Cervicogenic and Tension-Type Headaches Care Pathway

Interventions Not Consistently Supported by Guidelines

• Spinal manipulation for tension-type headache.

• Needling therapies, electrotherapies (e.g., TENS, IFC), and traction, have limited or mixed evidence for benefit or harm.

• These interventions may be considered as adjuncts through shared decision-making with patients.

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Examples

 

Example 1: Chronic Tension-type Headache

 

Patient Presentation: A 35-year old patient presents with headaches characterized by bilateral pressure. She reports they usually feel like a “tight squeeze” and demonstrates a band-like pattern distribution around her head, though she reports her headaches are occasionally just at the base of her skull. She has been experiencing these headaches almost every-other day for the past six months, and sometimes they last longer than others.

 

1. Education and Reassurance:

   • Frequency: Initial visit and reinforced in follow-up visits.

   • Protocol: Provide a clear explanation of the condition, expected course with treatment (may be 6-12 weeks), and encourage the patient to stay active. Use visual aids or pamphlets for better understanding.

2. Self-Care Practices:

   • Frequency: Daily.

   • Protocol: Recommend a home exercise program focused on general strengthening exercises tailored to the patient's abilities and pain levels. Advise on proper nutrition, adequate sleep, and stress management techniques.

3. Maintain Activities of Daily Living:

   • Frequency: Daily.

   • Protocol: Encourage the patient to continue with normal activities as much as possible, avoiding prolonged bed rest. Provide specific instructions on safe movements and ergonomics.

4. Address Yellow Flags (Psychosocial Factors):

   • Frequency: Regularly, integrated into each visit.

   • Protocol: Identify and address psychosocial factors such as fear of movement, depression, or anxiety. Use cognitive-behavioral strategies to modify negative beliefs about pain.

 

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1. Manual Therapy:

   • Frequency: 9 sessions over 8 weeks, included as a component of multimodal care (spinal mobilization, craniocervical exercises, postural correction).

   • Protocol: Manual therapy and soft tissue techniques to cervical and thoracic spine. Adjust techniques based on the patient's response.

2. Exercise Therapy:

   • Frequency: Specific exercise for 6 weeks. General exercise for 12 weeks.

   • Protocol: Low-load craniocervical and cervicospinal endurance exercises. Begin with supervised sessions and transition to the home program. Include 25 sessions over 12 weeks of general exercise.

3. Electromodalities (e.g., TENS, IFC, low-level laser):

   • Frequency: 2-3 times per week.

   • Dose: Utilize Transcutaneous Electrical Nerve Stimulation (TENS), Interferential Current Therapy (IFC), or low-level laser therapy to provide temporary pain relief and comfort. Use in conjunction with other interventions.

4. Medications:

   • Frequency: As needed with caution to prevent medication overuse headache.

   • Protocol: Over-the-counter NSAIDs or acetaminophen for pain relief, used judiciously and in combination with other treatments. Consider muscle relaxants if indicated. Options and risks should be discussed with the medical provider.

5. Psychological Support:

   • Frequency: Weekly or as needed.

   • Protocol: Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other techniques to manage chronic pain and improve mental health.

Follow-Up:

• • Regular follow-up at each visit. Reassess pain levels, functional status, and goal achievement every 2-4 weeks and adjust the treatment plan as necessary.

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Example 2: Cervicogenic Headache

 

Patient Presentation: A patient presents with one-sided headache that begins at the base of her neck in the back and extended to her forehead and eye on the same side. She reports that she started experiencing neck pain around the same time as the headache, and both started shortly after a new job that requires her to work on a computer for a prolonged time. Her head and neck both feel achy, and although not debilitating they are quite bothersome. She’s discovered she can get some relief by massaging/pressing on her own neck.

 

1. Education and Reassurance:

   • Frequency: Initial visit and reinforced in follow-up visits.

   • Protocol: Explain the nature of the condition, expected course (may be 4 to 12 weeks), and encourage active participation in the treatment plan. Use visual aids (e.g. diagrams, models, digital resources) to illustrate the condition.

2. Self-Care Practices:

   • Frequency: Daily.

   • Protocol: Tailored home exercise program focusing on neck and shoulder stretching and strengthening. Include lifestyle advice on proper posture, nutrition, and sleep.

3. Maintain Activities of Daily Living:

   • Frequency: Daily.

   • Protocol: Encourage modified activities to avoid exacerbating the symptoms while staying active. Provide guidance on ergonomics and safe movement strategies.

4. Address Yellow Flags (Psychosocial Factors):

   • Frequency: At each visit.

   • Protocol: Identify and address factors such as fear of movement, poor recovery expectations, depression, anxiety, work-related or family issues, and maladaptive coping mechanisms. Provide appropriate reassurance, counseling, or referrals to mental health professionals as needed.

 

1. Exercise Therapy:

   • Frequency: 8 sessions over 6 weeks.

   • Protocol: Include low-load craniocervical and cervicospinal endurance exercises. Begin with supervised sessions and transition to the home program.

2. Manual Therapy:

   • Frequency: Spinal mobilization/manipulation (10 sessions over 6 weeks). A second course may be indicated if the patient demonstrates ongoing and significant improvement according to their goals. Eight 45-minutes sessions of massage therapy to neck and shoulder area over 4 weeks.

   • Protocol: Adjust techniques based on patient response and pain levels.

3. Electromodalities (e.g., TENS, IFC, low-level laser):

   • Frequency: 2-5 times per week for 3 weeks.

   • Protocol: Utilize TENS, IFC, or low-level laser therapy to provide temporary pain relief and comfort. Use as an adjunct to other therapies.

4. Medications:

   • Frequency: As needed with caution to prevent medication overuse headache.

   • Protocol: NSAIDs or acetaminophen for pain management, possibly combined with muscle relaxants for short-term relief of acute symptoms. Options and risks should be discussed with medical provider.

5. Psychological Support:

   • Frequency: Weekly or as needed.

   • Protocol: Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and other techniques to manage chronic pain and improve mental health.

Follow-Up:

• Regular follow-up at each visit. Reassess pain levels, functional status, goal achievement every 2-4 weeks and adjust the treatment plan as necessary.