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Cervicogenic and Tension-Type Headaches Care Pathway

Date of last update: September, 2024

About Cervicogenic and Tension-Type Headaches

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Overview: Headaches, a prevalent health concern, are broadly categorized as primary, where pain or symptomology is not attributed to a distinct pathology, or secondary, where it is linked to an underlying physical, psychiatric, or systemic condition. Tension-type headaches, characterized by a dull, aching sensation across the head, are one of the most common primary headache types. Cervicogenic headaches, which originate from neck disorders and manifest as referred pain in the head, are a common type of secondary headache. It is also important to note that individuals can experience multiple headache types simultaneously, and one type of headache, such as a migraine, can be triggered by another type, such as a cervicogenic headache.

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Diagnosis: The diagnosis of tension-type and cervicogenic headache, both of which are amendable to conservative care, is primarily clinical. It relies on patient history and clinical examination and aims to exclude identifiable pathologies. Further diagnostic testing may be required to rule out serious underlying conditions causing headache.​

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Effective Management: Given its multifactorial and recurring nature, influenced by physical, psychological, social, and environmental elements, there is no one-size-fits-all treatment for headache. Effective management is ethical, evidence-driven, transparent, flexible, and responsive to the person's needs. Essential interventions include education, reassurance that headache is typically of a limited-time nature, maintaining daily activities, self-care practices, and addressing psychosocial factors. Additional interventions are selected through shared decision-making, aiming to optimize function and participation. Continuous monitoring and assessment of outcomes ensure alignment with patient goals. Effective management can occur through in-person, virtual or hybrid care.

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About the Care Pathway

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  • Principles: Based on recommendations drawn from established clinical guidelines, integrating the best available evidence, clinical expertise, and patient preferences. Treatments are aligned with current guideline-supported practices and expert consensus. Developed with input from professional leaders, clinicians, and researchers.

 

  • Target Audience: Supports clinicians who deliver conservative care and informs those who do not but may see people with these conditions for referral or co-management. Provides essential, concise guidance on key steps of a clinical encounter, with access to detailed information by clicking on specific sections. Includes a downloadable one-page quick guide for quick access to key information.

 

  • Updates: Regular updates are communicated through social media to ensure users have current information. The care pathways are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. They may be updated to ensure they remain current, and evidence driven.

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  • ​Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.

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***CLICK HERE FOR A ONE-PAGE QUICK GUIDE: Cervicogenic and Tension-Type Headaches Quick Guide

1. Record Keeping

  • Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).

  • Adhere to jurisdictional standards.

2. Informed Consent

  • Document verbal consent for health history taking, physical examination, contact in sensitive areas.

  • Obtain written consent for treatment.

  • Adhere to jurisdictional standards.

3. Health History

  • ​Apply cultural awareness and trauma-informed care principles.

  • Sociodemographic: Age, gender, sex.

  • Main complaint: Location, temporal factors (onset, mechanism, duration, time of day, pattern, triggering events), radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.

  • Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.

  • Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids, oral contraception, etc.), supplements, trauma/injuries, hospitalizations, surgeries, volume and intensity of exercise, diet, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.

  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

  • Previous treatments and responses: Effectiveness and any adverse events.

  • Beliefs and expectations: Understanding of their condition, treatment expectations.

  • Red, yellow, and orange flags (sections 4 – 6).

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Meaningful Outcomes:

4. Differential Diagnosis Requiring Medical Attention

 

ACTION: Refer to emergency care immediately for red flags:

  • Meningitis: Neck stiffness, severe headache worsening with neck flexion, fever, vomiting, rash, altered mental status, photophobia, drowsiness, flexed hip/knee posturing.

  • Spinal Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, unexplained constitutional symptoms (e.g., fever/chills), IV drug use, poor living conditions.

  • Intracranial/Brain Lesion: Sudden intense headache (thunderclap); unexplained headache, dizziness, or visual changes.

  • Vertebral/Carotid Artery Dissection: Severe neck pain or headache (“worst pain ever”), double vision, difficulty swallowing, facial numbness, difficulty walking, drop attacks, nausea, nystagmus.

  • Traumatic Spinal Fracture: Age ≥65 years, dangerous mechanism (e.g., pedestrian struck, high-speed motor vehicle collision, rollover, ejection from motor vehicle, fall from elevation ≥3 feet or 5 stairs, axial load to head), extremity weakness/tingling/burning, inability to actively rotate neck 45° left and right, midline cervical spine tenderness (Canadian C-Spine Rule).

  • Acute Narrow-angle Glaucoma: Severe unilateral eye pain, blurred vision, light halos, nausea or vomiting.

  • Cervical Myelopathy: Gait disturbances, hand clumsiness, non-dermatomal numbness, lower extremity numbness or weakness, bowel or bladder dysfunction.

  • Giant Cell Arteritis: Temporal headache, scalp tenderness, jaw claudication, intermittent or permanent vision loss. Commonly associated with polymyalgia rheumatica.
     

 

ACTION: Refer to appropriate medical provider:

  • Non-traumatic Spinal Fracture: Sudden severe pain, osteoporosis, corticosteroid use, female sex, age >60, spinal fracture/cancer history.

  • Spinal Malignancy: Progressive pain, cancer history, constitutional symptoms (e.g., fatigue, weight loss), progressive headache worse with exertion.

  • Inflammatory Arthritides (e.g., spondyloarthropathies, rheumatoid arthritis, systemic lupus erythematosus): Morning stiffness >1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), symmetrical joint pain, joint swelling/deformity, skin lesions.

  • Migraine: Moderate to severe unilateral or bilateral throbbing pain, aggravated by physical activity, associated with nausea, vomiting, photophobia, phonophobia, possible aura.

5. Psychiatric Disorders (Orange Flags)

  • Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.

  • Screening tools: PHQ-9,  GAD-7.

  • Action: Refer to appropriate provider/psychiatric specialist.

6. Psychosocial Factors (Yellow Flags)

  • Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims, maladaptive coping mechanisms.

  • Screening tools: PHQ-9,  GAD-7, FABQ, ORT, PCS.

  • Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination

  • Observation: Abnormalities, asymmetries, posture, balance, gait, movements, facial expression.

  • Vitals: Blood pressure, heart rate, respiratory rate, temperature. May include eye exam (e.g.., visual acuity, pupil response, fundoscopic examination).

  • Range of Motion: Cervical spine’s active, passive, resisted ROM (flexion, extension, lateral flexion, rotation).

  • Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.

  • Neurological Examination: Motor strength, sensory and reflex testing (C5, C6, C7, C8, T1); upper and lower motor neuron signs, cranial nerves screening (including facial numbness; facial movements such as smile, tongue deviation, eye movements).

  • Special/Orthopedic Tests: Select as appropriate based on clinical judgment.

  • Advanced Diagnostics: Radiography is not routinely recommended in the absence of red flags or other specific individual factors (e.g., potential contraindications to treatment).

8. Diagnostic Criteria for Cervicogenic and Tension-Type Headaches

A. Cervicogenic Headache (secondary to cervical spine disorders)

  • Pain: Unilateral, starting from the nuchal area and extending to oculofrontal area.

  • Signs/Symptoms: Moderate-intensity, non-throbbing, episodic pain. Headache and cervical disorder develop in a similar time frame.

  • Exam: Headache reproduced during cervical spine range of motion and tests (e.g., cervical flexion-rotation, myofascial trigger points). Normal upper extremity and cranial nerve neurological tests.

 

B. Tension-Type Headache (TTH)

  • Pain: Bilateral, pressing/tightening, non-pulsating, “tight band around head” or at base of skull. Can be episodic or chronic.

  • Signs/Symptoms: Varies from mild to moderate intensity. May include one of: photophobia, phonophobia, or mild nausea, but not associated with moderate or severe nausea/vomiting. May involve scalp or neck muscle tenderness. Does not worsen with routine activity.

  • Exam: Normal upper extremity and cranial nerve neurological tests.

9. Treatment Considerations for Cervicogenic and Tension-Type Headaches

After providing a report of findings and obtaining written informed consent.

  • Core Interventions:

    • Education and reassurance: Provide clear information about the nature of headache (e.g., it is commonly a limited-time condition).

    • Address yellow flags (psychosocial factors): Incorporate strategies such as education, mindfulness, meditation, CBT, or referral to mitigate fear-avoidance behaviours and other barriers to recovery.

    • Maintain activities of daily living: Encourage continued movement and activity as much as possible, avoiding prolonged rest.

    • Self-care: Provide recommendations for home-based exercise, balanced nutrition, good sleep hygiene, stress management, maintaining a healthy body weight, and avoiding smoking/substance abuse.

    • Engage in social and work activities: Encourage social and work activities as part of the rehabilitation process.

    • Exercise therapy: For cervicogenic headache, tailored exercises targeting the cervicothoracic region, deep cervical flexors, and scapular retraction/postural muscles. For tension-type headache, focus on postural correction and muscle relaxation exercises.

 

  • Optional Interventions:

    • Manual therapy: E.g., spinal manipulation/mobilization, soft tissue techniques, or massage for cervicogenic headache.

    • Psychological support: Cognitive-behavioural therapy (CBT) or other forms of psychological support to manage psychosocial contributors (e.g., anxiety, depression).

    • Mind-body interventions: E.g., mindfulness, meditation.

    • Multimodal care: E.g., combine exercise therapy, structured education and manual therapy.

    • Medications: Consult with a medical provider. Short-term use of medications for pain relief (e.g., analgesics, NSAIDs) may be considered after non-pharmacological treatments. Long-term use and opioids should be avoided due to the risk of medication-overuse headache (MOH).

10. Prognosis

  • Recovery: Can be episodic, chronic, or recurrent.

  • Negative Prognostic Factors: Passive coping strategies, higher initial pain levels, poor recovery expectations, mental health issues, younger age, persistent symptoms, arm pain, work-related factors, previous neck pain, functional limitations.

11. Ongoing Follow-up

  • Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgment.

  • Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).

12. Criteria for Discharge

  • Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).

  • ​Discuss post-discharge plans, including self-management strategies and potential follow-ups.

References

 

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Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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