Cervicogenic headache (CGH) is a secondary headache that originates from dysfunction in the upper cervical spine, particularly the atlanto-occipital and C1-C3 segments, and is perceived in one or more regions of the head and/or face. The underlying mechanism involves convergence of cervical and trigeminal afferents in the trigeminocervical nucleus. Structures innervated by the C1, C2, and C3 spinal nerves are capable of producing referred pain to the head. CGH is relatively common, accounting for approximately 15-20% of all chronic headaches. It typically worsens with neck movement and is often associated with limited cervical range of motion. One of the key impairments in individuals with CGH is disrupted cervical sensorimotor control, particularly affecting proprioception and deep cervical muscle coordination. Physical therapy is widely recognized as the first-line treatment for CGH, with emerging evidence supporting interventions aimed at improving cervical proprioception and neuromuscular control. This study aims to compare the effectiveness of two sensorimotor-based physical therapy approaches-eye-cervical re-education and pressure biofeedback training of deep cervical flexors (DCF)-in patients with CGH. The primary outcomes include pain intensity, functional disability, cervical range of motion (ROM), and cervical joint position sense (proprioception). Participants will be recruited using purposive sampling from Fauji Foundation Hospital and Foundation University College of Physical Therapy (FUCP), Islamabad. After providing written informed consent, eligible participants will be randomized into two groups. Group 1 will receive conventional physical therapy along with eye-cervical re-education exercises, while Group 2 will receive conventional therapy combined with pressure biofeedback DCF training. Data will be collected at baseline and after the 10th treatment session to assess within- and between-group changes in the outcome measures. This study aims to inform evidence-based physical therapy practice in the management of cervicogenic headache.

Conventional Physical Therapy Protocol:

Hot pack is placed on posterior cervical area for 10 minutes while the patient was relaxed prone lying position.

Isometric exercises are applied with sustain 5 sec in all cervical motion (flexion, extension, side bending and rotation) with ten repetitions for each direction while the patient sits in erect position and the therapist stood back of the patient.

SNAGS are applied for 5 to 6 times. The therapist applies the appropriate accessory zygapophyseal glide while the patient performs the symptomatic movement. This must result in full range pain free movement.

Eye cervical re-education exercises:

This program composed of ten exercises for re-training of proprioceptive input in the cervical spine through the three following phases: a) Ocular mobility without cervical movement phase b) Cervical mobility exercises phase c) Eye-cervical co-ordination exercise phase

Pressure Biofeedback training of deep cervical flexors:

It is performed in supine crook lying position. The neck is aligned in a neutral position. The pressure biofeedback unit is centered just below the occiput between the plinth and the back of the neck and inflated to a baseline of 20 mmHg. Each subject is asked to gently and slowly execute the head nodding action (as if they said yes) at five different levels of pressure (22, 24, 26, 28 and 30 mmHg) and to maintain each level for 10 seconds There was a 30-second rest period between each level. The test protocol ended when the subject is unable to hold the same pressure level for 10 sec or reached a peak level of 30 mmHg.

Inclusion Criteria:

• Age 18 to 45 years
• Both genders
• Unilateral neck pain and referred headache
• Headache is precipitated by neck movements or sustained positions.
• Positive cervical flexion rotation test
• Headache reproduced with provocation of the involved upper cervical segments.
• Restricted upper cervical segmental mobility.

Exclusion Criteria:

• • Cervical radiculopathy

  • Known or suspected vestibular disorders such as BBPV (Benign Paroxysmal Positional Vertigo), vestibular neuritis, meniere's disease, labyrinthitis
  • Visual problems such as occipital neuralgia
  • History of traumatic neck injury/surgery or cervical instability
  • Rheumatoid arthritis
  • Osteoporosis
  • Metabolic disorders
  • Spinal infection or tumors
  • Vertebrobasilar insufficiency
  • Other headache types such as tension headache, migraine etc