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Cervicogenic and Tension-Type Headaches Care Pathway

Date of last update: December, 2024

About Cervicogenic and Tension-Type Headaches

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Headaches are broadly categorized as primary – not attributed to a distinct pathology – or secondary – linked to an underlying physical, psychiatric, or systemic condition. Tension-type headache (TTH) is the most common primary headache type, while cervicogenic headache arises from neck disorders and is thus secondary. Individuals may experience multiple headache types simultaneously, and one headache (e.g., migraine) can be triggered by another (e.g., cervicogenic headache).

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The The diagnosis of these headaches is primarily clinical – most serious pathologies can be excluded by a thorough history and physical examination. Further diagnostic testing may be needed if specific findings or red flags suggest another underlying condition. Because headaches often have multifactorial causes (physical, psychological, social, and environmental) management strategies must be tailored, person-centered, and adaptable. Shared decision-making and regular outcome assessment  help ensure that care aligns with individual goals. Management may also be delivered through virtual or hybrid care options.

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About the Care Pathway

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  • Purpose: This pathway offers structured, evidence-based guidance for clinicians delivering conservative care, covering key steps of the clinical encounter. It also serves as a resource for referral or co-management for those not directly providing conservative care. Key information is available in a one-page quick guide, with more detailed content accessible through specific sections.

 

  • Development and evidence selection:         

  • The pathway integrates established clinical knowledge with the latest research, drawing from high-quality systematic reviews and guidelines assessed using critical appraisal tools. Recommendations reflect consistent evidence of benefit or harm, while evolving or conflicting recommendations are addressed in expanded notes. Input from clinical leaders, educators, and researchers ensures practical alignment with current evidence and practical application.

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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 findings and recommendations using structured notes (e.g., SOAP format) at each visit, adhering to jurisdictional standards.

2. Informed Consent

  • Obtain and document verbal consent for history taking, examinations, and contact in sensitive areas; secure written consent for treatments per jurisdictional standards.

3. Health History

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

  • Sociodemographic: Age, gender, sex, race/ethnicity.

  • 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 review: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.

  • Health, lifestyle, and 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, social isolation.

  • Previous treatments and responses: Document prior treatments, effectiveness and any adverse effects.

  • Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.

  • Flag considerations: Identify red, yellow, and orange flags for potential referrals [see Sections 4 – 6].

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Outcome Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

  • Pain: Use pain scales (e.g., NRS) and diagrams.

  • Function and participation: Evaluate impact on daily activities (PSFS, WHODAS, HIT6, HDI, NDI, MYMOP, MYMOP Follow-up).

  • Recovery: Use self-rated recovery scales.

  • Quality of life: Assess using tools such as SF-12.

  • Work/school status: Monitor return to activities.

  • Individual goals: Set SMART goals (Specific, Measurable, Achievable, Relevant, Timely).

  • Patient feedback: Gather and integrate patient experience and satisfaction.

4. Red Flags: Differential Diagnosis Requiring Medical Attention

 

ACTION: Refer immediately to emergency care:

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

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  • Spinal infection: Progressive neck pain (worse at night), constitutional symptoms (e.g., fever/chills), recent infection/surgery, immunosuppression, TB history, IV drug use, poor living conditions, tenderness on palpation or tap test.

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  • Intracranial/brain lesion: Sudden intense headache (thunderclap) or progressive headache (± neck pain), dizziness, visual changes, nausea/vomiting, focal neurological signs. Worse in the morning, with coughing/straining, or forward bending; cranial nerve abnormalities, motor and sensory deficits in limbs, papilledema, positive Romberg test (coordination and balance issues), signs of increased intracranial pressure (e.g., Cushing’s triad: hypertension, bradycardia, irregular respirations).

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  • Vertebral/carotid artery dissection: Severe neck pain, “worst headache ever”, double vision, difficulty swallowing/speaking/walking, dizziness, facial numbness/sensory deficits, drop attacks, nausea, nystagmus, contralateral trunk sensory deficits, focal neurological signs.

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  • Traumatic spinal fracture: Severe localized pain following trauma (e.g., pedestrian struck, high-speed collision, rollover, ejection from motor vehicle, fall ≥3 feet/5 stairs, axial load to head), age ≥65, extremity weakness/tingling/burning, inability to rotate neck 45° left/right, midline cervical spine tenderness (Canadian C-Spine Rule).

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  • Acute narrow-angle glaucoma: Severe unilateral eye pain, blurred vision, light halos, nausea/ vomiting; exam may reveal optic nerve cupping and visual field deficits.

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  • Cervical myelopathy: Gait disturbances, hand clumsiness, non-dermatomal numbness/weakness (upper/lower extremities), bowel/bladder dysfunction, hyperreflexia, hypertonia, pathological reflexes (e.g., positive L’Hermitte sign, finger escape sign).

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  • Giant Cell Arteritis: Typically age >60 years (often with polymyalgia rheumatica). Presents with new temporal headache, scalp tenderness, jaw claudication, vision changes (including loss), tender/nodular temporal artery, bruits over carotid/temporal artery, abnormal fundoscopy (e.g., optic disc edema).

 

ACTION: Refer to appropriate medical provider:

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  • Non-traumatic spinal fracture: Sudden severe pain, osteoporosis, corticosteroid use, female, age >60, spinal fracture/cancer history, point tenderness over vertebra, inability to rotate neck 45°, extremity neurological signs.

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  • Spinal malignancy: Progressive headache (worse at night or with exertion/unrelieved by rest), cancer history, constitutional symptoms (e.g., fatigue, weight loss, night sweats), localized tenderness, neurological deficits.

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  • Inflammatory arthritides: Neck and joint pain/stiffness, morning stiffness >1 hour, systemic symptoms (e.g., fatigue, weight loss, fever), joint swelling/tenderness/deformity.

    • Spondyloarthropathies (e.g., ankylosing spondylitis): Pain/stiffness radiating to shoulders/upper back, improves with activity, may include uveitis/psoriasis.

    • Rheumatoid arthritis: Symmetrical joint involvement, joint deformities.

    • Systemic lupus erythematosus (SLE): Butterfly rash, photosensitivity, organ involvement (e.g., kidney or pleuritis).

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  • Migraine: Moderate to severe unilateral (can be bilateral) throbbing pain, worsened by activity, often with nausea/vomiting, photophobia, phonophobia; possible aura; neurologic exam is typically normal.

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

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Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

 

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   

  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.

  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

 

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

 

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.

  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.

  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:

    • PHQ-9 (depressive symptoms)

    • GAD-7 (anxiety symptoms)

    • FABQ (fear related to physical activity/work)

    • PCS (catastrophic thoughts)

    • ORT (opioid risk)​

6. Yellow Flags: Psychosocial Factors that May Delay Recovery

 

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

 

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.

  • Social: Lack of family/social support, limited connections.

  • Socioeconomic: Employment status, financial stress, litigation/compensation.

  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.

  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).

  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

 

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  

  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.

  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:

    • PHQ-9 (depressive symptoms)

    • GAD-7 (anxiety symptoms)

    • FABQ (fear related to physical activity/work)

    • PCS (catastrophic thoughts)

    • ORT (opioid risk)​

7. Physical Examination

 

  • Observation: Evaluate for abnormalities, asymmetries, posture, balance, gait, movements, facial expression.

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

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  • Range of motion (ROM): Assess active, passive, and resisted cervical spine ROM in flexion, extension, lateral flexion, and rotation. Note regional or segmental hypo-/hypermobility and aberrant movements.

 

  • Palpation: Examine for tenderness, swelling, tightness, or temperature changes in bones, joints, and soft tissues of the head and neck region.

 

  • Neurological Examination:

 

  • Motor strength testing: Assess for asymmetry or weakness indicating nerve root involvement:

    • C5: Shoulder abduction

    • C6: Wrist extension

    • C7: Wrist flexion and finger extension

    • C8: Finger flexion

    • T1: Finger abduction/adduction

 

  • Sensory testing: Assess for sensory deficits in dermatomal distributions:

    • C5: Lateral arm

    • C6: Lateral forearm, thumb, index finger

    • C7: Middle finger

    • C8: Ring and small finger, medial forearm

    • T1: Medial arm

    • T2: Axilla

 

  • Reflex testing: Assess for asymmetry, diminished/absent reflexes:

    • C5: Biceps

    • C6: Brachioradialis

    • C7: Triceps

 

  • Upper motor neuron signs: Assess for increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate central nervous system disorders (e.g., myelopathy, multiple sclerosis, stroke).

 

  • Lower motor neuron signs: Assess for muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate systemic neurological conditions (e.g., radiculopathy, peripheral neuropathy, ALS).

 

  • Cranial nerves tests:

    • CN I (Olfactory): Sense of smell.

    • CN II (Optic): Visual acuity and visual fields.

    • CN III, IV, VI (Oculomotor, Trochlear, Abducens): Eye movements, pupil response.

    • CN V (Trigeminal): Facial sensation, mastication muscles.

    • CN VII (Facial): Facial expressions (smile, frown), taste (anterior 2/3 of the tongue).

    • CN VIII (Vestibulocochlear): Hearing and balance.

    • CN IX, X (Glossopharyngeal, Vagus): Gag reflex, palate elevation, swallowing.

    • CN XI (Accessory): Shoulder shrug, head rotation.

    • CN XII (Hypoglossal): Tongue movements (deviation).

 

  • Special/Orthopedic Tests: Perform as clinically indicated.

 

  • Advanced Diagnostics: Radiography is generally not recommended without red flags or specific individual factors (e.g., contraindications to treatment).

8. Diagnostic Criteria for Cervicogenic and Tension-Type Headaches

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Cervicogenic Headache (secondary to cervical spine disorders)

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  • Definition: Headache arising from disorders of the cervical spine or soft tissues, typically provoked by cervical ROM or other neck-specific tests (e.g., cervical flexion-rotation, myofascial trigger points).

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  • Prevalence: Accounts for 15–20% of all chronic recurrent headaches.

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  • Pain location: Usually unilateral, originating in the nuchal region and extending to the oculofrontal area.

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  • Duration: May fluctuate or be continuous.

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

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  • Examination: Normal upper extremity and cranial nerve exam.

 

Tension-type Headache (TTH)

 

  • Definition: A primary headache not attributable to another pathology requiring medical intervention (e.g., infection, tumor).

 

  • Prevalence: The most common primary headache globally (≈26%); peak prevalence at ages 35–39.

 

  • Pain location: Bilateral, pressing/tightening, non-throbbing (“band-like”), mild to moderate intensity.

 

  • Duration:

    • Episodic

      • Infrequent: At least 10 episodes/year occurring on <1 day/month on average (<12 days/year), lasting 30 minutes to 7 days.

      • Frequent: At least 10 episodes on 1–14 days/month over >3 months (≥12 and <180 days/year), lasting 30 minutes to 7 days.

    • Chronic

      • ≥15 days/month for >3 months (≥180 days/year), episodes last hours or may be continuous.

 

  • Signs/Symptoms:

    • May include only one of photophobia, phonophobia, or mild nausea; not associated with moderate/severe nausea or vomiting.

    • May involve scalp/neck muscle tenderness.

    • Does not worsen with routine activity.

 

  • Examination: Normal upper extremity and cranial nerve exams.

9. Treatment Considerations for Cervicogenic and Tension-Type Headaches

 

Guideline-Supported Interventions

Treatments should integrate clinician experience, patient preferences, and individual needs with a multimodal approach to reduce pain, optimize function, and promote daily activity participation. Informed consent must follow a comprehensive report of findings.

 

1. Education and Self-Management (Bussières et al., 2016; Côté et al., 2016; Côté et al., 2019)

    These interventions address modifiable prognostic factors for recovery [see Section 10].

 

  • Education & reassurance: Clarify pain's biopsychosocial dimensions and set realistic expectations. Reassure patients that tension-type and cervicogenic headaches typically do not stem from serious pathology. Use tailored, evidence-based information in various formats (written, digital, visual) to empower individuals. Limited evidence suggests no single superior type of education for improving patient outcomes, but consistent reinforcement improves understanding and engagement.

 

  • Self-care: Encourage regular exercise, nutrition, sleep hygiene, stress management, weight maintenance, and avoidance of smoking/substance abuse. Employ SMART goals and Brief Action Planning for sustained engagement.

 

  • Daily activities: Promote continued movement and daily activity participation; discourage prolonged rest, immobilization, or the use of neck collars. Maintaining normal activity reduces recovery time and prevents disability.

 

  • Social & work engagement: Encourage participation using pacing strategies and workplace accommodations to support social functioning and productivity.

 

2. Exercise Therapy (Bussières et al., 2016; Blanpied et al., 2017; Côté et al., 2016; Côté et al., 2019)

  • Tailor individualized programs to improve strength, mobility, and aerobic capacity.

  • Exercise reduces pain, improves quality of life, and enhances function. No single type is superior; selection should align with patient preferences and needs.

  • Monitor psychological responses to exercise; refer to medical/mental health providers if signs of distress or aversion arise.

 

3. Manual Therapy (Bussières et al., 2016; Blanpied et al., 2017; Côté et al., 2016; Côté et al., 2019)

  • Incorporate spinal manipulation (for cervicogenic headache), mobilization, and soft tissue techniques to reduce pain and improve function.

  • Manual therapy should be integrated as part of a broader care plan to maximize effectiveness.

 

4. Psychosocial and Psychological Support (Bussières et al., 2016; Côté et al., 2016; Côté et al., 2019)

  • Address barriers: Screen for psychosocial barriers (e.g., fear of movement, low recovery expectations, anxiety) using tools (e.g., FABQ, PHQ-9, GAD-7, ORT,  PCS). Addressing these factors improves engagement and recovery. Provide education and strategies within the scope of care to support recovery (e.g., stress management, self-efficacy building, social/occupational engagement) [see Sections 5 and 6].

 

  • Resources & instruction: Offer resources (e.g., online tools, written materials, mindfulness programs). Refer mind-body practitioners (e.g., yoga, meditation) for further support when conservative care is insufficient.

 

  • Medical/mental health referral: Refer people with severe, persistent, or impairing symptoms to qualified medical/mental health providers or community support services to address psychological and social barriers to recovery [see Sections 5 and 6].

 

5. Medication (Côté et al., 2016)

  • Short-term use of analgesics, NSAIDs, or muscle relaxants may be considered for pain relief, in consultation with a medical provider.

  • Long-term opioid use is discouraged due to dependency risk.

 

6. Multimodal Care (Bussières et al., 2016; Côté et al., 2016; Côté et al., 2019)

  • Integrate physical, psychological, and social interventions tailored to individual needs, particularly for persistent headache, to support function, work, and community engagement through predominantly non-pharmacologic care.​

10. Risk and Prognostic Factors for Cervicogenic and Tension-Type Headaches

 

  • Risk Factors:

    • Cervicogenic headache (Huguet et al., 2016; Kazeminasab et al., 2022): Female, having sustained an injury that limits neck movement, unemployed.

    • Tension-type headache (Huguet et al., 2016; Lyngberg et al., 2005): Younger age, female, poor self-rated health, inability to relax after work, sleeping few hours per night.

 

  • Prognosis: Cervicogenic and tension-type headaches can be episodic, chronic, or recurrent.

 

  • Negative Prognostic Factors:

    • Cervicogenic headache (Fleming 2007; Probyn et al., 2017; Shearer et al., 2021): Depression, anxiety, poor sleep, stress, medication overuse, younger age, unemployment, headache not provoked or relieved by movement, passive coping strategies, higher initial pain level, poor recovery expectations, persistent symptoms, work-related factors, functional limitations, previous neck pain, arm pain.

    • Tension-type headache (Bendtsen & Jensen, 2006; Castien et al., 2012; Huguet et al., 2016; Probyn et al., 2017): Female, chronic TTH, coexisting migraine, sleep problems, not being married, depression, anxiety, poor sleep, stress, medication overuse, poor self-efficacy, multiple-site pain, reduced cervical range of motion, higher headache intensity. Children: negative emotional states (anxiety, depression, mental distress).

11. Ongoing Follow-up

 

  • Adjust treatment plan: Continuously realign the treatment plan based on the patient’s evolving goals, feedback, clinical outcomes, and professional judgment.

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  • Referral/co-management: Consider referring or co-managing the patient with other providers if there is no significant improvement within the established treatment timeline (e.g., 6-8 weeks).

12. Criteria for Discharge

 

  • Discharge criteria: Establish clear criteria, such as achieving initial goals, reaching a plateau in progress, or significant improvement/management of signs and symptoms.

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  • ​Post-discharge planning: Discuss strategies for self-management and provide guidance on potential follow-ups or future care needs.

References

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  • Bendtsen L and Jensen R. Tension-type headache: the most common, but also the most neglected, headache disorder. Current Opinion in Neurology, 2006.

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  • Fleming R. Influential variables associated with outcomes in patients with cervicogenic headache. JMPT, 2007.

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  • Huguet A, et al. Systematic review of childhood and adolescent risk and prognostic factors for recurrent headaches. J Pain, 2016.

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  • Lyngberg A, et al. Incidence of primary headache: a Danish epidemiologic follow-up study. American Journal of Epidemiology, 2005.

 

  • Probyn K, et al. Prognostic factors for chronic headache. A systematic review. Neurology, 2017.

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Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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