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Tension-type and Cervicogenic Headache Care Pathway

Date of last update: April, 2024

Signs or Symptoms of Pathology (Red Flags)


Clinical Cornerstone: Consider asking additional questions that help to further evaluate for the potential presence of red flags in headaches. Red flags are symptoms or signs that may indicate the presence of a serious pathology and should be deliberated in the clinician’s differential diagnosis.

  • Spinal fracture

    • Red flags include: history of osteoporosis, corticosteroid use, severe trauma or dangerous mechanism, female sex, older age, history of spinal fracture, history of cancer, history of falls, ≥65 years of age, paresthesias in extremities, inability to actively rotate the neck 45 degrees to the left and right (Canadian C-Spine Rule).

    • Action: to appropriate provider for immediate imaging.


  • Intracranial tumor (benign or malignant)

    • Red flags include: history of cancer, unexplained weight loss, unexplained significant night sweats, pains worse at night or that wake the patient, progressive headaches worse with exertion or coughing, personality change, new onset or change of headache after age 40.

    • Action: Refer to an appropriate provider.

  • Infectious disease

    • Red flags include: progressive headache, intravenous drug use, poor living conditions, immunosuppression, recent surgery/invasive interventions, history of TB/born in TB-endemic country, recent infection, unexplained constitutional symptoms (e.g. fever/chills).

    • Action: Immediate emergency referral.

  • Cervical myelopathy

    • Red flags include: gait disturbances, hand clumsiness, non-dermatomal numbness, weakness or numbness and weakness involving  lower extremity / bowel / bladder, coordination problems.

    • Action: Immediate emergency referral.

  • Meningitis

    • Red flags include: neck stiffness, severe generalized headache that is worse upon flexion with reactive hip / knee flexion, neck pain or headache with fever or  vomiting or rash,  altered mental status, photophobia.

    • Action: Immediate emergency referral.

  • Cranial or Cervical Vascular Disorders

    • Red flags include: severe neck pain and/or headache (described as the worst pain ever)(may be acute onset or progressive), double vision, difficulty initiating swallowing, dizziness, drop attacks,facial numbness, difficulty walking, nausea, nystagmus, new onset of headache after age 40, jaw claudication.

    • Action: Immediate emergency referral.

  • Intracranial/Brain Lesion

    • Red flags include: sudden (reaches maximum intensity within five minutes) and intense onset headache (“thunderclap headache”), recent (within three months) trauma.

    • Action: Immediate emergency referral.

  • Neurological disorders (e.g., MS, ALS, neurodegenerative disorders)

    • Red flags include: upper/lower motor neuron findings, clonus.

    • Action: Refer to appropriate provider.

  • Acute narrow-angle glaucoma

    • Red flags include: associated severe unilateral eye pain, blurred vision, light halos, nausea or vomiting.

    • Action: Immediate emergency referral.

Orange Flags


Clinical Cornerstone: Orange Flags are symptoms or signs that may represent the presence of serious psychiatric disorder (e.g., major depression, major personality disorders, post-traumatic stress disorders [PTSD], substance addiction and abuse). In the event such disorders are present, referral to a psychiatric specialist would be indicated over usual care in the presence of non-major disorders such as anxiety. Screening can include:

Conduct patient assessment

Red flags or Orange flags present

Red flags or Orange flags present

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Refer to appropriate emergency or healthcare provider





(Diagnosis of tension-type headaches,

diagnosis of cervicogenic headaches, prognosis)

Headache Associated with Neck Pain

  • Structured patient education

  • Assurance

  • Self care

  • Emotional/social support

Additionally for Persistent Tension-type Headaches

  • Specific neck and shoulder exercises

  • Manual therapy

Additionally for Persistent Cervicogenic Headaches

  • Specific neck and shoulder exercises

  • Manual therapy

Major symptom/sign change

Goals not achieved


Adjust treatment and management plan or refer

Differential Diagnosis

Differential Diagnosis

(Primary headaches, secondary headaches, cranial neuralgias)




References or links to primary sources

  • Bussières A.E, et al. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. Journal of manipulative and physiological therapeutics. 2008;31(1):33-88. doi:10.1016/j.jmpt.2007.11.003.

  • Bussières A.E, et al. The treatment of neck pain -associated disorders and whiplash-associated disorders: A clinical practice guideline. J Man Phys Ther. 2016; 39(8):P523-564.

  • Berman D., et al Comparison of Clinical Guidelines for Authorization of MRI in the Evaluation of Neck Pain and Cervical Radiculopathy in the United States. Journal of the American Academy of Orthopaedic Surgeons 31(2):p 64-70, January 15, 2023. | DOI: 10.5435/JAAOS-D-22-00517.

  • Côté P, et al. Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. European journal of pain (London, England). 2019;23(6):1051-1070.

  • Côté P, et al. Management of neck pain and associated disorders: A clinical practice guidelines from the Ontario Protocol for Traffic Injury (OPTIMa) Collaboration. Eur Spine J. 2016; 28:2000-2022.

  • Demont A., et al. Cervicogenic headache, an easy diagnosis? A systematic review and meta-analysis of diagnostic studies. Musculoskelet Sci Pract. 2022 Dec;62:102640.

  • Fernandez M., et al. Spinal manipulation for the management of cervicogenic headache: A systematic review and meta-analysis. European Journal of Pain. 2020;24(9):1687-1702.

  • Knackstedt H, et al. Cervicogenic headache in the general population: the Akershus study of chronic headache. Cephalalgia : an international journal of headache. 2010;30(12):1468-147.

  • Núñez CP, Leirós RR. Effectiveness of manual therapy in the treatment of cervicogenic headache: A systematic review. Headache: The Journal of Head & Face Pain. 2022;62(3):271-283.

  • Rubio-Ochoa J., et al.  Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review. Manual Therapy. 2016;21:35-40.

  • Shearer H.M., et al. The course and factors associated with recovery of whiplash-associated disorders: an updated systematic review by the Ontario protocol for traffic injury management (OPTIMa) collaboration. European Journal of Physiotherapy. 2021 Sep 3;23(5):279-94.

  • Sjaastad O, Bakketeig LS. Prevalence of cervicogenic headache: Vågå study of headache epidemiology. Acta neurologica Scandinavica. 2008;117(3):173-180.

  • Stiell I.G., et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA. 2001;286(15):1841–1848. doi:10.1001/jama.286.15.1841.

  • Stovner LJ,, et al. Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2018 Nov 1;17(11):954-76.

  • Stovner LJ, et al. The global prevalence of headache: an update, with analysis of the influences of methodological factors on prevalence estimates. The journal of headache and pain. 2022 Dec;23(1):34.

Contact information for further inquiries or feedback

These care pathways are intended to provide information to practitioners who provide care to people with musculoskeletal conditions. The care pathways on this website are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. As knowledge and healthcare practices evolve, these pathways may be updated to ensure they remain current and evidence driven. These pathways are not intended to replace advice from a qualified healthcare provider.

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