Guidelines - Headaches Associated with Neck Pain

Scope and Purpose

Objective: This guideline aims to provide non-pharmacological recommendations for the management of persistent headaches associated with neck pain. This guideline aims to: 1) accelerate recovery; 2) reduce the intensity of symptoms; 3) promote early restoration of function; 4) prevent chronic pain and disability; 5) improve health-related quality of life; 6) reduce recurrences; 7) promote active participation of patients in their care; 8) promote uniform high-quality care. 

CCGI Guideline Summary

 

Target population: 

  • Adults (18 years of age or older) with persistent (>3 months duration) headaches associated with neck pain. This includes tension-type (episodic or chronic) and cervicogenic headaches. 

Title of guideline: Management of neck pain and associated disorders

Author(s): Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Year of publication: 2016

Link to full guideline: Link

Wording of Recommendations

 

This guideline adapted the National Institutes for Health and Care Excellence methodology to develop the wording of guideline recommendations:

  • Offer: interventions that are of superior effectiveness compared to other interventions, placebo/sham interventions or no intervention

  • Consider: interventions providing similar effectiveness to other interventions

  • Do Not Offer: interventions providing no benefit beyond placebo/sham or are harmful

  • Inconclusive Evidence: evidence was deemed inconclusive when the results of multiple low risk of bias studies conflicted

Key Recommendations

Assessment:

  • Clinicians should rule out risk factors for serious pathologies (e.g., migraines with or without aura, and traumatic brain injuries) as the cause of presenting signs and symptoms (red flags)

  • Once major pathology has been ruled out, clinicians should classify headaches as tension-type or cervicogenic headaches

  • Conduct ongoing assessment for symptom improvement or progression during intervention and refer accordingly

  • Discharge patients as appropriate at any point during intervention and recovery

Education and self-management:

  • Clinicians should provide care in partnership with the patient and involve the patient in care planning and decision-making

    • Aim to understand the patient’s beliefs and expectations about headaches and address any misunderstandings or apprehension through education and reassurance​

  • Provide information about the nature, management and course of headaches associated with neck pain as a framework for the initiation of the programme of care​

  • Advise patients to stay active or exercise, provide information about pain and its mechanisms, reassure patients about the nature and course of headaches, and deliver time-limited care that includes effective management

  • In the presence of prognostic factors (e.g., psychosocial factors, demographics and headache characteristics) for delayed recovery, clinicians should discuss them with the patient and adjust their care plan accordingly

Treatment

For persistent cervicogenic headaches (>3 months):

Based on shared-decision making between the patient and provider, the following therapeutic interventions are recommended*:

  • Provide information about the nature, management and course of headaches associated with neck pain as a framework for the initiation of the programme of care

  • Clinicians may consider low-load endurance craniocervical and cervicoscapular exercises with resistance

    • Limited to a maximum of 8 sessions over 6 weeks. This involves supervised and home-based low-load endurance exercises against resistance over time to train muscular control of the craniocervical and cervicoscapular region. The exercise programme should be taught to the patient by a healthcare professional​

  • Clinicians may consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine​

    • Limited to a maximum of 10 sessions over 6 weeks​

  • Clinicians should not offer a multimodal programme of care that includes a combination of exercise, spinal manipulation and spinal mobilization​ª

 

For episodic tension-type headaches (>3 months):

Based on shared-decision making between the patient and provider, the following therapeutic interventions are recommended:

  • Provide information about the nature, management and course of headaches associated with neck pain as a framework for the initiation of the programme of care

  • Clinicians may consider low-load endurance craniocervical and cervicoscapular exercises with resistance (maximum of 8 sessions over 6 weeks with resistence in a supervised clinical environment) in addition to structured patient education

    • This involves supervised and home-based low-load endurance exercises to perform a slow and controlled craniocervical flexion against resistance over time to train muscular control of the craniocervical and cervicoscapular region. The exercise programme should be taught to the patient by a healthcare professional​

  • Clinicians should not offer manipulation of the cervical spine​ª

For chronic tension-type headaches (>3 months):

Based on shared-decision making between the patient and provider, any one of the following therapeutic interventions are recommended*:

  • Provide information about the nature, management and course of headaches associated with neck pain as a framework for the initiation of the programme of care

  • Clinicians may consider general exercise (including warm-up, neck and shoulder stretching and strengthening, and aerobic exercises)

    • General clinic- and home-based exercise programme (limited to a maximum of 25 sessions over 12 weeks). The exercise programme should be taught and supervised by a healthcare professional​

  • Clinicians may consider low-load craniocervical and cervicoscapular exercises

    • Limited to a maximum of 8 sessions over 6 weeks with resistance. This involves supervised and home-based low-load endurance exercises against resistance over time to train muscular control of the craniocervical and cervicoscapular region. The exercise programme should be taught to the patient by a healthcare professional​

  • Clinicians may consider multimodal care (combining spinal mobilization, craniocervical exercise and postural correction)​

    • Clinicians may offer a maximum of 9 sessions over 8 weeks. This multimodal care program should be provided to the patient by a healthcare professional​

  • Clinicians may consider clinical massage​

    • A maximum of 8, 45 min sessions of clinical massage (2 sessions per week over 4 weeks). on shoulders, upper back, connecting area of neck and shoulders, shoulder tips, the back of head, the middle line of head, face​

  • Clinicians should not offer manipulation of the cervical spine as the sole form of treatment​​ª

Re-evaluation and Discharge

  • Clinicians should reassess the patient at every visit to determine whether additional care is necessary, the condition is worsening, or the patient has recovered. Patients should be discharged as soon as they report significant recovery

    • Healthcare professionals should use the self-rated recovery question to measure recovery: “How well do you feel you are recovering from your injuries?”​

      • The response options include: completely better, much improved, slightly improved, no change, slightly worse, and worse than ever.​

      • Patient reporting to be “completely better” or “much improved” should be considered recovered.

*This refers to the consideration of any one of these interventions in isolation. Clinicians should reassess the patient at every visit and adjust the treatment plan accordingly

ª"Do Not Offer” recommendations describe interventions providing no benefit beyond placebo/sham or are harmful

 
 
 
 
 
 

Referrals and Collaborations

 
  • With an unrecovered/incomplete recovery or major symptom change (new condition or worsening physical, mental or psychological symptoms), refer to a physician for further evaluation^

^Healthcare professionals should use the self‐rated recovery question to measure recovery: “How well do you feel you are recovering from your injuries?” (Carroll, Lis, Weiser, & Torti, 2016; Fischer, Stewart, Bloch, Lorig, & Laurent, 1999). The response options include (a) completely better, (b) much improved, (c) slightly improved, (d) no change, (e) slightly worse, (f) much worse and (g) worse than ever. Patients reporting to be “completely better” or “much improved” should be considered recovered

  • Facebook Social Icon
  • Twitter Social Icon
  • YouTube Social  Icon
  • LinkedIn Social Icon

CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

OnTEchU logo_transparent.png