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Cervicogenic and Tension-Type Headaches Care Pathway

Date of last update: August, 2024

4. Differential Diagnosis Requiring Medical Attention

 

Red Flags: Immediate Referral to Emergency Care:

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1. Meningitis

  • Pain Location: Neck stiffness, generalized headache.

  • Signs/Symptoms/Red Flags: Severe headache worse with neck flexion, fever, vomiting, rash, altered mental status, lethargy or drowsiness, photophobia, flexed hip and knee posturing.

  • Physical and Neurological Examination: Positive tests include Brudzinski and Kernig signs.

  • Action: Immediate referral to emergency care.

 

2. Intracranial/Brain Lesion

  • Pain Location: Headache, may or may not be accompanied by neck pain.

  • Signs/Symptoms/Red Flags: Sudden intense generalized headache (thunderclap); unexplained headache, dizziness, or visual changes; aggravated by coughing or straining; worse in the morning or after prolonged recumbency; possible vomiting or focal neurological signs.

  • Physical and Neurological Examination: Headache provoked by forward bending; possible cranial nerve abnormalities, papilledema, motor and sensory deficits in limbs, positive Romberg test (coordination and balance issues), signs of increased intracranial pressure (e.g., Cushing’s triad – hypertension, bradycardia, irregular respirations).

  • Action: Immediate referral to emergency care.

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3. Vertebral/Carotid Artery Dissection

  • Pain Location: Neck pain, may or may not be accompanied by headache.

  • Signs/Symptoms/Red Flags: Severe neck pain or headache (“worst pain ever”); double vision; difficulty swallowing, speaking, walking; dizziness, drop attacks, facial numbness, nausea, nystagmus.

  • Physical and Neurological Examination: Facial and contralateral trunk sensory deficits, focal neurological signs.

  • Action: Immediate referral to emergency care.

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4. Spinal Infection

  • Pain Location: Neck pain and stiffness.

  • Signs/Symptoms/Red Flags: Progressive or constant pain, pain worse at night, unexplained constitutional symptoms (e.g. fever/chills), immunosuppression, recent infection or surgery, TB (tuberculosis) history, IV drug use, poor living conditions.

  • Physical and Neurological Examination: Tenderness on palpation or tap test, possible redness or heat.

  • Action: Immediate referral to emergency care.

 

5. Acute Narrow-angle Glaucoma

  • Pain Location: Severe unilateral eye pain.

  • Signs/Symptoms/Red Flags: Blurred vision, light halos, nausea or vomiting.

  • Physical and Neurological Examination: Cupping of the optic nerve on ophthalmoscopic exam, visual field deficits, other cranial nerves unaffected.

  • Action: Immediate referral to emergency care.

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6. Cervical Myelopathy

  • Pain Location: Neck pain may or may not be present.

  • Signs/Symptoms/Red Flags: Wide-based disturbances, hand clumsiness, non-dermatomal numbness or weakness in upper and lower extremities, bowel/bladder dysfunction.

  • Physical and Neurological Examination: Hyperreflexia, hypertonia, pathological reflexes, finger escape sign, lower extremity paresis, positive L’Hermitte sign.

  • Action: Immediate referral to emergency care.

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7. Traumatic Spinal Fracture

  • Pain Location: Localized pain in the neck.

  • Signs/Symptoms/Red Flags: Sudden onset of severe pain following trauma, age ≥65 years, dangerous mechanism (e.g., pedestrian struck, high-speed collision), extremity weakness/tingling/burning, inability to rotate neck 45° left and right, midline cervical spine tenderness.

  • Physical and Neurological Examination: Point tenderness over the affected vertebra, extremity neurological signs (weakness/tingling/burning).

  • Action: Immediate referral to emergency care.

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8. Giant Cell Arteritis

  • Pain Location: Temporal headache.

  • Signs/Symptoms/Red Flags: New temporal headache, scalp tenderness, age over > 60 years, jaw claudication (i.e., pain or fatigue with chewing), sudden transient or permanent loss of vision in one eye or double vision, constitutional signs and symptoms (e.g., fever, fatigue, unexplained weight loss), often associated with polymyalgia rheumatica.

  • Physical and Neurological Examination: Prominent temporal artery or nodules, tenderness over the temporal artery and surrounding area, abnormal fundoscopy exam (e.g., possible edema of the optic disc, signs of ischemic optic neuropathy), bruits over the carotid or temporal artery on auscultation.

  • Action: Immediate referral to emergency care.

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Refer to Medical Provider:

 

1. Non-traumatic Spinal Fracture

  • Pain Location: Localized pain in the neck.

  • Signs/Symptoms: Sudden onset, severe pain, osteoporosis, corticosteroid use, female sex, age >60 years, history of spinal fracture or cancer.

  • Physical and Neurological Examination: Point tenderness over the affected vertebra, inability to rotate neck 45° left and right, possible extremity neurological signs (weakness/tingling/burning).

  • Action: Referral to appropriate medical provider.

 

2. Spinal Malignancy

  • Pain Location: Severe, progressive, localized neck pain.

  • Signs/Symptoms: History of cancer; persistent pain, worse at night, not relieved by rest, constitutional symptoms (night sweats, unexplained weight loss, fatigue, fever).

  • Physical and Neurological Examination: Localized tenderness, possible neurological deficits.

  • Action: Referral to appropriate medical provider.

 

3. Inflammatory Arthritides

1. Spondyloarthropathies (e.g., ankylosing spondylitis, psoriatic arthritis, reactive arthritis):

  • Pain Location: Neck pain, may radiate to shoulders and upper back.

  • Signs/Symptoms: Morning stiffness > 1 hour, pain improves with activity, pain worse at night, presence of other inflammatory signs (e.g., uveitis, psoriasis), systemic symptoms (fatigue, weight loss, fever).

  • Physical and Neurological Examination: Possible reduced neck mobility, tenderness over cervical spine and other joints. No neurological deficits.

  • Action: Referral to appropriate medical provider.

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2. Rheumatoid Arthritis

  • Pain Location: Diffuse joint pain including the neck.

  • Signs/Symptoms: Symmetrical joint pain, morning stiffness >1 hour, systemic symptoms (fatigue, weight loss, fever).

  • Physical and Neurological Examination: Joint swelling, tenderness, and deformity. No neurological deficits.

  • Action: Referral to appropriate medical provider.

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3. Systematic Lupus Erythematosus (SLE)

  • Pain Location: Can include neck and other joints.

  • Signs/Symptoms: Joint pain and swelling, fatigue, butterfly-shaped rash on the face, photosensitivity, systemic symptoms (fatigue, weight loss, fever).

  • Physical and Neurological Examination: Joint tenderness and swelling, skin rashes, signs of organ involvement such as kidney issues or pleuritis. No neurological deficits.

  • Action: Referral to appropriate medical provider.

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4. Polymyalgia Rheumatica

  • Pain Location: Bilateral shoulders or hips. Often associated with Giant Cell Arteritis, which can cause temporal headaches.

  • Signs/Symptoms: Bilateral shoulder/hip pain and stiffness, morning stiffness >1 hour, constitutional signs and symptoms (e.g., fever, unexplained weight loss, fatigue), pain and stiffness worsening with rest.

  • Physical and Neurological Examination: Normal muscle strength and no muscle atrophy, possibly reduced range of motion in the shoulders/hips, diffuse tenderness over the shoulders/hips. No neurological deficits.

  • Action: Referral to appropriate medical provider.

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4. Migraine

  • Pain Location: Typically unilateral, can be bilateral; throbbing or pulsating pain.

  • Signs/Symptoms: Moderate to severe intensity, aggravated by physical activity. Associated with nausea, vomiting, photophobia, and phonophobia. May be preceded by aura (visual disturbances, sensory changes, etc.).

  • Physical and Neurological Examination: Normal findings, though a thorough neurological exam is essential to rule out secondary causes.

  • Action: Referral to appropriate medical provider.

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.

References

 

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Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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