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Tension-type and Cervicogenic Headache Care Pathway

Date of last update: April, 2024

Patient History

Clinical Cornerstone:

  • Taking a patient's history goes beyond data collection; it's about forging and upholding a therapeutic relationship. Actively and empathetically listening to the patient's narrative offers insights into their condition and its optimal approach to management. The essence of history-taking lies in turning into the patient's story, discerning their non-verbal cues, and steering the conversation to ensure a comprehensive, yet seamless, patient history.

  • Clinicians should exercise judgment during history-taking. Adopting principles of trauma-informed care (safety, trustworthiness, collaboration, choice and empowerment, culturally responsive) could help minimize potential barriers. This might involve signposting to signal the direction of the consultation and explaining the rationale behind sensitive questions or tests.

  • While history taking needs to be thorough, it does not need to be linear. Reports can be explored as the patient makes them, using care to ensure needed details are not subsequently missed. While certain topics like prior episodes of headache or neck pain, past care experiences, and recovery expectations are crucial, they might be broached at different times during the patient encounter, not just during the initial history.

  • When re-evaluating existing patients, especially those presenting with new headache complaints, a thorough assessment is imperative, just as it is with new patients. Explore the patient's new headache complaint to better understand it's characteristics. Identify any relationship between the new complaint and pre-existing conditions or treatments.

  • Sociodemographic: Age, sex (some primary headaches are more likely in women, some are more likely in men), occupation.

  • Chief complaint: Main issues.

  • Characteristics of Present Condition: Onset (acute/progressive), mechanism, location (unilateral/bilateral, frontal/occipital), duration (minutes, hours, or clustered), frequency (number of headaches per month), character, alleviating/aggravating factors, radiation (e.g. pain, numbness, tingling or weakness), timing (e.g. constant/intermittent, morning/end-of-day/night pain, improving/staying-the-same/getting worse), severity, associated symptoms (including symptoms that started around the same time, and any distal symptoms).

  • Past Health History: Previous or concurrent conditions, medications, injuries, hospitalization, surgeries, and treatments. Includes orange flags: significant psychiatric symptoms or disorders (e.g., major depression, anxiety disorders, post-traumatic stress disorders [PTSD]).

  • Narrative: How the headaches affect activities of daily living.

  • Previous History of Headaches: Previous history of headaches (including if they were similar or different) (e.g. some primary headaches typically begin in childhood). Inquiry should also explore experience with previous treatments (effectiveness, any adverse effects).

  • Associated Complaints: Ask about focal neurological signs. Identify any co-morbid disorders (e.g., concussion, TMD, occipital neuralgia, etc.).

  • Health History: Previous or concurrent conditions (physical, systemic, or mental health conditions), medications, injuries, hospitalizations, surgeries, and medical treatments.

  • Orange flags: significant psychiatric symptoms or disorders (e.g., major depression, anxiety disorders, post-traumatic stress disorders [PTSD]), volume and intensity of weekly physical activity and exercise.

  • Family History: Genetic and familial predispositions, familial major medical history (e.g., cancer, cardiovascular).

  • Social History: Family support, caregiver responsibilities, role of family or caregivers in care.

  • Review of Systems: Comprehensive review of body systems to identify any related or unrelated symptoms (neurologic, cardiovascular (including hypertension), genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health, bone density, medications, pregnancy, children).

  • Psychosocial Assessment:

    • Beliefs and perceptions: Negative beliefs about the prognosis, fear of movement or re-injury, misconceptions about the nature of the pain, or poor expectations of recovery.

    • Behavioural factors: Avoidance behaviors, reduced activity levels, over-reliance on passive treatments, or high self-reported disability levels.

    • Social or environmental factors: Lack of social support, work-related issues, or family pressures.

  • Lifestyle Assessment: Nutrition, exercise (type, duration and frequency), hobbies, sleep, stress; smoking, alcohol, and recreational drug use.

  • Occupational History: Type of work they do (sedentary, physical labour, etc.), ergonomics of workplace, other work stressors (including social environment), any time off due to LBP, any work accommodations/modifications.

  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

  • Goals and expectations: Goals for treatment, expectations from intervention.

Documentation: Record all findings in the patient record.

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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