Many of the headache patients I see in my office are not people who started having headaches last week.
They have often been dealing with them for months or even years.
Some have tried medication. Some have tried massage, physical therapy, injections, or previous chiropractic care. Others have seen their primary care doctor, neurologist, ENT, or another specialist. Sometimes those treatments help temporarily, but the headaches eventually return.
After enough time, patients start asking a different question:
Why do these headaches keep coming back?
That is usually where my job becomes less about simply treating the headache and more about trying to understand whether something else is contributing to it.
Sometimes that means looking closely at the very top of the neck.
There are two small bones here called the atlas and axis, and a pair of ligaments called the alar ligaments. Most people have never heard of them, but they play an important role in controlling movement and stability between the head and upper neck. The alar ligaments attach near the upper sides of the dens of C2 and travel toward the base of the skull. Their job is to help control excessive rotation and movement of the upper cervical spine.
Could an alar ligament problem explain every headache? Absolutely not.
But in certain patients—especially those with chronic headaches combined with neck pain, dizziness, vertigo, or a history of previous neck trauma—upper cervical mechanics may be one piece of the puzzle that has never been evaluated closely.
Patients often come into our office saying, “I have migraines,” or, “I keep getting headaches.”
That is an important starting point, but it is not a complete diagnosis.
A responsible chiropractor should want to understand where the headache starts, whether it is on one side or both, how often it occurs, how severe it becomes, what makes it worse, and whether other symptoms happen with it.
Does the pain begin at the base of the skull and move upward? Does it travel toward the temple, forehead, or behind one eye? Does turning the neck make it worse? Do light, sound, movement, or smells make the headache more intense? Are there also symptoms such as neck stiffness, dizziness, nausea, visual changes, jaw pain, or balance problems?
It is also important to know when the headaches started and what treatments have already been tried.
A headache that starts in the neck and is made worse by neck movement may have a cervicogenic, or neck-related, component. Pain from the upper cervical spine can sometimes be felt at the back of the head, around the temple, or even behind the eye.
At the same time, neck pain and migraines can overlap. Migraine is a neurological condition and should not be reduced to a simple “bone out of place” explanation.
The goal is not to force every headache into a chiropractic diagnosis.
The goal is to determine whether part of the problem may be mechanical and whether the neck is contributing to the patient's overall headache pattern.
At the very top of your neck are two unusual bones.
The first cervical vertebra is the atlas, or C1. It supports the skull. The second vertebra is the axis, or C2.
A bony structure called the dens rises upward from C2 and acts like a pivot around which the upper neck turns.
The alar ligaments are two short, strong bands of connective tissue that help control movement in this area. They attach near the sides of the dens and travel toward the base of the skull.
Think of them almost like small guide ropes or seat belts for the upper neck.
They allow normal movement, but they help prevent too much movement.
Because the alar ligaments help control the relationship between the skull, atlas, and axis, a problem in this area may change how those structures move together. That can potentially contribute to joint irritation, muscle guarding, stiffness, and abnormal pain signals traveling from the neck toward the head.
This does not mean the alar ligament is the cause of every headache.
It simply means that in the right patient, upper cervical stability may deserve a closer look.
The upper neck and the head share part of the same pain communication system.
Nerves coming from the upper cervical spine communicate with pathways from the trigeminal nerve, which carries sensation from much of the head and face.
I often explain this like two roads joining the same highway.
When tissues in the upper neck become irritated, the brain may sometimes experience that signal as pain at the back of the head, temple, forehead, or around the eye.
This helps explain why a patient may feel pain in the head even when part of the irritation is actually coming from the neck.
It also explains why the location of the headache matters.
A headache that begins at the base of the skull, worsens with neck movement, or is associated with significant neck stiffness deserves a different evaluation than a headache associated with fever, illness, major neurological changes, or other warning signs.
One of the most common patterns I see is a patient who has been dealing with headaches for a long time.
Maybe medication helps temporarily.
Maybe massage helps for a few days.
Maybe previous adjustments reduce the headache, but it eventually returns.
Maybe the patient has seen multiple healthcare providers and has been told that the headaches are something they are simply going to have to manage.
Eventually, they consider chiropractic care because they are looking for another explanation.
That is where I think chiropractic can be very different from simply providing another treatment.
Before we decide how to treat someone, we should ask:
Is there actually a mechanical problem in the neck that could be contributing to these headaches?
That question may involve the physical examination, range of motion, neurological testing, muscle tenderness, previous injuries, posture, and in certain patients, imaging.
Sometimes a basic X-ray can provide mechanical information that cannot be determined by simply touching the neck.
One of the X-rays we may use to evaluate the upper cervical spine is called an AP open-mouth view.
The patient opens their mouth while the X-ray is taken from the front.
This allows us to see the dens of C2 in the middle and the lateral masses of the atlas on either side.
When you look at the image, the spaces between the dens and the right and left lateral masses can almost look like the two sides of a bow tie.
These spaces can be measured.
This is an important distinction:
The X-ray does not show the alar ligament itself.
What it shows us is the relationship between the bones.
If the space between the dens and the lateral mass of C1 is noticeably different on one side compared with the other, that finding may raise questions about positioning, rotation, normal anatomical variation, previous trauma, or possible instability.
It is one piece of information—not a stand-alone diagnosis.
Some people naturally have a small amount of asymmetry. Patient positioning can also change the appearance of these spaces.
That is why the X-ray must be taken correctly.
If we are going to measure something that may only be a few millimeters wide, the patient's head position matters.
A small amount of head tilt or rotation can change how the spaces around the dens appear.
If the patient moves, leans, or looks slightly to one side, the image may create an asymmetry that is related to positioning rather than the patient's actual mechanics.
In our office, the patient's head is stabilized and positioned looking straight ahead. The goal is to limit unnecessary motion, reduce head tilt, and create an image that can be measured as accurately as possible.
If the positioning is not correct, the measurements become less useful.
This is a simple concept:
Bad positioning can create bad data.
And if I am going to use a measurement to help determine how someone should be treated, I want that measurement to be as reliable as possible.
This is one of my favorite examples of why chiropractic care should be more than simply feeling the spine and adjusting whatever seems tight.
There are many valuable things we can learn through a hands-on examination.
We can identify tenderness, muscle guarding, restricted movement, painful movement, and areas that may not be functioning normally.
But touch cannot measure a deep dens-to-lateral-mass space in millimeters.
It cannot directly show an alar ligament.
And it cannot reliably tell a chiropractor whether an apparent asymmetry represents a positioning issue, a normal difference, or a finding that deserves further investigation.
The physical examination and imaging should support each other.
Neither should be used alone.
This is an important difference between simply “getting adjusted” and receiving a more complete chiropractic spine evaluation.
One patient in our office had recurring headaches along with dizziness and vertigo.
Those symptoms can come from many different sources, so the answer was not to assume that everything was automatically coming from the neck.
We first needed to understand the headache pattern, evaluate the upper cervical spine, perform the appropriate examination, and determine whether imaging or referral was necessary.
A carefully positioned AP open-mouth X-ray showed a meaningful difference between the spaces on the two sides of the dens.
Again, the ligament itself was not visible.
The X-ray did not prove that the patient had an alar ligament tear.
What it did provide was additional information about the relationship between the atlas and axis.
That data changed how we approached the patient's care and how the upper neck was treated.
The patient did not simply receive a generic adjustment based on where the neck felt tight.
Over time, the patient reported improvement in the headaches, dizziness, and vertigo.
That improvement does not prove that the alar ligament was the only cause of those symptoms.
What it demonstrates is why a diagnosis-first approach matters.
When the data changes, the treatment plan may need to change too.
Not every patient with a headache needs an X-ray.
Imaging should be based on the history, examination, trauma, age, symptoms, and whether the result is likely to change care.
When imaging is appropriate, the findings may change the direction or force used during an adjustment. They may lead us to use a gentler technique, avoid unnecessary rotation, focus more on stabilization exercises, monitor the patient differently, or investigate another area of the cervical spine.
Sometimes imaging raises enough concern that the next step should not be an adjustment at all.
The correct next step may be MRI, CT imaging, neurological evaluation, ENT consultation, vestibular therapy, pain management, or another spine specialist.
Good chiropractic care is not defined by whether an adjustment is performed.
It is defined by whether the patient receives the right care for the problem in front of us.
Sometimes that includes an adjustment.
Sometimes it includes rehabilitation or other conservative treatments.
And sometimes the correct treatment is a referral.
Many patients who eventually come to our office for chronic headaches are not coming in immediately after an accident. Sometimes the original injury happened years earlier. The neck pain may have improved, while headaches, stiffness, dizziness, or other symptoms gradually became something the patient simply learned to live with.
Whiplash is not simply a sore muscle. During a collision, rapid movement of the head and neck can load muscles, joints, discs, nerves, and ligaments. In some patients, the position of the head at the moment of impact may also matter.
Imagine being stopped at a light while looking into a side mirror, turning toward a child in the back seat, or looking toward a passenger. A rear impact while the head is already rotated may load the right and left sides of the upper cervical spine differently.
This has specifically been studied in relation to the alar and transverse ligaments. One study of 92 patients with long-lasting whiplash symptoms found that those who reported having their head rotated at the time of the collision were more likely to demonstrate higher-grade MRI signal changes in these upper cervical ligaments. The imaging was performed years after the accidents, so the study showed an association rather than proving that a specific collision directly caused each ligament finding.
Other research has been more cautious. Laboratory testing of rear impacts with the head rotated did not demonstrate a significant increase in alar ligament injury risk under the conditions tested, and other MRI studies have questioned whether changes in ligament signal can reliably identify a previous traumatic injury or predict a patient's long-term symptoms.
That is an important distinction.
Head position and collision mechanics may provide useful clues, but they do not prove that an alar ligament was injured.
This is where the history, examination, and imaging have to be looked at together. If a patient reports that headaches, dizziness, or upper-neck symptoms began after a rear-end collision—especially when the head was turned at impact—that history deserves attention.
It is also possible for the alar ligament to be overlooked initially because a larger whiplash injury may involve several structures at the same time. Disc injuries, joint pain, muscle spasm, radicular symptoms, concussion symptoms, or other ligament injuries may receive most of the early attention. The upper cervical mechanics may not become the main concern until much later.
That is why an old accident can still be relevant years afterward.
The question is not simply, “Were you in a car accident?”
The better questions are: How did the collision happen? Where was your head positioned? When did the headaches start? What other symptoms followed? And what never completely went away?
For a whiplash chiropractor, understanding those details can help determine whether the previous trauma may still be contributing to the patient's current mechanical problem.
Migraine is a neurological disorder.
A neck problem does not explain every migraine, and chiropractic care should not be presented as a cure for migraine.
However, migraine and neck-related headache problems can overlap.
Some patients have migraine and also have a significant mechanical problem in the cervical spine.
That is why when someone comes into our office with neck pain and migraines, I want to determine whether there is a mechanical component in the neck that may be adding to the overall headache pattern.
If there is, we address it.
If there is not, we should not pretend there is.
And if the symptoms suggest that the patient needs a neurologist, primary care provider, ENT, vestibular therapist, pain specialist, or another healthcare provider, we make that referral.
Chiropractic cannot help every headache.
But an underlying mechanical problem in the cervical spine can contribute to headaches in certain patients.
The goal is determining whether that is happening in the person sitting in front of us.
Some headaches should not be treated first in a chiropractic office.
A sudden “worst headache of your life,” new weakness, facial drooping, slurred speech, confusion, fainting, seizure, major vision changes, fever with severe headache or neck stiffness, or a rapidly worsening and unusual headache may require immediate medical evaluation.
A severe headache following significant trauma may also require additional imaging or medical assessment.
A chiropractor should screen for these warning signs.
Sometimes the most important thing I can do for a patient is not adjust them.
If another provider needs to evaluate the patient first, that is the appropriate care.
Referral is not a failure of chiropractic.
It is part of responsible healthcare.
Patients sometimes think chiropractic care begins when they lie down on a table and receive an adjustment.
It should begin much earlier than that.
For someone dealing with chronic headaches, the first step should be understanding where the headaches start, what they feel like, how often they occur, what makes them worse, what other symptoms occur with them, what treatments have already been tried, and whether there is a history of an old accident or injury.
The examination should then help determine whether there is evidence of a mechanical problem in the neck.
If imaging is clinically appropriate, that information can add another layer to the evaluation.
The alar ligament is only one possible part of a much larger puzzle.
It may be relevant in selected patients, particularly when chronic headaches occur with upper neck pain, dizziness, vertigo, previous trauma, or abnormal upper cervical mechanics.
But the real lesson is not that every headache comes from this ligament.
The real lesson is:
You should not guess at the cause of a headache, and you should not guess at the treatment.
Many patients who come into our office already know how to treat their next headache.
They know which medication helps.
They know whether ice, heat, massage, or lying in a dark room gives them temporary relief.
But after months or years of the same problem returning, there may be a more important question to ask:
Why do my headaches keep coming back?
Maybe the answer is migraine.
Maybe it is stress, sleep, medication, or another medical problem.
Maybe part of the problem is coming from the neck.
And sometimes there may be an underlying mechanical issue in the upper cervical spine that has simply never been evaluated closely.
That is where chiropractic care can offer something different from simply another treatment for the next headache.
The adjustment is a treatment.
Understanding the problem should come first.
At Elite Family Chiropractic, our goal is to determine whether there is a mechanical reason contributing to the patient's symptoms and then build the treatment plan around what we actually find.
Sometimes we find that the neck is contributing far more to the headaches than anyone previously realized.
Sometimes we find that it isn't.
Both answers are valuable.
Chiropractic care cannot treat every headache, but when an underlying mechanical problem in the neck is contributing to someone's symptoms, finding that problem can completely change the care they receive.
And for someone who has spent years wondering how to make the next headache go away, that may finally help answer the more important question:
Yes. Certain headaches can originate from structures in the cervical spine and refer pain into the head. This is often called a cervicogenic headache.
No. A regular X-ray does not directly show the alar ligament.
An AP open-mouth X-ray can show the dens of C2, the lateral masses of C1, and the relationship between those structures. Those measurements may provide useful mechanical information when interpreted together with the patient's history and examination.
No.
Uneven spacing may be related to normal anatomical differences, head positioning, rotation, previous trauma, or other mechanical factors. It should not be interpreted by itself as proof of an alar ligament tear.
Possibly. Previous trauma can be relevant when neck pain, headaches, dizziness, or other symptoms began following an injury or never completely resolved.
The presence of an old accident does not prove that a particular ligament was damaged, but it may be an important part of understanding the patient's current mechanical problem.
Migraine is a neurological condition, and chiropractic care should not be presented as a cure for migraine.
However, some migraine patients also have mechanical neck pain or a cervicogenic headache component. Identifying and treating a contributing neck problem may be useful as part of a broader treatment plan.
No.
Imaging should be based on the patient's history, examination, trauma history, symptoms, and whether the findings are likely to change the treatment plan.
