Pain at the Base of the Skull: Could Your Neck Be Involved?

Read about the wider assessment and treatment approach for persistent post-concussion symptoms.

Pain or tightness where the neck meets the skull can be surprisingly persistent.

Some people describe it as a deep ache. Others feel pressure, a knot that never quite releases, or tension that seems to travel from the upper neck over the back of the head.

It can develop after a concussion, whiplash injury or other trauma involving rapid movement of the head and neck.

And there is an important anatomical reason the area deserves attention.

The deep muscles at the base of the skull are not simply attached to bone. Some have connective-tissue relationships with the dura — the membrane surrounding the brain and spinal cord — through structures known collectively as the myodural bridge complex.

This creates a direct anatomical relationship between the upper neck, cranial base and dural system.

At Cranial Solutions, this is one reason we assess the cervical spine and cranial system together rather than treating them as unrelated areas.

The Occiput: An Important Part of the Picture

Base-of-skull pain is often discussed as though it must originate from the neck or suboccipital muscles.

At Cranial Solutions, we also pay close attention to the occipital bone itself and its movement within the cranial system.

The occiput forms the back and much of the base of the skull. It articulates with the temporal bones on either side and with the sphenoid anteriorly through the cranial base. Inferiorly, it articulates with the atlas — the first cervical vertebra.

This places the occiput at an important mechanical junction between the cranium and cervical spine.

Following concussion, whiplash or other trauma, we frequently identify restriction in the movement of the occipital region alongside the patient's base-of-skull pain or headache.

Clinically, this can be important because the occiput does not exist as an isolated bone. Its mechanical relationships extend into the upper cervical spine, cranial base, dura, temporal bones and surrounding connective tissues.

For some patients, the important finding is not simply a “tight neck.” It is a broader restriction involving the occipital and posterior cranial region.

Why Can Occipital Restriction Feel Like Scalp Tension?

The tissues over the back and sides of the skull form a continuous mechanical envelope rather than ending at the base of the skull.

The occipital region has extensive muscular and fascial attachments, while the posterior temporal region includes structures such as the mastoid processes of the temporal bones, immediately adjacent to the occiput.

When we find reduced movement through this region, patients will sometimes describe much more than local neck pain.

They may report:

• a pulling or tight sensation across the back of the scalp
• pressure over the occipital region
• tenderness behind the ears
• tension around the mastoid region
• pain spreading from the base of the skull toward the temples
• a feeling that the back of the head is compressed or “stuck”
• headache associated with neck or head movement

At Cranial Solutions, these symptoms make us particularly interested in the relationship between the occiput, temporal bones, upper cervical spine and surrounding soft tissues.

The clinical question becomes:

Is there a restriction through the posterior cranial system that corresponds with the patient's pattern of pain and tension?

The Occiput, Temporal Bones and Dura

The occiput is also important because of its relationship with the dura.

The dura has substantial attachments around the cranial base, including the posterior cranial region. This means that the occiput, temporal bones, cranial base and dural membranes form part of the same interconnected anatomical environment.

The temporal bones are particularly relevant because their mastoid regions sit immediately beside the occiput and provide attachment for several muscles and fascial structures associated with the head and neck.

This does not mean that every headache at the back of the skull is caused by an occipital fixation.

But when a patient has a combination of base-of-skull pain, posterior scalp tension, mastoid-region tension and restricted cranial or cervical mechanics, the occipital region becomes an important part of our assessment.

Where Does the Myodural Bridge Fit?

The myodural bridge adds another layer to this picture.

Connective-tissue fibres link several deep suboccipital muscles with the spinal dura in the upper cervical region.

This provides a direct anatomical relationship between the deep muscles beneath the occiput, the upper cervical spine and the dural system.

Rather than viewing the myodural bridge as the single cause of base-of-skull pain, we consider it as one component of a larger occipital-cervical-dural system.

Following trauma, we may therefore find a combination of:

• restricted occipital mechanics
• upper cervical joint restriction
• increased suboccipital muscular tension
• altered movement through the posterior temporal and mastoid region
• broader cranial and facial restriction

This is why simply treating the superficial neck muscles may not always address the entire mechanical pattern.

How NasalRx Can Influence the Posterior Cranial System

This is also where NasalRx becomes particularly relevant to our approach.

Although NasalRx is performed through the nasal passages, its mechanical objective is not simply to change the nose.

Controlled endonasal pressure is used to influence movement and restriction through the internal nasal and craniofacial complex. These structures have mechanical relationships with the sphenoid and broader cranial base, which in turn interact with the temporal and occipital regions.

Clinically, we often observe changes in occipital and posterior cranial movement following NasalRx.

When this occurs, patients may simultaneously report changes in the tension they feel across the back or sides of the scalp, around the base of the skull or through the posterior temporal and mastoid regions.

This is an important distinction between NasalRx and treatment directed only at the neck.

Cervical treatment allows us to address restriction from below through the cervical and occipito-cervical system.

NasalRx gives us a way of influencing the interconnected craniofacial and cranial-base mechanics from within the nasal passages.

For patients in whom both are relevant, we can work with the system from both directions.

What Changes Do We Look For?

When occipital and posterior cranial restriction appears to form part of the presentation, we monitor changes such as:

• improved occipital and posterior cranial movement on reassessment
• reduced base-of-skull pain or pressure
• reduced posterior scalp tension
• reduced pulling or tension around the mastoid and posterior temporal regions
• reduced headache
• improved cervical movement
• reduced suboccipital tension
• reduced head pressure
• improved comfort with head movement

The important point is that we do not assume these symptoms prove an occipital restriction.

We assess the mechanics first and then look for correspondence between changes in the physical findings and changes in the patient's symptoms.

How Cranial Solutions Assesses Base-of-Skull Pain

Our assessment looks beyond the location of the pain itself.

We consider:

• how the symptoms began
• whether concussion, whiplash or another injury was involved
• cervical movement and joint restriction
• suboccipital muscular tension
• the relationship between neck movement and headache
• cranial and facial mechanics
• jaw involvement where relevant
• associated post-concussion symptoms
• internal nasal and craniofacial restriction where relevant

This helps determine whether the problem appears primarily cervical, involves a broader craniofacial mechanical pattern, or requires assessment outside our scope.

Treatment: Why We Look at Both the Neck and Cranial System

Where cervical restriction is identified, appropriate cervical treatment can be incorporated directly into care.

But following concussion or other head trauma, the cervical findings may not exist in isolation.

This is where NasalRx provides another dimension to our approach.

NasalRx uses brief, controlled pressure within the nasal passages to influence restriction and movement through the internal nasal and craniofacial structures.

Because these structures form part of the broader mechanical environment of the cranial base and dura, NasalRx allows us to approach the craniofacial component from a direction that conventional external cervical treatment cannot reproduce.

For some patients, treatment is predominantly cervical.

For others, cranial or internal nasal restriction is also relevant.

And for some, cervical treatment and NasalRx are used together.

The treatment plan depends on what we find during assessment and how the patient responds.

What Changes Do We Look For?

Where base-of-skull restriction forms part of a broader mechanical presentation, patients may report changes including:

• reduced tightness at the base of the skull
• improved neck movement
• reduced headache
• reduced head pressure
• reduced cranial or facial tension
• improved comfort with head movement
• changes in associated post-concussion symptoms

Individual responses vary.

What matters clinically is whether the mechanical findings and symptom pattern change together as treatment progresses.

Frequently Asked Questions

What causes pain at the base of the skull?

There are many possible causes, including muscular tension, cervical joint restriction, headache disorders and injury. Following concussion or whiplash, the upper cervical and suboccipital region may also have been affected by the forces involved in the original injury.

What is the myodural bridge?

The myodural bridge describes connective-tissue relationships between several deep suboccipital muscles and the spinal dura in the upper cervical region. It demonstrates a direct anatomical connection between parts of the upper neck and the membrane surrounding the spinal cord.

Can the myodural bridge cause headaches?

The myodural bridge is anatomically relevant to the cranial-cervical region, but it should not be assumed to be the cause of every headache. Upper cervical structures can contribute to head pain through several mechanical and neurological pathways, which is why assessment is important.

Does base-of-skull tightness mean my CSF flow is blocked?

No. Base-of-skull tightness does not demonstrate that cerebrospinal fluid flow is blocked. Research is investigating relationships between cervical mechanics, the myodural bridge and CSF dynamics, but these should not be interpreted as a diagnosis of impaired CSF circulation in an individual patient.

Can NasalRx help base-of-skull pain?

NasalRx may be considered when base-of-skull symptoms occur alongside relevant cranial, facial or internal nasal restriction. Where the primary findings are cervical, cervical treatment may be more important. In some patients, both components are addressed together.

Persistent Pain or Tightness at the Base of Your Skull?

If the area where your neck meets your skull has remained painful or restricted — particularly following concussion, whiplash or another injury — the next step is determining what structures are contributing to the problem.

Cranial Solutions assesses the cervical spine alongside the cranial, facial and internal nasal system and determines whether cervical treatment, NasalRx, or a combination of both is appropriate.

Assessment is available at Cranial Solutions in Auckland and Christchurch.