Headache at the Base of the Skull: What It Means and What Helps
It often starts as a tightness just under the back of your skull. By mid-afternoon it has crept up over the back of your head, and sometimes it settles behind one eye. Rubbing the spot where your neck meets your head feels good, and turning your head feels stiff.
If that sounds familiar, you're far from alone. Pain at the base of the skull is one of the most common ways people describe their headaches. It usually points to a handful of causes, and most of them involve the muscles, joints and nerves of the upper neck.
This guide explains what's usually going on, how to tell the causes apart, when to see a doctor, and what can help.
What's actually at the base of your skull?
The area where your head sits on your neck is small but busy.
The suboccipital muscles are four small muscles on each side that run between the base of the skull and the top two vertebrae. They make fine adjustments to your head position all day, especially when you're looking at a screen.
The upper cervical joints are the joints between your skull and the first vertebra (C0–C1) and between the first three vertebrae (C1–C3). They account for a large share of your neck's rotation and nodding movement.
The occipital nerves travel from the upper neck, through these muscles, and up over the back of the head.
Here's the key point: nerves from the upper neck share a relay station in the brainstem with the nerve that supplies sensation to your forehead and around your eyes. That's why a problem in the top of your neck can be felt at the back of your head, over the top, or even behind your eye.
Common causes of headache at the base of the skull
1. Tension-type headache
Tension-type headache is the most common headache in the world. It typically feels like a dull, pressing band or tightness, often on both sides of the head, and many people feel it most at the back of the head and neck. The muscles around the head and neck are often tender to touch.
It's usually mild to moderate. You can generally keep going with your day, and it doesn't typically come with nausea.
Read our full guide: Tension Headaches: Causes, Triggers and Treatment
2. Cervicogenic headache
A cervicogenic headache comes from a problem in the neck itself, most often the upper cervical joints. Common features include:
pain that usually stays on one side and starts in the neck before spreading forward
headaches brought on or worsened by particular neck movements or sustained postures, like long stretches at a desk or driving
reduced or stiff neck movement
tenderness over the upper neck joints on the painful side
Read our full guide: Cervicogenic Headaches: When Your Neck Is the Source
3. Occipital neuralgia
Occipital neuralgia is less common. The pain has a different character: sharp, shooting, stabbing or electric, running from the base of the skull up the back of the head along the path of the occipital nerve. The scalp may feel tender or sensitive to touch, such as when brushing your hair.
Occipital neuralgia often needs medical management, so if your pain fits this description, your GP should be involved. Manual therapy may still help with the muscle and joint factors around the nerve.
4. Posture and sustained positions
Posture is rarely the whole story, but it can be a strong trigger. When you hold your head forward, whether over a laptop, a phone or a steering wheel, the suboccipital muscles and upper neck joints work harder to keep your eyes level. Over a long day that load builds, and the headache often builds with it.
There isn't one "correct" posture. The bigger problem is staying in any single position for too long.
5. Migraine
Migraine can also be felt at the back of the head, and neck pain is common before and during a migraine attack. Migraine is usually moderate to severe, throbbing, made worse by routine activity, and often comes with nausea or sensitivity to light and sound.
Not sure which headache you have? See our guide: Tension, Cervicogenic or Migraine? How to Tell What Kind of Headache You Have
When to see a doctor straight away
Most headaches at the base of the skull are not dangerous. Some signs, however, need prompt medical attention.
Call 000 or go to the emergency department if you have:
a sudden, severe headache that peaks within seconds to minutes (often described as "the worst headache of my life")
headache with fever, a stiff neck, a rash, confusion or drowsiness
headache with weakness, numbness, slurred speech, double vision, loss of balance or trouble swallowing
a new headache and neck pain after a fall, car accident or other injury to the head or neck
See your GP soon if you have:
a new headache pattern after age 50
headaches that are steadily getting worse or more frequent
headaches that wake you from sleep, or that are worse when coughing, straining or lying down
headaches with unexplained weight loss, or a history of cancer or a weakened immune system
headaches that started during pregnancy or after childbirth
At Medela Osteopathy, we screen for these warning signs at every headache assessment. If anything suggests your headache needs medical investigation, we'll refer you to your GP.
How an osteopath assesses a headache at the base of the skull
Headaches from the neck and headaches from other sources can feel similar, so treatment starts with working out where yours is coming from. A headache assessment with us usually includes:
A detailed history covering where the pain is, what it feels like, when it started, what triggers it, what eases it, and your work, sleep and stress.
Red-flag screening for anything that needs medical attention first.
A neck movement examination of how your neck moves in each direction, and whether any movement reproduces your headache.
Hands-on examination of the upper neck joints and muscles, feeling for stiffness, tenderness, and whether pressure on a particular spot brings on your familiar headache. That last finding is one of the most useful clues that the neck is involved.
Deep neck muscle testing, which checks how well the small stabilising muscles at the front of your neck are working. These muscles are often underperforming in people with neck-related headaches.
By the end of the appointment we'll explain what we think is driving your headaches and what we recommend.
What helps?
Hands-on treatment
For headaches driven by the upper neck, treatment focuses on the joints and muscles involved. It can include joint mobilisation, soft tissue techniques to the suboccipital and upper neck muscles, and, where appropriate and with your consent, manipulation.
Targeted exercise
Exercise is a central part of treatment, not an add-on. A well-known randomised controlled trial found that manipulative therapy and specific neck exercises each reduced headache frequency and intensity in people with cervicogenic headache, and the benefits were still present at 12 months. Programs usually include:
deep neck flexor training (gentle, controlled nodding exercises)
shoulder blade and upper back strengthening
movement drills to restore rotation in the upper neck
We'll send your program by email so you have clear instructions at home.
Changes to your day
Break up long positions. A short movement break every 30–45 minutes at a desk often matters more than your exact setup.
Raise your screen. Put the top of your monitor at about eye level, and bring your laptop up with a stand and a separate keyboard.
Check your pillow. Your pillow should keep your neck roughly level with your body, not propped up or dropped down.
Look after the basics. Sleep, hydration, regular meals and stress management all affect headache frequency.
Medication
Over-the-counter pain relief can be useful for occasional headaches. Taking it on many days each month can lead to medication overuse headache, which makes headaches more frequent. If you're reaching for tablets often, talk to your GP or pharmacist.
Frequently asked questions
Why does the base of my skull hurt when I turn my head? Pain that is brought on or worsened by turning your head is a common feature of headaches that come from the upper neck joints and muscles. An assessment can confirm whether your neck is the source.
Can a stiff neck cause a headache behind the eye? Yes. Nerves from the upper neck share a pathway in the brainstem with the nerve that supplies the forehead and eye region, so neck problems can be felt behind the eye.
Is a headache at the back of the head serious? Most aren't. See a doctor urgently if your headache is sudden and severe, follows an injury, or comes with fever, a stiff neck, or neurological symptoms such as weakness, numbness or trouble speaking.
Do I need a referral to see an osteopath? No. Osteopaths in Australia are AHPRA-registered primary contact practitioners, so you can book directly.
How many treatments will I need? It depends on the cause, how long you've had the headaches, and how you respond. We'll give you a clear plan at your first appointment and review your progress as we go.
Book a headache assessment in Tweed Heads
If this sounds like your headaches, book an assessment at Medela Osteopathy. We'll work out what's driving your pain and build a plan around it, with hands-on treatment, exercises and practical changes that fit your day.
Book an appointment · See our osteopathy services
Medela Osteopathy & Co · Suite 9, 69 Wharf Street, Tweed Heads NSW 2485
This article provides general information only and is not a substitute for individual medical advice. If you have concerns about your headaches, please see your GP or a registered health practitioner.
References
Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1–211.
Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27(17):1835–1843.
Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurology. 2009;8(10):959–968.
Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134–144.
