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Cervicogenic and Tension-Type Headaches Care Pathway

Date of last update: August, 2024

8. Diagnostic Criteria for Neck Pain Amenable to Conservative Care

 

Diagnosis requires a thorough understanding of the patient's condition. It integrates patient stories; clinical findings; risk factor evaluations; and physical, psychological, social, and environmental aspects of pain.

 

A. Cervicogenic Headache

  • Definition: Headache secondary to disorders of the cervical spine or soft tissues, provoked by mechanical provocation of those cervical disorders.

  • Prevalence: The one-year prevalence of cervicogenic headache is estimated at 2%. Cervicogenic headaches account for 15% - 20% of all chronic recurrent headaches. Prevalence increases with age.

  • Risk Factors: Include sociodemographic factors (e.g., female sex), having sustained an injury that limits neck movement, unemployed job status.

  • Prognostic Factors for Delayed Recovery: 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.

  • Pain Location: Often with a characteristic unilateral distribution that starts from the nuchal area posteriorly and extends anteriorly to the oculofrontal area.

  • Duration: Episodes may vary in duration; may be fluctuating or continuous pain.

  • Signs and Symptoms: Moderate-intensity, non-throbbing, episodic pain.

  • Physical and Neurological Examination: Reproduction of headache during cervical spine range of motion and tests (cervical flexion-rotation, manual posterior-to-anterior intervertebral movements of cervical spine, myofascial trigger points in paraspinal muscles). Additional tests for cervical spine disorders include cervical Kemp's, cervical compression, and Spurling's tests. Normal upper extremity and cranial nerve neurological tests.

  • Other Diagnostic Studies: Relief of headache with a diagnostic greater occipital nerve anesthetic pain block.

 

 

B. Tension-Type Headache (TTH)

  • Definition: A primary headache not attributable to a pathology requiring medical attention (e.g., infection, tumor, osteoporosis, disc herniation).

  • Prevalence: The most prevalent primary headache, estimated at 26% globally. Peak prevalence at ages 35-39.

  • Risk Factors: Include psychosocial factors (e.g., stress, sleep disturbance), sociodemographic factors (e.g., female sex), and comorbid conditions (e.g., anxiety, depression).

  • Prognostic Factors for Delayed Recovery: Passive coping strategies, higher initial pain levels, poor recovery expectations, mental health issues, younger age, persistent symptoms, work-related factors, functional limitations.

  • Pain Location: Bilateral pressing, non-throbbing quality, described as a tight band around the head.

  • Duration:

    • Episodic:

      • Infrequent Episodic: At least 10 episodes per year, occurring on <1 day per month on average (<12 days per year). Episodes last from 30 minutes to 7 days

      • Frequent Episodic: At least 10 episodes of headache occurring on 1-14 days per month on average for >3 months (≥12 and <180 days per year). Episodes last from 30 minutes to 7 days

    • Chronic: Occur ≥15 days/month for >3 months (≥180 days per year). Episodes last hours or may be continuous.

  • Signs and Symptoms:

    • Varies in intensity from mild to moderate.

    • May include no more than one of photophobia, phonophobia, or mild nausea

    • Not associated with moderate or severe nausea or vomiting

    • May be associated with scalp or neck muscle tenderness

    • Does not worsen with routine activity

  • Physical and Neurological Examination: Normal upper extremity and cranial nerve neurological tests.

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

    • 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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