Cervicogenic vs Migraine vs Tension Headache — The Post-Concussion Differential
“Post-concussion headache” is a timing category, not a diagnosis. The phenotype underneath it — not the concussion label — is what decides the treatment.
Quick answer
Headache is the most common persistent symptom after concussion — but “post-traumatic headache” is a timing category, not a headache type. The ICHD-3 definition is simply a headache that starts within 7 days of the injury. It tells you when the headache began, not what is driving it.
The clinically useful move is to phenotype it. The same post-concussion headache is usually one of three patterns — cervicogenic, migraine-phenotype, or tension-type — or a mixture. Each responds to a different treatment. The concussion label doesn’t point you anywhere; the phenotype does.
Get the phenotype wrong and the headache doesn’t resolve: blanket analgesia risks medication-overuse headache, a cervicogenic driver keeps firing until the neck is treated, and a migraine phenotype needs migraine-directed management. This article gives you the differential framework and the side-by-side signs; the full workup and management protocol is covered in the course.
Why the concussion label isn't a diagnosis
Under ICHD-3, an acute post-traumatic headache is defined purely by timing — onset within 7 days of the head injury, of regaining consciousness, or of regaining the ability to sense and report pain. It becomes persistent post-traumatic headache when it continues beyond 3 months. Nothing in that definition specifies a mechanism or a phenotype.
That matters because the treatment lives in the phenotype, not the timing. Two patients with identical “post-concussion headache” on the referral letter can need completely different plans: one a course of cervical manual therapy and deep neck flexor work, the other a migraine-directed strategy. Assigning the single label “post-concussion headache” and prescribing rest plus analgesia is where a treatable headache quietly becomes a chronic one.
The differential at a glance
The three phenotypes separate cleanly on a handful of features. Use this as a first-pass screen, then confirm with targeted examination.
| Feature | Cervicogenic | Migraine-phenotype | Tension-type |
|---|---|---|---|
| Laterality | Unilateral, side-locked | Unilateral or bilateral | Bilateral |
| Quality & severity | Dull, aching, non-throbbing; moderate | Throbbing/pulsating; moderate–severe | Pressing/tightening “band”; mild–moderate |
| Origin / pattern | Starts occiput/neck, refers frontotemporal | Discrete attacks, 4–72 h | Diffuse, often daily background |
| Provoked by | Neck movement, sustained posture, upper-cervical palpation | Routine physical activity, sensory load, triggers | Stress, fatigue, poor sleep — not routine activity |
| Associated features | Neck pain/stiffness; usually no nausea or aura | Photophobia + phonophobia, nausea, ± aura | No nausea; not both photo- and phonophobia |
| Cervical signs | Reduced ROM, positive flexion-rotation test, tender C0–C3 | Usually normal (may coexist) | Often tender pericranial muscles |
| Management direction | Cervical: manual therapy + deep neck flexor training | Migraine-directed; trigger & load management | Load, sleep, stress, posture; manual therapy adjunct |
Screening aid, not a substitute for examination. Mixed presentations are common — assess for each phenotype rather than forcing one label.
Cervicogenic headache — the one most often missed
Any concussion mechanism is also a cervical-acceleration mechanism, so the neck is injured in the same event as the brain. That makes cervicogenic headache common after concussion — and the phenotype most often missed, because acute attention goes to the head injury.
The signal to look for: a unilateral, side-locked headache that starts in the neck or occiput and refers forward, is reproduced by neck movement or palpation of the upper cervical joints, and sits with restricted cervical range of motion (a positive cervical flexion-rotation test points to C1–C2). Migraine-typical features are usually absent. Because it is driven by a treatable structural source, it responds to cervical management once identified — but only if it’s identified. We cover the cervical workup in depth in the cervicogenic drivers in chronic concussion article.
Migraine-phenotype and tension-type after concussion
Migraine-phenotype (post-traumatic migraine) is the most disabling of the three and is frequently under-recognised after concussion. Look for a throbbing, moderate-to-severe headache that is aggravated by routine activity and carries photophobia, phonophobia, and nausea, sometimes with aura. It matters clinically because it overlaps with the exercise-intolerance picture of concussion — light and sound sensitivity and activity aggravation can blur with the wider symptom set — and because it needs migraine-directed management rather than generic analgesia.
Tension-type is a bilateral, pressing/tightening “band” of mild-to-moderate intensity that is not aggravated by routine activity and lacks nausea. It is the most benign phenotype and responds to load management, sleep and stress work, posture, and manual therapy as an adjunct — but it is also the easiest to over-attribute to, so confirm you haven’t mislabelled a cervicogenic or migraine phenotype as “just tension.”
Red flags and medication-overuse headache
Phenotyping assumes you have already cleared the dangerous causes. Escalate urgently for any of:
- Thunderclap or first-and-worst headache — suspect haemorrhage
- Progressively worsening headache over days to weeks
- New focal neurological signs, seizure, or reduced consciousness
- Fever with neck stiffness or systemic features
- Any positive item on standard post-trauma / cervical red-flag screening
Then check the medication history. Medication-overuse headache — from analgesic or triptan use on more than roughly 10–15 days per month — is a common reason a post-concussion headache stops resolving and mimics a treatment-resistant phenotype. It won’t improve until the overused medication is addressed, no matter how good the rest of the plan is.
Why the phenotype changes the plan
The whole point of the differential is that the three phenotypes diverge on treatment. A cervicogenic headache managed as “rest and paracetamol” keeps firing until the neck is loaded and retrained. A migraine phenotype treated as a neck problem gets manual therapy it doesn’t need and misses migraine-directed care. And a headache managed with escalating analgesia risks becoming a medication-overuse headache on top of the original driver.
This is also why the concussion often looks like it isn’t resolving: the recovery is on track, but an untreated headache phenotype — usually cervicogenic, often mixed — keeps the patient symptomatic. Phenotype first, treat the phenotype, and reassess for a coexisting driver. The structured headache workup and the phenotype-specific management pathways are exactly what the persistent post-concussion symptoms workup builds out.
Go from “post-concussion headache” to a phenotype-specific plan
Concussion Clinical Mastery takes you through the full headache workup — phenotyping, the cervical and vestibulo-ocular examinations, and the management pathway for each driver — alongside the complete assessment-to-rehab framework. Endorsed by Osteopathy Australia.