What causes headaches at the back of the head?

Causes of Headaches at the Back of the Head

Headaches at the back of the head (occipital/suboccipital region) are most commonly caused by cervical strain, tension-type headache, or may represent migraine with atypical location, though certain red flag features require urgent evaluation for secondary causes. 1

Primary Causes

Cervical Strain

• Cervical strain is a key cause of occipital/suboccipital headaches, particularly following head or neck injury 1
• This presents with neck pain, neck stiffness, and persistent headache in the occipital region that worsens with head movement or palpation 1
• Clinical examination reveals tenderness in the cervical spine (midline and paraspinal muscles), pain with cervical motion, and limitation of neck range of motion 1
• Upper extremity weakness or radicular symptoms may be present 1

Tension-Type Headache

• Tension-type headache typically causes bilateral, mild to moderate pain with a pressing or tightening quality 1
• This headache type lacks the accompanying symptoms of migraine (nausea, photophobia, phonophobia) 1
• Pain is not aggravated by routine physical activity 1

Migraine

• While migraine classically presents with unilateral pain, it can occur in any head location including occipital regions 1
• Migraine is characterized by moderate to severe throbbing pain with associated nausea, vomiting, photophobia, and phonophobia 2, 3
• Pain is typically aggravated by physical activity 2, 3

Secondary Causes Requiring Urgent Evaluation

Red Flag Features

You must immediately consider neuroimaging and further investigation if any of these features are present: 1

• Thunderclap headache (abrupt onset of severe headache) 1
• Headache awakening patient from sleep 1, 4
• New headache in patients over age 50 4, 5
• Headache worsened by Valsalva maneuver 1, 5
• Progressive worsening or rapidly increasing frequency 1
• Focal neurological signs or symptoms 1
• Recent head trauma 1
• Fever, impaired memory, or systemic symptoms 1, 5
• Headache brought on by exertion or cough 5

Specific Secondary Causes

• Obstructive sleep apnea causes morning headaches that resolve within hours of waking 4
• Increased intracranial pressure presents with headaches that improve with upright positioning 4
• Temporal arteritis must be excluded in patients over 50 with new headache by checking ESR and CRP 4
• Life-threatening causes include meningitis, subarachnoid hemorrhage, and brain tumors 1

Medication-Related Causes

Medication Overuse Headache

• Frequent use of analgesics (>2 days per week) can cause medication overuse headache, which presents as chronic daily headache 1, 4, 6
• This occurs with overuse of opiates, triptans, ergotamine, NSAIDs, and analgesics containing caffeine, isometheptene, or butalbital 6, 7
• Always verify over-the-counter medication use, as patients may not report this 4

Diagnostic Approach

When to Order Neuroimaging

• MRI is preferred over CT for investigating suspected secondary headache disorders, as it offers higher resolution without ionizing radiation 1
• Neuroimaging is indicated only when red flags suggest secondary causes 1, 4
• Obtain MRI in patients over 50 with new-onset headache patterns 4
• Obtain MRI for morning headaches that improve with upright positioning 4
• Routine neuroimaging is not indicated for typical primary headache disorders and can be harmful due to radiation exposure and false-positive findings 1

Clinical Evaluation

• Assess for cervical spine tenderness, limitation of motion, and pain with palpation or movement 1
• Evaluate for signs of sleep apnea (snoring, obesity, daytime fatigue) if morning headaches are present 4
• Document headache frequency, duration, severity, and associated symptoms using validated tools like headache diaries 1, 6
• Perform neurological examination to identify focal deficits 1

Common Pitfalls

• Do not assume all occipital headaches are tension-type; cervical strain is frequently overlooked 1
• Do not miss medication overuse headache by failing to ask about over-the-counter analgesic use 4, 6
• Do not delay neuroimaging in patients over 50 with new headaches, as this population has higher risk of serious pathology 4, 5
• Do not order routine neuroimaging for typical primary headaches without red flags, as this exposes patients to unnecessary radiation and anxiety from incidental findings 1