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Tension-type and Cervicogenic Headache Care Pathway

Date of last update: April, 2024

Differential Diagnosis

Diagnosis of Tension Type Headaches (with or without neck pain) - a primary Headache

Clinical Cornerstone:

  • Diagnosis involves a thorough history and physical examination, and differentiating from other headache disorders, especially if in the presence of somewhat any  overlapping symptoms (e.g. photo/phonophobia).

  • Definition: Primary headaches are not attributable to a discernible, specific pathology (e.g., infection, tumor, osteoporosis, disc herniation).

  • Episodic Tension-Type Headaches are characterized by  the presence of at least ten episodes occurring one-or-more days per month, but less than 15 days per month, for at-least three months. Persistent Tension-Type Headaches occur on 15 or-more days per month, for at-least three months.

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

  • Risk Factors: May include Psychosocial factors (e.g., stress, sleep disturbance); Sociodemographic factors (e.g., female sex); Anxiety and depression may be co-morbid factors triggering more frequent headaches.

  • Pain Location: Characterized by bilateral pressure (often described as “a tight band around the head”, though may be just at the base of the skull)

  • Duration: Headaches can vary in duration from minutes to days. The complaint of headaches often begins before the age of 10.

  • Signs and Symptoms:

    • Varies in intensity from mild to moderate

    • Not associated with nausea or vomiting

    • May be associated with one of: photophobia or phonophobia

    • Does not worsen with physical activity

    • May be associated with scalp or neck  muscle tenderness on manual palpation.

  • Neurological Examination: Normal findings on upper extremity sensory, motor and deep tendon reflex testing is expected.

  • Response to Conservative Management: Tension‐type headaches can be treated effectively with specific low-load endurance exercises.

  • Psychosocial Factors: Consider psychosocial factors that might influence pain perception and recovery (e.g., beliefs about pain, fear of movement, catastrophizing).

Diagnosis of Cervicogenic Headaches - a Secondary Headache (associated with neck pain)

Clinical Cornerstone:

  • The goal is to identify a disorder within the cervical spine or cervical soft tissues that is known to cause headache.

  • Diagnosis involves a thorough history and physical examination, and differentiating from other headache disorders, especially if in the presence of any overlapping symptoms (e.g. dizziness, photo/phonophobia). The presence of cervicogenic headache does not preclude the presence of other headache disorders (migraine may be comorbid in 42% of cases).

  • Diagnosis relies on evidence of two of the following:  i) onset of headache corresponding in time to onset of the cervical disorder; ii) headache has significantly improved in temporal relation to improvement of the cervical disorder; iii) cervical range of motion is reduced and headache can mechanically be made worse with provocative manouvers.

  • 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.

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

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

  • Signs and Symptoms:

    • Moderate-intensity non-throbbing episodic pain.

  • Physical Examination:

    • Special Tests: Reproduction of symptoms during cervical spine range of movement; Cervical Flexion-Rotation Test; Tenderness on manual palpation paraspinal soft tissues; Provocation with manual posterior-to-anterior intervertebral movements of cervical spine; Reproduction of symptoms during cervical range of motion

    • Special Tests for Cervical Spine Disorders: Cervical Kemps; Spurlings.   

    • Neurological Examination: Normal findings on upper extremity sensory, motor and deep tendon reflex testing is expected

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

  • Response to Conservative Management: Cervicogenic  headaches  can  be  treated  effectively  with  specific exercises. Manual therapy can be considered as an adjunct therapy to exercise.

  • Psychosocial Factors: Important to explore and address psychosocial factors that may impact pain, disability, and recovery, such as fear of movement, beliefs about pain, and emotional well-being, ensuring a comprehensive management approach.

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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