C2-3 The Most Common Source Of Headache

Headache Was Alleviated In 75 Percent of Patients

Analysing diagnostic blocks in 166 patients fulfilling diagnostic criteria for Cervicogenic Headache

I have been consulting exclusively those with chronic headache/migraine for the past 30 years i.e. 33000 hours of clinical experience with over 8300 patients. The Watson Headache® Approach, which I have been teaching internationally since 1997, embodies this experience.

Clinically, I can reproduce (and resolution as the technique is sustained) typical head pain in around 90 percent of patients. Some key observations from this experience and which I have been teaching are:

  • the most common segment is C2-3
  • in 80 percent of patients, referral from both C2-3 and 0-C1 (my PhD demonstrated 100 percent)1
  • headache from C1-2 is rare – around five percent (more likely if there is history of trauma)
  • C3-4 very rare

Basis For Observations

These observations are based on reproduction and resolution of typical head pain (an original and basic tenet of the Watson Headache® Approach), not a ‘comparable sign’ which invites an assumption, i.e. less powerful.

Furthermore, colleagues who have attended Level 1 and returning for a Level 2 course frequently comment that addressing C2-3 often alleviates neck pain in their patients.

Consequently, it was gratifying to come across this article Govind J, Bogduk N. Sources of Cervicogenic Headache Among the Upper Cervical Synovial Joints. Pain Medicine, 00(0), 2021, 1–7, analysing diagnostic blocks in 166 patients fulfilling diagnostic criteria for Cervicogenic Headache in which headache was alleviated in 75 percent of patients. The C2-3 joint was the source of pain in 62 percent, C1-2, 7 percent and C3-4, 6 percent. In patients in whom headache was less severe than neck pain, blocks were successful in 67 percent; C2-3 was the source of pain in 42 percent.

The Study

This study appears to support my 33000 hours of clinical experience but has limitations. The study did not address 0-C1 and it is recognized that blocks of 0-C1 ameliorate headache.2,3 Furthermore, blocking information from the C2-3 disc (a potential source of headache)4 is problematic5 – if this were possible and incorporating 0-C1 blocks, it is not unreasonable that the positive outcomes would be higher (than 75 percent). Anaesthetic blocks have their limitations.

Professor Bogduk is to be congratulated for bringing the late Dr Govind’s excellent clinical work to light.


  • Watson DH, Drummond PD. Head pain referral during examination of the neck in migraine and tension-type headache. Headache. Sep 2012;52(8):1226-1235.
  • Dreyfuss P, Rogers J, Dreyer S, Fletcher D. Atlanto-occipital joint pain. A report of three cases and description of an intraarticular joint block technique. Reg Anesth. Sep-Oct 1994;19(5):344-351.
  • Dreyfuss P, Michaelsen M, Fletcher D. Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine (Phila Pa 1976). May 15 1994;19(10):1125-1131.
  • Bogduk N. Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep. Aug 2001;5(4):382-386.
  • Bogduk N, Derby R, Aprill C, Lord S, Schwarzer A. Precision Diagnosis of Spinal Pain.

Until next time

If you are new to Watson Headache®, welcome to the Watson Headache® Approach, an evidence-informed practice when considering the role of the neck in Cervicogenic and Primary Headache.

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