercer MA, Turk DC. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups.Headache. 1999;39:21-27

Biondi D., cervicogenic headache: a review of a diagnostic process and treatment strategies, JAOA, 2005

Becker WJ. Cervicogenic Headache: Evidence that the neck is a pain generator. Headache. 2010;4 699-705

Haldeman S. Dagenais S. Choosing a treatment for cervicogenic headache: when? what? how much?. The Spine journal 2010;10 169-171


*This post originally appeared on the South Perth Physiotherapy blog page.


Referred Pain

Pain is complicated, and complex.  Many times where you are feeling your pain, and where it is coming from are two very different things.

Is your headache a problem with your head? Or is it referred from your neck? OR your sinuses? Or your TMJ (jaw)?

That sore toe you have could be a problem with your low back….. or it could be a sore toe. That ‘shoulder’ pain you’ve had for weeks could be an issue with your neck. (Below is a diagram showing common pain referral patterns from different areas of the neck).






At EMC Physiotherapy, we are highly trained in identifying and treating the source of your problem, rather than just treating your symptoms. On top of this, we can accurately identify the underlying reasons why you have developed this pain.   Is there injury, or inflammation? Do you have underlying muscle weakness, or tightness? Is your posture and activity contributing to your problem? At EMC Physiotherapy, we can answer all these questions and more.

So if massaging your shoulder just isn’t getting rid of your shoulder pain, Feel free to call us on 9297 2555.  We can help.