Ankylosing spondylitis (AS) does cause headaches, and at rates significantly higher than in the general population. An Italian cohort study published in Biomedicines found that about 46% of people with axial spondyloarthritis reported headaches in the previous three months, compared to 26% of healthy controls. Migraine without aura was also more common, affecting nearly 29% of participants with the condition.
Why AS Triggers Headaches
The most direct link between AS and headaches runs through the cervical spine. AS causes chronic inflammation in the joints and ligaments of the spine, and when that inflammation reaches the neck, it can produce what’s known as a cervicogenic headache. This is pain that starts in the bony structures or soft tissues of the neck and radiates upward into the head. It’s typically felt on one side.
Cervicogenic headaches from AS are often triggered by active neck movement or passive extension with rotation. Pressing on the affected facet joints in the neck or on the greater occipital nerve (the nerve running up the back of the skull) can reproduce the pain. Because these headaches can closely mimic migraines or tension headaches, they’re often misidentified, which means the neck source goes untreated.
Over time, AS can also lead to more structural problems in the upper cervical spine. Atlantoaxial subluxation, a partial displacement of the top two vertebrae, is a recognized complication. It’s often asymptomatic, but when it does cause symptoms, the most common ones are vague neck pain and occipital headache, a dull ache at the base of the skull. In rare cases, it can compress the spinal cord.
The Role of Posture Changes
AS progressively stiffens the spine, and in many people it creates an exaggerated forward curve in the upper back (thoracic kyphosis). To compensate, the head shifts forward, which places sustained strain on the muscles and joints at the base of the skull. This forward head posture compresses the suboccipital nerves and keeps the neck muscles in a state of constant tension, both of which generate headache pain. The more advanced the spinal fusion, the greater the postural load on the cervical spine.
Medication-Related Headaches
NSAIDs are the first-line treatment for AS, and many people take them daily or near-daily for years. A population-based survey found that headache and dizziness were among the most commonly reported side effects in AS patients using these medications. When you take pain relievers frequently, you also risk developing medication overuse headaches, sometimes called rebound headaches, where the drugs themselves begin to perpetuate a cycle of head pain.
Biologic therapies used for AS, particularly TNF inhibitors, can also list headache as a side effect. Interestingly, one study found that anti-TNF therapy actually decreased the frequency of headaches upon waking, likely because it reduced the underlying inflammation and improved sleep quality. So the relationship between AS medications and headaches isn’t straightforward: some contribute to headaches while others reduce them.
Sleep Disruption and Morning Headaches
AS can restrict the flexibility of the chest wall and alter the structure of the upper airway, raising the risk of sleep apnea. People with sleep apnea frequently wake with headaches because oxygen levels dip repeatedly overnight. If you have AS and notice headaches that are worst in the morning and improve as the day goes on, disrupted breathing during sleep is worth investigating.
Telling Headache Types Apart
Because AS can generate headaches through several different pathways, it helps to pay attention to specific patterns:
- Cervicogenic headache: One-sided pain that starts at the base of the skull or neck and spreads forward. Worsened by neck movement or sustained postures. Pressing on the neck reproduces the headache.
- Migraine: Throbbing pain, often one-sided, sometimes with nausea, light sensitivity, or visual disturbances. Nearly 29% of people with axial spondyloarthritis in the Italian cohort had migraine without aura.
- Tension-type headache: A band-like pressure around the head, often related to muscle tightness in the neck and shoulders that AS promotes.
- Medication overuse headache: A near-daily headache that paradoxically worsens with continued pain reliever use and improves when the medication is reduced.
These types can overlap, and more than one may be present at the same time. The distinction matters because each responds to different management strategies.
Managing AS-Related Headaches
Treating the underlying neck involvement is the most effective approach. Physical therapy focused on cervical spine mobility, chest expansion, and stretching of shortened muscle chains has shown promising results for AS overall. A randomized controlled trial found that both conventional exercise programs (targeting cervical, thoracic, and lumbar mobility) and a method called Global Posture Reeducation, which stretches and strengthens entire muscle chains, improved outcomes in people with AS. Maintaining neck range of motion is particularly important for preventing the postural changes that feed cervicogenic headaches.
For headaches driven by inflammation, keeping AS disease activity well controlled tends to reduce headache frequency. If you’re experiencing frequent headaches and taking NSAIDs daily, it’s worth evaluating whether the medications are part of the solution or part of the problem. Tracking headache timing, location, and triggers in a simple log can help you and your provider sort out which mechanism is most likely at play.