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Tension-type and Cervicogenic Headache Care Pathway

Date of last update: April, 2024

Treatment and Management


Headache Associated with Neck Pain after Ruling Out Risk Factors for Serious Pathologies

Clinical Cornerstone:

  • A comprehensive approach to managing involves integrating education, assurance, self-care, conservative management, and specific interventions when necessary. This approach should be grounded in evidence-based practice, respectful of cultural nuances, and prioritize patient needs and values. It emphasizes professional collaboration and is continuously fine-tuned based on patient feedback  and progress, ensuring a unified, empathetic, and efficient pathway.

  • While passive modalities such as Transcutaneous Electrical Nerve Stimulation (TENS), needling therapies (acupuncture, dry needling), and traction might offer neck pain relief or relaxation, it is essential to integrate these with active management strategies. This combination addresses the multifaceted nature of headache associated with neck pain, fostering sustainable pain management and enhancing function and participation.


Strategy Details


  • Patient Education: Focus on patient understanding the nature of the condition, the course of the condition, implementing pain management strategies, and actively participating in the rehabilitation process.

  • Reassure patients that tension-type and cervicogenic headaches typically do not stem from serious pathology. Clarify the biopsychosocial dimensions of pain, address underlying psychosocial factors, and underscore the importance of  active participation in care and setting realistic expectations.

  • Self-care: Crucial for managing LBP and facilitating a return to meaningful activities. Incorporate strategies like goal setting/Brief Action Planning/SMART goals.

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

    • Lifestyle changes: Prioritize a healthy diet, regular physical activity, good sleep habits, maintaining a healthy body weight, and abstaining from smoking.

    • Ergonomics and behaviour change to reduce strain during physical or sedentary work.

    • Engage in social and work activities.

  • Social support: Solicit an appropriate level of personal-network support, engage in social and work activities.

  • Psychological therapy: Referral to an appropriate healthcare provider if needed.

  • Mind-Body Interventions: Techniques like mindfulness, meditation, and cognitive-behavioral therapy (CBT).

Consider Additional Treatment Strategies for Persistent Tension-Type Headaches:

  • Specific Exercise: low-load endurance craniocervical and cervicoscapular exercises with resistance.

  • Manual therapy: manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for Persistent Tension-Type Headaches (no evidence of effectiveness for cervical spine manipulation in Episodic Tension-Type Headaches).

Consider Additional Treatment Strategies for Chronic Cervicogenic Headaches:

  • Specific Exercise: low-load endurance craniocervical and cervicoscapular exercises

  • General exercise (including warm-up, neck and shoulder stretching and strengthening, and aerobic exercise).

  • Manual therapy: e.g., mobilization, manipulation, clinical massage. (No evidence of effectiveness when manipulation is offered as the sole form of treatment)

  • Self-care: Therapist-guided/directed postural correction of the cervical and thoracic spine in a sitting position

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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