Guidelines - Headaches

This tool provides information to facilitate the management of persistent headaches associated with neck pain for adults.

Focused examination

1. Patient History 

  • Rule out risk factors for major structural or other pathologies. If required, refer to an appropriate healthcare provider.

  • Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.

  • Address prognostic factors that may delay recovery.

Major structural or other pathologies (red flags):

  • Worsening headache with fever; sudden-onset headache (thunderclap) reaching maximum intensity within 5 minutes; new-onset neurological deficit; new-onset cognitive dysfunction; change in personality; impaired level of consciousness; recent (typically within the past 3 months) head trauma; headache triggered by exertion (e.g., cough, valsalva maneuver (trying to breathe out with nose and mouth blocked), sneeze or exercise); headache that changes with posture; symptoms suggestive of giant cell arteritis; symptoms and signs of acute narrow-angle glaucoma; a substantial change in the characteristics of the patient’s headache; new onset or change in headache in patients who are aged over 40; headache wakening the patient up (migraine is the most frequent cause of morning headache); patients with risk factors for cerebral venous sinus thrombosis; jaw claudication or visual disturbance; neck pain or stiffness; limited neck flexion upon examination; new onset headache in patients with a history of human immunodeficiency virus (HIV) infection; new –onset headache in patients with a history of cancer

Examples of other conditions/co-morbidities:

  • Physical conditions: back pain, neck pain

  • Psychological conditions: depression, anxiety

  • Co-morbidities: diabetes, heart disease

Examples of prognostic factors that may delay recovery:

  • Symptoms of depression or anxiety, passive coping strategies, job dissatisfaction, high self-reported disability levels, disputed compensation claims, somatization

2. Physical Examination

  • Rule out major structural or other pathologies​.

  • Assess for neurological signs.

  • Identify type of headache.

Tension-type headache feels like there is a tight band around the head

  • Episodic: at least 10 episodes occurring on ≥1 but <15 days per month for at least 3 months (≥12 and <180 days per year) 

  • Chronic: occurring on ≥15 days per month on average for >3 months (≥180 days per year)

 

Cervicogenic headache is head pain coming from the neck

3. Management 

  • Offer information on nature, management, and the course of headaches associated with neck pain. See patient handouts for more information to provide to patients. 

  • Discuss the range of effective interventions with the patient and, together, select a therapeutic intervention.

Patient Handouts

CCGI_headaches associated with neck pain
 

Management of persistent (>3 months duration) cervicogenic headaches

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

  • Consider low-load endurance craniocervical and cervicoscapular exercises with resistance

  • Consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine

  • Do not offer multimodal care that includes a combination of exercise, spinal manipulation and spinal mobilization

Management of episodic tension-type headache (>3 months duration)

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and the following therapeutic intervention*:

  • Consider low-load endurance craniocervical and cervicoscapular exercises with resistance in addition to structured patient education

  • Do not offer manipulation of the cervical spine

Management of chronic tension-type headache (>3 months duration)

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

  • Consider general exercise (including warm-up, neck and shoulder stretching and strengthening, and aerobic exercise)

  • Consider low-load craniocervical and cervicoscapular exercises

  • Consider multimodal careᶧ combining spinal mobilization, craniocervical exercise and postural correction

  • Consider clinical massage

Do not offer manipulation of the cervical spine as the sole form of treatment

*Interventions are recommended if guidelines used terms such as ‘recommended for consideration’ (e.g., ‘offer’, ‘consider’), ‘strongly recommended’, ‘recommended without any conditions required’, or ‘should be used’. Recommendations from low-quality evidence are not listed.

ᶧMultimodal care: treatment involving at least two distinct therapeutic modalities, provided by one or more health care disciplines.

Care Pathway for the management of cervicogenic headaches

(click here for French version)

Care Pathway for the management of tension-type headaches

(click here for French version)

Exercise Videos

The shoulder pain videos are based on the recommendations from the Clinical Practice Guideline for the Management of Shoulder Pain. Select a link below to view the patient exercise videos. 

 

4. Reevaluation and Discharge

  • Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors that may delay recovery.

5. Referrals and Collaboration

  • Refer the patient to an appropriate healthcare provider for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms.

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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.

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