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Cervicogenic and Tension-Type Headaches Care Pathway

Date of last update: September, 2024

9. Treatment Considerations for Cervicogenic and Tension-Type Headaches

 

Report of Findings (ROF) and Informed Consent

The Report of Findings (ROF) and Informed Consent process is crucial to patient care and to the therapeutic relationship. It involves explaining the diagnosis, prognosis, and treatment plan to the patient. This ensures the patient understands their condition and the proposed management strategies and agrees to the treatment plan voluntarily. Consider the following opportunities to develop a shared understanding:

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1. Review of Diagnosis and Prognosis:

  • Clearly explain the diagnosis, results of examinations and tests, and the expected course of the condition using understandable language and visual aids if necessary.

 

2. Treatment Plan Overview:

  • Discuss the recommended treatments and their rationale.

  • Explain how each intervention aligns with the patient's goals and preferences.

 

3. Informed Consent:

  • Explain the condition: Use clear and simple language to describe the patient's condition and how it affects their health.

  • Discuss treatment options: Provide detailed information about each treatment option, including the potential benefits, risks, and alternatives.

  • Address questions and concerns:

    1. Encourage the patient to ask questions and discuss any concerns they may have.

    2. Provide thorough and understandable answers to ensure the patient feels comfortable and informed.

  • Obtain explicit consent:

    1. Review the diagnosis.

    2. Propose a plan of care that relates to the patient’s condition and circumstances.

    3. Contextualize the potential risks and benefits of the proposed treatments.

    4. Encourage the patient to ask questions or express any concerns they may have. Consider utilizing strategies such as “teach-back” to confirm patient understanding.

    5. Ensure that all questions and concerns are appropriately addressed before proceeding.

    6. Obtain explicit consent from the patient to proceed with the proposed treatment plan.

  • Document the consent: Ensure the patient's consent is documented in their clinical record. Concisely record the information provided, questions asked by the patient, and the patient's understanding and agreement to the treatment plan.

  • Adhere to jurisdictional standards: Ensure the practitioner is meeting their jurisdiction’s standards of practice for informed consent.

 

Core Interventions:

Core for managing cervicogenic and tension-type headaches, focusing on optimizing function and participation in daily life.

 

Education and Reassurance:

  • Rationale: Helps patients understand their condition, implement pain management strategies, and actively participate in the rehabilitation process.

  • Advantages: Increases patient confidence and engagement in their care.

  • Disadvantages: Requires time and effective communication skills.

  • Key Points:

    • Clarify pain's biopsychosocial dimensions and set realistic expectations. Reassure patients that tension-type and cervicogenic headaches typically do not stem from serious pathology.

    • There is limited evidence of superior education types for improving patient outcomes. Tailor education strategies to individual patient needs and preferences (e.g., written, digital, visual).

    • Regularly engage patients in the educational process and assess their understanding to ensure effective communication and knowledge retention.

 

Address Yellow Flags:

  • Rationale: Factors (fear of movement, anxiety, depression, and social or occupational stressors) can significantly influence the perception of pain, adherence to treatment, and overall recovery.

  • Advantages: Promotes a more comprehensive approach to treatment, promotes active participation, improves recovery outcomes.

  • Disadvantages: Requires time and resources; some people may resist addressing psychosocial factors; may require a multidisciplinary approach.

  • Key Points:

    • Screen for psychosocial factors using validated tools, such as the Fear-Avoidance Beliefs Questionnaire (FABQ), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), Opioid Risk Tool (ORT), or the Pain Catastrophizing Scale (PCS).

    • Educate patients on how these factors influence their pain and recovery, and incorporate cognitive behavioral techniques (CBT) to help them manage fear, anxiety, and negative thoughts.

    • Refer to mental health professionals when necessary, especially for significant distress or mental health disorders. Collaborate with other healthcare providers for an integrated, multidisciplinary approach.

    • Encourage support from family, friends, and support groups, and maintain open, empathetic communication to regularly discuss concerns and progress.

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Maintain Activities of Daily Living:

  • Rationale: Prevents deconditioning and promotes recovery.

  • Advantages: Maintains function and reduces disability.

  • Disadvantages: Patients may need guidance on safe activities.

  • Key Points:

    • Encourage normal activities and proper self-care. Use Brief Action Planning for self-management.

 

Self Care:

  • Rationale: Supports long-term health.

  • Advantages: Empowers patients.

  • Disadvantages: May require continuous motivation and support.

  • Key Points:

    • Set SMART goals, prioritize a healthy diet, regular physical activity, good sleep habits, stress management, and avoid smoking/substance abuse.

    • Implement ergonomics and behavior changes to reduce strain.

    • Utilize techniques like Brief Action Planning to support self-management and promote regular movement and engagement in normal activities, including work.

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Engage in Social and Work Activities:

 

  • Rationale: Promotes well-being and independence.

  • Advantages: Enhances mental health and maintains conditioning.

  • Disadvantages: May be challenging for severe pain cases, risk of symptom exacerbation, requires balanced activity.

  • Key Points:

    • Encourage gradual re-engagement.

    • Modify activities to fit current functional levels.

    • Educate on pacing and support workplace accommodations/modifications if needed.

 

Exercise Therapy:

  • Rationale: Enhances strength, flexibility, and fitness.

  • Advantages: Improves function and reduces pain.

  • Disadvantages: Requires regular commitment and proper technique.

  • Key Points:

    • Types of exercises: Includes low-load endurance craniocervical and cervicoscapular strengthening, neck and shoulder stretching and strengthening; range of motion, aerobic, mind-body exercises (e.g., yoga, tai chi). There is limited evidence of superior exercise types for improving patient outcomes. Tailor to individual needs and preferences.

    • Psychological considerations: Challenging patients during exercise therapy (beyond psychotherapy) can have psychological implications. Watch for signs of increased anxiety, depression, or distress related to the exercise regimen. Be mindful if the person’s mental health condition worsens despite adherence to the exercise program or if the person expresses a strong aversion or fear of the exercises.

    • Referral threshold: Consider referral to the appropriate provider (physician, psychologist, psychiatrist, mental health professional) when the psychological burden of exercise therapy exceeds the patient’s coping capacity or falls outside of the scope (e.g., person exhibits significant psychological barriers or disorders such as severe anxiety or depression).

 

Optional Interventions: Tailored to patient needs and preferences through rationale and shared decision-making (SDM). These interventions have varying evidence levels.

 

​​Manual Therapy:

  • Rationale: Provides symptom relief and improves mobility.

  • Advantages: Immediate pain relief.

  • Disadvantages: Effects may be temporary; requires skilled practitioners.

  • Key Points: Techniques include mobilization, manipulation, soft tissue techniques, and massage (cervical and thoracic spine) (particularly for cervicogenic headache). Adjust based on pain exacerbation. Contraindications to spinal manipulation therapy include:

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Absolute Contraindications

Relative Contraindications

Region-specific Contraindications

- Acute fracture
- Acute infection (osteomyelitis, septic discitis, tuberculosis of the spine)
- Aggressive benign tumors (aneurismal bone cyst, giant cell tumor, osteoblastoma, osteoid osteoma)
- Anomalies such as dens hypoplasia,
unstable os odontoideum
- Arnold Chiari malformation
- Basilar invagination of the upper cervical spine
- Congenital generalized hypermobility
- Diastematomyelia
- Dislocation of a vertebra
- Frank disc herniation with progressive neurological deficit
- Hematomas (spinal cord or intracanalicular)
- Hydrocephalus of unknown etiology
- Internal fixation/stabilization devices
- Malignancy of the spine
- Meningeal tumor
- Neoplastic disease of muscle or soft tissue
- Positive Kernig’s or L’hermitte’s signs
- Signs or patterns of instability
- Spinal cord tumor
- Syringomyelia

- Articular hypermobility and uncertain joint stability
- Acute injuries of joints and soft tissues
- Benign bone tumors with risk of pathological
- Bone weakened by metabolic disorders
- Circulatory and hematological disorders
- Demineralization of bone (osteoporosis, long-term steroid therapy)
fractures
- Infection of bone and joint
- Malignancies, including malignant bone tumors
- Neurological disorders
- Postsurgical joints or segments with no evidence of instability
- Severe or painful disc pathology (discitis, disc herniations)
- Traumatic events requiring careful examination for excessive motion
- Tumor-like and dysplastic bone lesions

- Aneurysm involving a major blood vessel
- Atlantoaxial instability
- Bleeding disorders (anticoagulant therapy, blood dyscrasias)
- Vertebrobasilar insufficiency syndrome

Psychological Support:

  • Rationale: Addresses emotional and cognitive aspects of pain.

  • Advantages: Reduces psychological barriers to recovery.

  • Disadvantages: Requires patient willingness to engage.

  • Key Points: Techniques like mindfulness, meditation, CBT, counselling.

    • Referral Threshold: Referrals should be considered for patients showing significant disorders of thought, mood, or behavior, particularly when: symptoms are severe or persistent; there is no improvement in symptoms despite conservative management; functional impairment significantly impacts the patient’s daily activities and quality of life; there are signs of moderate to severe pathology based on Patient-Reported Outcome Measures (PROMs) thresholds (e.g., PHQ-9, GAD-7); management falls outside the scope of practice, such as the need for specialized psychotherapy or psychiatric intervention.

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Social Support:

  • Rationale: Enhances coping mechanisms through community and family support.

  • Advantages: Provides emotional and practical support.

  • Disadvantages: Social dynamics can be complex.

  • Key Points: Encourages engagement in social and work activities, fostering a supportive environment.

    • Referral Threshold: Consider referrals when the person lacks adequate social support, which may impact their recovery; there are significant social or environmental barriers that cannot be addressed within the scope of clinical practice; the patient needs specialized support services, such as social work or community resources.

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Mind-Body Interventions:

  • Rationale: Integrates mental and physical health.

  • Advantages: Reduces stress and improves well-being.

  • Disadvantages: Requires patient openness and engagement.

  • Key Points: Includes practices like mindfulness, meditation, yoga, tai chi.

    • Referral Threshold: Consider referral to practitioners who specialize in mind-body therapies (e.g., yoga therapists, meditation instructors, tai chi practitioners) when the person exhibits high levels of stress or anxiety that could benefit from structured mind-body interventions; conservative management alone does not adequately address the patient’s psychological or physical stress symptoms; the person needs specialized instruction or support in engaging with mind-body practices.

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​​​Multimodal Care:

  • Rationale: Integrates multiple therapeutic approaches.

  • Advantages: Comprehensive and holistic.

  • Disadvantages: Requires coordination among multiple healthcare providers, can be resource intensive.

  • Key Points: Combines therapies such as CBT, manual and exercise therapy, social support. Tailored to patient needs.

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Medications:

  • Rationale: Alleviates pain.

  • Advantages: Quick relief.

  • Disadvantages: Potential side effects and risk of dependency or medication overuse/rebound headaches (chronic headache from frequent use of pain relief medications).

  • Key Points: Includes over the counter (OTC) pain relievers, muscle relaxants, NSAIDs. Use judiciously and combine with other treatments. If OTC/prescribed medication is out of practice scope for practitioners (e.g., chiropractors, physiotherapists) refer to the appropriate provider (e.g., medical physician, nurse practitioner, pharmacist).

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Interventions to Consider with Caution Due to Less Robust Guideline Evidence:

 

Electrotherapies (e.g., TENS, IFC, low-level laser):

  • Rationale: May provide temporary relief.

  • Advantages: Non-invasive.

  • Disadvantages: Limited evidence on benefits.

  • Key Points: Should be considered as supportive to core interventions. While passive modalities such as Transcutaneous Electrical Nerve Stimulation (TENS), needling therapies (acupuncture, dry needling), and traction might offer pain relief or relaxation, it is essential to integrate these with active management strategies.

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Needling Therapies:

  • Rationale: May provide pain relief.

  • Advantages: Alternative pain management.

  • Disadvantages: Mixed evidence; may cause discomfort.

  • Key Points: Should be considered as supportive to core interventions.

 

Example: Chronic Tension-type Headache

 

Patient Presentation: A 35-year old patient presents with headaches characterized by bilateral pressure. She reports they usually feel like a “tight squeeze” and demonstrates a band-like pattern distribution around her head, though she reports her headaches are occasionally just at the base of her skull. She has been experiencing these headaches almost every-other day for the past six months, and sometimes they last longer than others.

 

Essential Interventions:

  1. Education and Reassurance:

    • Frequency: Initial visit and reinforced in follow-up visits.

    • Protocol: Provide a clear explanation of the condition, expected course with treatment (may be 6-12 weeks), and encourage the patient to stay active. Use visual aids or pamphlets for better understanding.

  2. Self-Care Practices:

    • Frequency: Daily.

    • Protocol: Recommend a home exercise program focused on general strengthening exercises tailored to the patient's abilities and pain levels. Advise on proper nutrition, adequate sleep, and stress management techniques.

  3. Maintain Activities of Daily Living:

    • Frequency: Daily.

    • Protocol: Encourage the patient to continue with normal activities as much as possible, avoiding prolonged bed rest. Provide specific instructions on safe movements and ergonomics.

  4. Address Yellow Flags (Psychosocial Factors):

    • Frequency: Regularly, integrated into each visit.

    • Protocol: Identify and address psychosocial factors such as fear of movement, depression, or anxiety. Use cognitive-behavioral strategies to modify negative beliefs about pain.

 

Optional Interventions:

  1. Manual Therapy:

    • Frequency: 9 sessions over 8 weeks, included as a component of multimodal care (spinal mobilization, craniocervical exercises, postural correction).

    • Protocol: Manual therapy and soft tissue techniques to cervical and thoracic spine. Adjust techniques based on the patient's response.

  2. Exercise Therapy:

    • Frequency: Specific exercise for 6 weeks. General exercise for 12 weeks.

    • Protocol: Low-load craniocervical and cervicospinal endurance exercises. Begin with supervised sessions and transition to the home program. Include 25 sessions over 12 weeks of general exercise.

  3. Electromodalities (e.g., TENS, IFC, low-level laser):

    • Frequency: 2-3 times per week.

    • Dose: Utilize Transcutaneous Electrical Nerve Stimulation (TENS), Interferential Current Therapy (IFC), or low-level laser therapy to provide temporary pain relief and comfort. Use in conjunction with other interventions.

  4. Medications:

    • Frequency: As needed with caution to prevent medication overuse headache.

    • Protocol: Over-the-counter NSAIDs or acetaminophen for pain relief, used judiciously and in combination with other treatments. Consider muscle relaxants if indicated. Options and risks should be discussed with the medical provider.

  5. Psychological Support:

    • Frequency: Weekly or as needed.

    • Protocol: Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other techniques to manage chronic pain and improve mental health.

Follow-Up:

  • • Regular follow-up at each visit. Reassess pain levels, functional status, and goal achievement every 2-4 weeks and adjust the treatment plan as necessary.

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Example: Cervicogenic Headache

 

Patient Presentation: A patient presents with one-sided headache that begins at the base of her neck in the back and extended to her forehead and eye on the same side. She reports that she started experiencing neck pain around the same time as the headache, and both started shortly after a new job that requires her to work on a computer for a prolonged time. Her head and neck both feel achy, and although not debilitating they are quite bothersome. She’s discovered she can get some relief by massaging/pressing on her own neck.

 

Essential Interventions:

  1. Education and Reassurance:

    • Frequency: Initial visit and reinforced in follow-up visits.

    • Protocol: Explain the nature of the condition, expected course (may be 4 to 12 weeks), and encourage active participation in the treatment plan. Use visual aids (e.g. diagrams, models, digital resources) to illustrate the condition.

  2. Self-Care Practices:

    • Frequency: Daily.

    • Protocol: Tailored home exercise program focusing on neck and shoulder stretching and strengthening. Include lifestyle advice on proper posture, nutrition, and sleep.

  3. Maintain Activities of Daily Living:

    • Frequency: Daily.

    • Protocol: Encourage modified activities to avoid exacerbating the symptoms while staying active. Provide guidance on ergonomics and safe movement strategies.

  4. Address Yellow Flags (Psychosocial Factors):

    • Frequency: At each visit.

    • Protocol: Identify and address factors such as fear of movement, poor recovery expectations, depression, anxiety, work-related or family issues, and maladaptive coping mechanisms. Provide appropriate reassurance, counseling, or referrals to mental health professionals as needed.

 

Optional Interventions:

  1. Exercise Therapy:

    • Frequency: 8 sessions over 6 weeks.

    • Protocol: Include low-load craniocervical and cervicospinal endurance exercises. Begin with supervised sessions and transition to the home program.

  2. Manual Therapy:

    • Frequency: Spinal mobilization/manipulation (10 sessions over 6 weeks). A second course may be indicated if the patient demonstrates ongoing and significant improvement according to their goals. Eight 45-minutes sessions of massage therapy to neck and shoulder area over 4 weeks.

    • Protocol: Adjust techniques based on patient response and pain levels.

  3. Electromodalities (e.g., TENS, IFC, low-level laser):

    • Frequency: 2-5 times per week for 3 weeks.

    • Protocol: Utilize TENS, IFC, or low-level laser therapy to provide temporary pain relief and comfort. Use as an adjunct to other therapies.

  4. Medications:

    • Frequency: As needed with caution to prevent medication overuse headache.

    • Protocol: NSAIDs or acetaminophen for pain management, possibly combined with muscle relaxants for short-term relief of acute symptoms. Options and risks should be discussed with medical provider.

  5. Psychological Support:

    • Frequency: Weekly or as needed.

    • Protocol: Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other techniques to manage chronic pain and improve mental health.

Follow-Up:

  • Regular follow-up at each visit. Reassess pain levels, functional status, goal achievement every 2-4 weeks and adjust the treatment plan as necessary.

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