Muscle:Suboccipital
The suboccipital muscles are a group of four small, deeply placed, paired muscles at the base of the skull. They are a common and frequently overlooked source of deep, poorly localised head pain that radiates from the occiput toward the eye and forehead. Because they lie beneath the semispinalis capitis and trapezius, trigger points (TrPs) in these muscles cannot be individually distinguished by palpation alone — involvement is inferred from specific movement restrictions. The group includes the rectus capitis posterior minor, rectus capitis posterior major, obliquus capitis superior, and obliquus capitis inferior.
It is rare for these muscles to develop TrPs in isolation. They nearly always develop active TrPs as satellites of TrPs in other posterior cervical muscles — particularly the semispinalis capitis and splenius capitis — or as a consequence of forward-head posture. Treating the key posterior cervical muscles first will often resolve suboccipital TrP activity without direct treatment.
Anatomy
Three of the four suboccipital muscles connect the first two cervical vertebrae with the occipital bone. The fourth, the obliquus capitis inferior, is the only one that does not attach to the skull.
- Rectus capitis posterior minor
- A short, nearly vertical muscle. Attaches below to the tubercle on the posterior arch of the atlas (C₁). Spreads above along the medial half of the inferior nuchal line of the occiput, just above the foramen magnum.
- Rectus capitis posterior major
- Skips the atlas entirely. Attaches below to the spinous process of the axis (C₂). Fans above to the lateral part of the inferior nuchal line of the occiput, lateral to the rectus capitis posterior minor.
- Obliquus capitis superior
- Fibres run almost vertically. Attaches below to the transverse process of the atlas (C₁). Passes above to attach between the superior and inferior nuchal lines of the occiput, deep to the lateral part of the semispinalis capitis.
- Obliquus capitis inferior
- The primary head rotator. The only suboccipital muscle without a skull attachment. Attaches medially and inferiorly to the spinous process of the axis (C₂), and laterally and superiorly to the transverse process of the atlas (C₁). Connects the upper two cervical vertebrae with each other.
Suboccipital Triangle
The suboccipital triangle is bounded by three of these muscles: the obliquus capitis inferior, the obliquus capitis superior, and the rectus capitis posterior major. Its floor is formed by the posterior atlanto-occipital membrane and the posterior arch of the atlas. The vertebral artery traverses the floor of this triangle in a groove on the surface of the posterior arch of the atlas, and the greater occipital nerve crosses its ceiling. These relationships are of critical importance when considering injection.
Innervation
All four muscles are supplied by branches of the dorsal primary division of the suboccipital nerve (first cervical nerve, C₁).
Referred Pain Patterns
The referred pain from suboccipital TrPs is characteristically diffuse and poorly localised — described as a "ghostly" deep head pain that seems to penetrate inside the skull. Patients typically describe the headache as hurting "all over," but on careful questioning, most describe the pain extending unilaterally forward from the occiput toward the eye and forehead, with a lack of clearly definable limits.
This pain does not have the straight-through-the-head quality of the pain referred from the splenius cervicis muscle, which is an important distinguishing feature.
Pain from these muscles tends to be more deeply seated in the upper neck region and located more laterally than that experienced from the posterior cervical muscles (semispinalis, splenius). Patients often poke at the base of the skull, locating "a sore spot right there."
Hypertonic saline injected experimentally into the suboccipital muscles produced deep head pain described as "headache."
When the obliquus capitis inferior is involved, head rotation — such as checking the blind spot while driving, or looking to the rear — is seriously compromised.
| Muscle(s) involved | Essential referred zone | Key clinical feature |
|---|---|---|
| All four muscles (general pattern) | Occiput → forward to the eye and forehead, unilaterally; diffuse, poorly bordered | "Deep headache." No clearly definable limits. No straight-through-the-head quality. |
| Obliquus capitis inferior | Upper cervical, head rotation pain | Rotation severely limited — driving, checking blind spot compromised |
| Rectus capitis posterior minor + obliquus capitis superior | Occiput → forehead (flexion-related pattern) | Relieved by flexion of the head on the neck (these muscles are stretched by nodding) |
| Rectus capitis posterior major | Occiput → forehead + rotation-related pattern | Stretched by combined flexion and contralateral rotation |
Satellite Relationship
TrPs in the upper and lower trapezius, semispinalis capitis, and splenius capitis are the most common key TrPs that produce satellite TrPs in the suboccipital group. Inactivating these key posterior cervical TrPs will often also inactivate their satellite suboccipital TrPs without direct treatment of the satellites.
Activation and Perpetuating Factors
Forward-head posture
Excessive anterior head positioning is the single most important perpetuating factor. Forward-head posture is typically accompanied by a posteriorly-rotated occiput to accommodate the line of vision. This position simultaneously shortens the suboccipital extensors and activates TrPs in them and in other posterior cervical muscles.
Sustained shortened positions
These muscles develop TrPs when held in a shortened position:
- Sustained extension — lying prone propped on the elbows while watching television (sustained upward head tilt)
- Sustained flexion — controlling (checkreining) head flexion, or sustained forward flexion of the head and neck
- Sustained head rotation and tilt — talking to someone to one side for a prolonged period, looking only to one side from a vehicle, avoiding glare from inside of eyeglass lenses, or sustained attention to work placed flat on the desk to one side of the keyboard
Visual apparatus problems
The checkrein function of the suboccipital extensors is overloaded by sustained forward head flexion that is often caused by:
- Maladjusted eyeglass frames
- Uncorrected nearsightedness
- Lenses with too short a focal length
- Trifocal lenses requiring frequent or sustained fine head position adjustment
- Inverted bifocals used for overhead work (without a second conventional pair for regular use)
Chilling
Chilling the back of the neck while tired neck muscles are being held in a fixed position contributes to TrP activation. Keeping the suboccipital region warm is a key corrective and preventive measure.
Trauma and articular dysfunction
The suboccipital muscles are a common source of post-traumatic headache. Articular dysfunctions — particularly at the occipitoatlantal (OA), atlantoaxial (AA), and C₂ on C₃ levels — and suboccipital muscle TrPs usually coexist and perpetuate each other cyclically, especially in patients with chronic pain.
Clinical Examination
Postural Assessment
Observe for forward-head posture with a posteriorly-rotated occiput — this is the most important perpetuating factor. Assess anterior head position as described in Muscle:Sternocleidomastoid#Postural_Assessment. Correction of forward-head posture must be addressed in any treatment plan.
Active Range of Motion
Myofascial TrPs in the suboccipital muscles can produce moderate restriction of head movement on the neck post specifically — this is distinct from movement of the cervical spine itself, which primarily occurs at lower cervical levels.
When TrPs remain untreated:
- Flexion is incomplete by the distance of one or two finger-breadths
- Sidebending is similarly restricted by one or two finger-breadths
- Rotation may be reduced by up to 30°
On examination for head mobility, the examiner feels increased resistance in the suboccipital region earlier than normal, causing early movement between successively lower cervical vertebrae rather than at the craniocervical junction.
The supine position is preferred for examination — it achieves better muscle relaxation and allows clearer distinction between muscle tightness and joint restriction than the seated position.
Trigger Point Examination
Because of the overlying semispinalis capitis and trapezius, flat palpation of the suboccipital muscles may elicit deep tenderness without producing palpable taut bands or visible local twitch responses. The finding that digital pressure on the suboccipital muscles induces symptoms the patient recognises as a familiar pain or complaint is diagnostically valuable.
Technique: The patient is supine and relaxed. The operator stands at the head of the table, supports the patient's head, and gently flexes the head on the neck (as in nodding) while palpating the suboccipital area for muscular tension and tenderness.
Individual muscles cannot reliably be distinguished by palpation alone. Which muscles are likely involved can be inferred from specific movement restriction:
- Restricted flexion → rectus capitis posterior minor and/or obliquus capitis superior (primary flexion antagonists)
- Restricted rotation → obliquus capitis inferior and/or rectus capitis posterior major on the same side
Testing for Atlantoaxial (AA) Rotation
With the patient supine, position the head and neck in full flexion — this fixes the lower cervical spine and isolates the atlantoaxial joint. With the patient's head fully supported against the examiner's body, apply only a rotation movement and test rotation to each side.
- Soft, pliable end-feel of rotation restriction → muscular involvement (suboccipital TrPs)
- Hard, rigid end-feel → joint restriction (articular dysfunction)
The consistent finding with suboccipital muscle involvement is restricted rotation toward the side opposite the involved muscles (obliquus capitis inferior and possibly rectus capitis posterior major that are shortened by TrPs).
Crepitus is a very common finding in patients with osteoarthritis of the C₁–C₂ (AA) joint; in these patients, pain is often partly due to suboccipital TrPs in addition to the articular pathology.
Testing for Occipitoatlantal (OA) Dysfunction
With the patient supine, place fingers directly under the base of the occiput. Ask the patient to perform an active chin-tuck (head retraction), or passively initiate a gliding chin-tuck motion. Asymmetry at the OA joint will appear as the patient's chin turning away from the side of the articular dysfunction.
Differential Diagnosis
Patients with head and neck pain caused by suboccipital TrPs are commonly misdiagnosed as having:
- Tension-type headache — the most common misdiagnosis; suboccipital TrP headache lacks clearly definable limits and is diffuse and deep
- Cervicogenic headache — a legitimate consideration; however, the articular component must be specifically examined and both the muscular and articular contributors treated
- Occipital neuralgia — suboccipital TrP pain does not have the lancinating, electric quality of true occipital neuralgia; the greater occipital nerve can be entrapped by the inferior oblique in rare cases
- Chronic intractable benign pain — one study found TrPs or tender points in the suboccipital muscles in 67.6% of 34 patients given this diagnosis; the authors questioned its validity whenever the examination did not include muscle palpation for TrPs
| Feature | Suboccipital TrPs | Splenius cervicis TrPs | Semispinalis capitis TrPs | Occipital neuralgia |
|---|---|---|---|---|
| Pain quality | Deep, diffuse, "ghostly" — poorly bordered | Straight-through-the-head; vertex and behind the eye | Band-like, occiput to eye | Lancinating, electric, clearly localised along nerve |
| Pain location | Occiput → eye and forehead, unilateral | Vertex and behind the ipsilateral eye | Occiput → vertex, temple | Posterior scalp along greater occipital nerve distribution |
| Rotation restriction | Toward opposite side (AA level) | To same side (mid-cervical) | Variable | None (neurological, not muscular) |
| Palpable taut band | Rarely (deep — overlying muscles intervene) | Yes, in lateral neck | Yes, in lateral neck | Tenderness at nerve exit point (occiput) |
| Associated features | Forward-head posture; articular AA/OA dysfunction common | Pain worsened by looking over shoulder to same side | Pain with sustained reading; suboccipital tenderness | Allodynia of scalp; tingling |
Related Articular Dysfunctions
Myofascial TrPs in the suboccipital muscles almost always coexist with articular (somatic) dysfunctions at the OA, AA, and C₂ on C₃ levels. These areas all need to be checked and treated. Treatment of joint dysfunction and release of muscle TrPs are mutually reinforcing — manual techniques for gentle release of TrP tightness and for treatment of articular restriction are often similar enough to address both simultaneously.
Nerve Entrapment
No clinically significant nerve entrapment has been identified as primarily due to TrPs in these muscles. Rarely, TrPs in the obliquus capitis inferior could potentially entrap the greater occipital nerve — in autopsy studies, the greater occipital nerve penetrated the inferior oblique muscle in 7.5% of cases, and entrapment was seen in one of those cases. The nerve more commonly emerges through the semispinalis capitis (90% of cases).
Treatment
Trigger Point Release
First priority: treat the key TrPs. The suboccipital muscles nearly always develop TrPs as satellites. Inactivating all active TrPs in the posterior cervical muscles (trapezius, semispinalis capitis, splenius capitis) by injection if desired will often also inactivate their satellite suboccipital TrPs without further direct treatment.
Prespray is applied to extend upward well above the hairline before any stretch release. With thick hair, the effectiveness of vapocoolant spray may be increased by separating the hairs to make a track through them.
Stretch-release technique: The head must be tilted on top of the neck post in specific directions to stretch those muscles that either extend, sidebend, or rotate the head:
| Muscle | Direction of head movement to stretch |
|---|---|
| Rectus capitis posterior minor + obliquus capitis superior | Flexion of the head on the neck (nodding) |
| Rectus capitis posterior major | Flexion and contralateral rotation |
| Obliquus capitis inferior | Rotation of the face to the opposite side |
| All four muscles | Combined flexion and rotation — turn face toward opposite side, then lower the chin (nodding down) |
Manual release (augmented postisometric relaxation):
- Operator flexes the patient's head gently to take up any slack in the suboccipital muscles
- While the patient looks up and slowly inhales, the therapist holds the head position and gently resists the patient's tendency to extend
- The patient then slowly exhales, looks down, and allows the head to flex, relaxing the posterior muscles; the operator exerts upward traction at the occiput (releasing compressive forces on the cervical articulations) and takes up the slack that develops
- Repeat with successive degrees of head rotation to fully stretch all suboccipital muscles
This technique can be performed as a self-stretch for home use: the patient places their own fingers under the occiput to exert upward traction prior to directing the nodding movement.
Important: The cervical spine itself should not be flexed unless the goal is to release all posterior cervical musculature. To specifically release the suboccipital muscles, only the head is flexed on the cervical spine (as in nodding).
The suboccipital triangle at the C₁ level, where the vertebral artery traverses horizontally, should be avoided if massage there causes any symptoms suggestive of brain ischaemia.
A hot pack covering the lower occiput and posterior neck region should follow stretch-and-spray. Keeping the suboccipital area adequately warm — including at night — is important. Patients with these TrPs usually find that a cervical collar is more annoying and irritating than helpful due to direct pressure on these muscles.
Suboccipital Decompression
A useful adjunct technique: with the patient supine, the examiner's fingertips are placed in the suboccipital recess bilaterally. The patient's head is supported on the pads of the examiner's fingers. Initially, pressure is applied anteriorly to induce regional extension at the OA, AA, and C₂ articulations. When relaxation of the suboccipital muscles is detected, the examiner applies traction in a cephalad direction with the fingertips while slightly spreading the fingers apart directly against the base of the occiput. This upward traction force releases compressive forces on the cervical articulations, induces regional flexion in a chin-tuck position, and helps release tension in the suboccipital muscles.
Trigger Point Injection
⚠ Safety Notice: Procedures described on this page involve structures in close proximity to major vessels or neurovascular bundles. This page is intended for qualified clinicians. Always identify relevant anatomy before proceeding. This site is not validated for clinical use — see the site disclaimer.
Repeated applications of stretch and spray with deep massage generally are effective in eliminating suboccipital TrP irritability, and injection is rarely necessary. If injection is considered after all noninvasive methods have failed, dry needling along the posterior arch of the atlas — directed parallel to the long axis of the vertebral artery — probably reduces the likelihood of arterial penetration.
Patient Education
Keep the neck warm
It is critically important to keep the suboccipital region warm. Nightwear rarely provides adequate coverage — patients should wear an old-fashioned nightcap, a soft hooded jacket, or drape a scarf to protect the suboccipital skin from cooling. Outdoors, a hood covering both the head and neck should be worn.
Correct forward-head posture
Anterior head position is the primary perpetuating factor. See the axial extension exercise described at Muscle:Sternocleidomastoid#Corrective_Axial_Extension_Exercise. The patient should learn how to relax the neck muscles and how to do a passive self-stretch exercise while seated (for postural relaxation) on a stool or chair under a warm shower.
Eliminate sustained and strained head positions
- Avoid use of trifocal lenses — use lenses with adequate focal length to allow the head to rest in a balanced upright position on the cervical spine
- Arrange room lighting or the patient's location to eliminate glare reflected from the inside of eyeglass lenses (alternatively, the inside of the lenses may be coated against glare)
- Place documents on a vertical stand in front of the typist — not flat to one side
- Sustained upward gaze with the head tilted up must be avoided — revise activities as necessary (e.g., a stage director who was seen by Dr. Travell learned to direct from farther back in the theatre rather than from the front row below stage level, eliminating prolonged upward gaze)
Self-stretch home programme
A series of passive stretches should be applied separately in unidirectional movements (no head rolling) with successive degrees of head rotation to fully stretch all suboccipital muscles. Passive stretching should be followed by full active range of motion, contracting and stretching muscles in both agonist and antagonist directions. Repeat the cycle several times, slowly without jerking.
Satellite Trigger Points
The suboccipital muscles develop TrPs as satellites of key TrPs in:
- Semispinalis capitis — the most common key muscle; overlies the suboccipitals and is frequently co-involved
- Splenius capitis — a common key TrP source for post-traumatic suboccipital headache
- Trapezius (upper and lower)
- Sternocleidomastoid
In turn, active TrPs in the suboccipital muscles may maintain satellite TrPs in other posterior cervical muscles, creating self-reinforcing cycles — particularly when articular dysfunction is also present.
Related Pages
- Muscle:Semispinalis_Capitis — primary key TrP muscle for suboccipital satellites
- Muscle:Splenius_Capitis — key TrP for post-traumatic headache
- Muscle:Sternocleidomastoid — frequently co-active; forward-head posture connection
- Muscle:Trapezius — overlying muscle; upper trap TrPs commonly co-active
- Muscle:Levator_Scapulae — shares cervical articular dysfunction patterns
- Pain:Neck — Neck pain diagnostic overview
- Pain:HeadOcciput — Occipital and vertex headache differential
- Differential:NeckPain — Neck pain diagnostic tree
References
- Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1: The Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. Chapter 17.