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Cervicogenic and Tension-Type Headaches Care Pathway

Date of last update: August, 2024

12. Criteria for Discharge

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  • Establish clear criteria for discharge, which may include achieving specific milestones, reaching a plateau in progress, or fulfilling the patient's initial goals.

  • Discuss post-discharge plans, including self-management strategies, potential follow-ups, and supportive strategies to reduce the risk of recurrence.

  • Monitor the case progression with periodic reassessments and repeat outcome measures.

References

 

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Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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 > 1hour, 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.

  • Essential Interventions:

    • Education and reassurance

    • Self-care (exercise, nutrition, sleep, stress management, healthy body weight, no smoking/substance abuse)

    • Encouragement to maintain activities of daily living

    • Address yellow flags (psychosocial factors) (e.g., education, mindfulness, meditation, CBT, referral)

    • Engage in social and work activities

 

  • Optional Interventions (with Rationale and Shared Decision Making):

    • Exercise therapy

    • Manual therapy (e.g., spinal manipulation/mobilization particularly for cervicogenic headache, soft tissue techniques, clinical or relaxation massage)

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

    • Needling therapies

    • Psychological or social support

    • Medications: Over-the-counter pain relievers (e.g., acetaminophen, ibuprofen)/prescription, with caution due to the risk of medication-overuse headache (MOH). Discuss options and risks with your medical provider.

    • Multicomponent biopsychosocial care (e.g., exercise therapy, cognitive behavioural therapy, structured education and social support)

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.

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