How Misalignment of the C1 Vertebra Can Trigger Headaches and Neck Pain — And How Manual Therapy Can Help

Headaches and neck pain are two of the most common complaints in physical therapy — and they’re often more connected than you might think. One of the most overlooked contributors to chronic or recurrent symptoms is dysfunction of the C1 vertebra, also known as the atlas. When this crucial bone becomes misaligned or restricted, it can create a ripple effect of tension, inflammation, and nervous system irritation — especially in the upper neck and base of the skull.

Fortunately, targeted manual therapy and spinal mobilization techniques to this region can restore normal alignment and movement, helping to significantly reduce or even eliminate these nagging symptoms.

Understanding the Upper Cervical Spine: C1 and C2

The upper cervical spine includes the atlas (C1) and the axis (C2) — two uniquely shaped vertebrae that support the weight of the skull and allow for a wide range of head movements. The C1 vertebra is a ring-like bone that sits just below the base of the skull and articulates with the occiput (the back of your head). Unlike other vertebrae, the atlas does not have a body or disc. Instead, it provides the foundation for head rotation, nodding, and postural stability.

Because of its close proximity to the brainstem, cranial nerves, and vertebral arteries, even a small dysfunction at this level can lead to headaches, dizziness, muscle tension, neck stiffness, and even jaw pain.

What Happens When the Atlas Is Out of Alignment?

When the C1 vertebra is translated or rotated to one side, it may:

• Compress or irritate suboccipital nerves (leading to tension headaches)

• Create abnormal stress on surrounding muscles and ligaments

• Limit the flow of cerebrospinal fluid or blood from the vertebral arteries

• Alter proprioceptive signals to the brain (leading to imbalance or dizziness)

This can be caused by:

• Poor posture (e.g., forward head posture)

• Whiplash or trauma

• Repetitive stress

• Sleep positioning

• Past injuries or chronic tightness

The result? Persistent headaches, often described as starting at the base of the skull and wrapping around to the eyes or temples, along with referred pain into the neck and shoulders.

How to Assess for Atlas Misalignment

Physical therapists trained in cervical biomechanics can assess atlas dysfunction through:

• Palpation of the transverse processes of C1 for asymmetry

• Checking rotation restrictions between C1 and C2 using passive intervertebral motion testing

• Evaluating head and neck posture

• Screening for suboccipital muscle tightness and headache reproduction

• Using positional testing (e.g., supine glide testing, lateral flexion-rotation test) to determine segmental mobility

If the C1 vertebra is translated to one side, patients often present with:

• Restricted rotation to the opposite side

• Increased tenderness at the suboccipital ridge

• Headaches that worsen with neck movement or sustained posture

  
  

Manual Therapy and Spinal Mobilization: A Powerful Solution

Research and clinical experience show that manual therapy and spinal mobilization targeting the upper cervical spine — particularly C1–C2 — can have dramatic effects on pain, mobility, and headache frequency.

Techniques may include:

• Gentle joint mobilizations to restore alignment and movement

• Soft tissue release of the suboccipital muscles

• Muscle energy techniques to realign the atlas using patient-assisted movement

• Targeted stretches and postural retraining to prevent recurrence

In some cases, high-velocity, low-amplitude (HVLA) manipulation may be used by qualified providers, but even low-force manual therapy can yield substantial benefits.

The Takeaway

If you suffer from chronic neck tension or recurring headaches, especially at the base of the skull, your C1 vertebra may be the culprit. When the atlas is even slightly out of position, it can affect your entire upper cervical complex and trigger a cascade of discomfort. But with the help of a skilled physical therapist trained in upper cervical assessment and manual therapy, you can get back to moving freely — and living pain-free.

At Healing Arts Physical Therapy, we specialize in evaluating and treating upper cervical dysfunction. If you’ve been living with stubborn headaches or neck pain, let’s explore if your atlas might be at the root — and how we can realign your health.

Call us today to schedule a comprehensive cervical spine assessment.