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Atlas · Neck

Suboccipital Group

Four small muscles connect the skull, atlas and axis. They help control small head movements. Skull-base tenderness can accompany headache and a painful or restricted nod, but a regional headache assessment is needed to identify the problem.

Suboccipital Group
Body region
Neck
Trigger points
3
documented in this muscle
Common symptoms
3
patterns cataloged
Contributors
3
Factors to assess

Muscle overview

Symptoms and first steps

Practical first steps

  • Support the head and forearms during long viewing tasks.
  • Practise small comfortable nods without pushing the skull into a ball.
  • Record headache days and one useful neck task.

When to seek assessment

  • Seek urgent care for a sudden unusual severe headache, new double vision or visual loss, imbalance, weakness or speech/swallowing change.
  • Arrange examination after substantial trauma or for a new or progressively changing headache.

Obliquus capitis inferior joins C2 to C1 and has no skull attachment. Surface palpation cannot reliably separate all four deep components.

Examination, palpation and treatment evidence

Illustrated overview

Suboccipital Group

Blue highlights the muscle. Crosses mark representative trigger-point sites; shaded areas show possible referred pain. These examples do not correspond one-to-one with the numbered points below. Patterns vary and cannot diagnose the cause of pain.

Illustrated overview

Suboccipitals · Anatomy 1

Anatomical view of the illustrated muscle.

Open full-size image

Trigger points

1. TrP1

Location. Posterior skull-base region over the deep suboccipital group

Trigger point map
Suboccipital Group — Suboccipitals · Trigger-point examples 1Open full-size image

Regional muscle reference; this is not an individual map of the selected numbered trigger point.

Referred pain map
Suboccipital Group — Suboccipitals · Referred-pain pattern 1Open full-size image

Regional muscle reference; this is not an individual map of the selected numbered trigger point.

Pain referral. Skull base and accompanying headache

Pain Pattern

  • Posterior head
  • Temple or forehead may also hurt

What This Pain Feels Like

A skull-base ache may accompany a headache extending toward the temple or forehead. Note whether nodding or sustained viewing changes the familiar pain; its distribution alone does not determine the headache diagnosis.

What Patients Report

  • Ache at the base of the skull
  • Headache with neck stiffness
  • Discomfort after sustained reading

What Makes It Worse

  • Prolonged viewing tasks
  • Looking up
  • Head turning
Browse related exercises (11)

Symptoms patients report

Skull-base ache May be noticeable during a small nod or after keeping the head still.

Headache with neck discomfort Record where it starts and what accompanies it; tenderness can occur in several headache disorders.

Restricted head turning Compare active movement rather than assuming C1 or C2 is displaced.

Contributors to assess

Sustained viewing Reading or work with little position variation can exceed current neck tolerance.

Recent neck injury A trauma history changes the examination before stretching or manual care.

Poor sleep or frequent headache These can amplify symptom burden without establishing a muscle lesion.

For clinicians and supervised training

Clinical reference

A headache map records a possible symptom distribution. It does not identify a particular suboccipital component or explain visual or balance symptoms.

Anatomy and palpation

Anatomical relationships

Rectus capitis posterior major runs from C2 to the occiput; minor from the C1 posterior tubercle to the occiput. Obliquus superior joins the C1 transverse process to the occiput; inferior joins C2 to C1.[2]

  • Occipital midline and nuchal ridge provide surface orientation.
  • C1 lies deep; C2 is a regional posterior landmark, not a pressure target.

Nearby structures. Semispinalis capitis covers the group. The vertebral artery and C1 dorsal ramus lie in the suboccipital triangle; nearby occipital nerves can produce neural pain.

Palpation

Patient position. Supine with head fully supported in neutral or slight comfortable flexion.

Find the landmarks

  • Locate the occipital ridge and midline gently.
  • Orient to soft tissue just below the ridge without seeking deep C1 landmarks.

Examination sequence

  1. Use broad finger-pad contact with minimal pressure.
  2. Compare sides, ask whether tenderness matches the presenting pain, then release.
  3. Repeat a small active nod to relate the finding to function.

Document the findings

  • Local sensitivity and familiar-pain reproduction may inform a regional hypothesis.
  • An electric scalp sensation suggests neural irritation rather than a desired release.

Limits and precautions

  • No deep probing, forceful rotation or home pressure into the suboccipital triangle.
[2][3]

Examination and tests

2

Active neck rotation with a repeatable task[3]

Measure the movement needed for checking a mirror or looking beside the body.

Position
Seated, trunk supported, looking forward.
Technique
Turn the head slowly left and right without turning the trunk. Record angle, familiar pain location and onset. Repeat the relevant task at a comfortable speed using the same starting position.
Positive finding
Consistent pain or reduced rotation on one side; record the actual finding rather than a positive trigger-point label.
Interpretation
Local pain guides movement dosing. Radiating arm symptoms require a neurological assessment.
Limitations
Rotation recruits several muscles and joints; the result cannot identify the suboccipital group as the sole source.

Clinician cervical flexion-rotation test[4][3]

Assess upper-cervical rotational restriction in an appropriate headache presentation.

Position
Supine; examiner supports the head throughout.
Technique
After screening for contraindications, bring the neck into tolerated flexion and gently assess rotation each way. Measure the arc and familiar pain; omit the test if flexion is not tolerated.
Positive finding
A reproducible restricted side with familiar symptoms supports an upper-cervical movement impairment.
Interpretation
Combine with headache history and active motion; this does not isolate a muscle or prove a headache mechanism.
Limitations
Do not force the endpoint or use this as a vascular clearance test. Thresholds from selected study samples are not a universal self-test.

Distinguishing other causes

Migraine or tension-type headache[5][3]

Findings that matter. Recurrent headache with light/sound sensitivity, nausea, activity sensitivity or bilateral pressure may coexist with neck tenderness.

Next step. Use headache history and a diary; arrange medical headache assessment when recurrent or disabling.

Upper-cervical joint-related pain[4]

Findings that matter. Neck movement repeatedly provokes familiar head pain, with restricted upper-cervical motion.

Next step. Assess the headache and cervical region together; palpation alone cannot distinguish joint from muscle pain.

Vestibular, visual or vascular disorder[5]

Findings that matter. New spinning, double vision, visual loss, imbalance, speech change or unusual abrupt head/neck pain does not establish a muscle diagnosis.

Next step. Urgent assessment for acute neurological or visual symptoms; appropriate vestibular/eye evaluation for other persistent symptoms.

Treatment selection and progression

Exercise and rehabilitation

Comfortable movement for the restricted task[3]

Consider when. Assessed movement-related neck pain.

Rest the head on a pillow and make a small yes-nod without lifting the head or pressing hard backward. Return to a relaxed starting position.

Dose and review
Starting example: 3–5 slow repetitions once daily; use a smaller arc if irritable.
Progression
Increase the comfortable arc, then practise comfortable nodding and short reading periods. Judge the next dose by the later-day and next-morning response.
Stop or reassess
Stop for a new severe headache, visual disturbance, dizziness, arm symptoms or worsening that persists after practice.
Evidence and limits
Active cervical rehabilitation has regional guideline support; this example is a clinical adaptation, not a muscle-specific efficacy claim.

Self-care and activity

Adjust sustained head-position tasks[3]

Consider when. Symptoms accumulating during reading or close screen work.

Bring the object being viewed into an easier position, support the forearms, and alternate the task with brief comfortable movement. Choose pillow height by morning comfort rather than a prescribed neck curve.

Dose and review
Trial one practical change during the usual task for several days.
Progression
Gradually extend comfortable task time; retain the changes that improve function.
Stop or reassess
Persistent worsening, new headache features or symptoms following significant trauma need reassessment.
Evidence and limits
This task adjustment applies regional neck-care advice. Judge its usefulness by reading or head-turning comfort and morning symptoms.

Clinician-delivered care

Cervical mobilization for cervicogenic headache[7]

Consider when. A clinician-assessed cervicogenic headache presentation, with a relevant neck movement restriction after headache and neck screening.

A trained clinician may select tolerable, non-thrust cervical joint mobilization and active neck-control practice. Measure headache days and intensity alongside a familiar head-turn task; local suboccipital tenderness alone does not establish the headache diagnosis.

Dose and review
A 200-person trial used 8–12 visits over six weeks, up to 30 minutes each. Agree the course with the clinician and review headache and movement outcomes before extending treatment.
Progression
Review the headache diary and turning tolerance across a limited course. Reduce hands-on care as active control and daily function improve.
Stop or reassess
Stop and seek assessment for an unusual severe headache or new neurological, visual or balance symptoms. Do not continue a maneuver that consistently worsens the headache.
Evidence and limits
The trial found headache frequency/intensity benefits through 12 months with manual care or low-load exercise; combined treatment was not statistically superior to either alone. Its manual arm allowed both joint mobilization and high-velocity manipulation, so those results cannot be assigned to non-thrust mobilization alone or isolated suboccipital massage.

Clinician-delivered care

Dry needling for assessed cervicogenic headache[6][2]

Consider when. Persistent cervicogenic headache with a clinically assessed tender cervical-muscle presentation, when an adjunct to active care is desired.

A suitably trained clinician can discuss needling as part of a headache rehabilitation plan. Select the anatomical target after examination; an Atlas marker is insufficient for procedural planning.

Dose and review
Use a limited trial with agreed headache and function measures; the cited study regimen is not a universal treatment course.
Progression
Review headache intensity and reading/head-turning tolerance after treatment and at follow-up before repeating.
Stop or reassess
Stop for unusual severe head/neck pain or neurological symptoms; procedural planning must account for deep neurovascular anatomy.
Evidence and limits
A 69-person randomized study found added pain/disability benefit with cervical needling through six months, but clinical relevance was small and headache-frequency differences were not significant. It did not isolate suboccipitals from the other treated muscles.

Reassessment and follow-up

  • Repeat the same comfortable nod and rotation measures.
  • Compare headache intensity, headache days and reading tolerance; use more than tenderness alone to judge benefit.
  • Record tolerance of lying with the same pillow/head support and awakenings caused by skull-base pain.

Evidence and sources

  1. University of Utah: Deep Back and Suboccipital Region

    2014 · University anatomy teaching reference

    Attachment and layer reference, particularly the distinct cranial versus cervical insertions of the splenius muscles.

  2. Anatomy, Head and Neck, Suboccipital Muscles

    2023 · Anatomical reference

    Four components and vertebral-artery relationships. Anatomical connections do not establish a headache or visual mechanism.

  3. Blanpied et al. Neck Pain: Revision 2017

    2017 · Clinical practice guideline

    Regional assessment and multimodal active care; the home examples here are individualized starting options, not trial prescriptions.

  4. Hall et al. Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test

    2010 · Diagnostic comparison study

    Upper-cervical movement assessment across headache presentations; does not isolate a suboccipital muscle or validate a trigger-point map.

  5. Seemungal et al. The Bárány Society position on Cervical Dizziness

    2022 · Society position statement

    A neck-to-vertigo mechanism is not established; vestibular and neurological alternatives require assessment.

  6. Mousavi-Khatir et al. The Effect of Adding Dry Needling to Physical Therapy in the Treatment of Cervicogenic Headache

    2022 · Randomized sham-controlled trial

    69 randomized; targeted suboccipital, upper-trapezius and SCM presentations. Pain/disability differences favored needling through six months, with small clinical relevance; headache-frequency difference was not significant. Combined treatment does not isolate an individual muscle.

  7. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache

    2002 · Randomized trial

    200 participants; 8–12 visits over six weeks, no more than 30 minutes each. Manual therapy allowed both mobilization and high-velocity manipulation; headache frequency/intensity benefits persisted to 12 months. Combined care was not statistically superior to either treatment alone; this is not isolated suboccipital-massage evidence.

Associated Trigger Points