Céphalées cervicogéniques et de tension

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada 2018).
  
• Informations sociodémographiques : age, sex and gender when relevant, language, occupation, school, caregiving responsibilities, preferred communication and participation in decisions, and access needs.

Primary concerns

• Context and onset: first or worst episode; sudden or gradual onset; new daily and persistent onset; recent head or neck trauma; recent illness, procedure or medication change; pregnancy or postpartum timing; cancer or immunosuppression; and prior headache or neck-pain episodes.
  
• Location and pattern: side and site; neck-to-head or head-to-neck spread; pressing, tightening, throbbing, sharp or other quality; intensity and irritability; duration; headache days per month; time of day; continuous or episodic course; and whether the pattern is stable, fluctuating or changing.
  
• Symptômes associés : nausea or vomiting; light or sound sensitivity; aura; eye redness, tearing or nasal symptoms; fever, rash or systemic illness; visual, speech, sensory, motor, balance or consciousness change; neck pain or stiffness; jaw symptoms; dizziness; and sleep disruption.
  
• Aggravating and relieving factors: routine physical activity, cervical movement or position, sustained posture, pressure over the neck, cough or straining, standing or lying, screen use, jaw activity, sleep, stress, meals, hydration, caffeine, menstruation when relevant, medication and previous care.
  
• Functioning and participation: effects on self-care, sleep, concentration, mood, driving, physical activity, work, school, caregiving, recreation, relationships and valued roles.
  
• Revue des systèmes corporels : select relevant neurological, cardiovascular, eye, ear, nose and throat, infectious, rheumatological, musculoskeletal, gastrointestinal, endocrine, reproductive, skin and constitutional questions based on the presentation.
  
• Health, lifestyle and history: other headache types and family history; neck or jaw disorders; concussion; cardiovascular or clotting conditions; inflammatory disease; cancer; medications and supplements, including the type and days of acute headache medication use; sleep; physical activity; stress; smoking; alcohol; substance use; meals and hydration.
  
• Social determinants of health: work, education, caregiving, income, housing, food security, discrimination, safety, social support and access when these may shape health, care or participation (Public Health Agency of Canada 2026a).
  
• Soins et interventions antérieurs : advice, exercise, hands-on care, acupuncture, medication, investigations or self-management tried; what helped or did not help; adverse effects; and reasons care was difficult to use or continue.
  
• Patient perspective: understanding of the headache, priorities, preferences, cultural context, concerns, expectations, confidence, strengths and previous experiences of care.
  
• Flag review: check Red Flags and use the separate fixed Orange Flags and Yellow Flags modules when relevant.

​​Outcomes measures: Use a small set of measures that are meaningful to the patient and practical to repeat. Record a baseline and reassess often enough to guide decisions.

• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Qualité de vie : WHOQOL-BREF, or another validated measure suitable for the patient and setting.
• Headache pattern and medication use: a headache diary can record headache days, duration, severity, associated symptoms, possible triggers, acute medication days and response. The format and review period need to be practical and long enough to clarify the pattern (National Institute for Health and Care Excellence 2025).
• Headache impact: a validated measure suitable for the setting, such as the Headache Impact Test (HIT-6); licensing or access conditions may apply.
• Additional focused measures: pain intensity, sleep, perceived recovery, work or school status, or a neck-specific disability measure when the result will guide care.
• Objectifs individuels : agree on patient-defined goals and how progress will be recognized. SMART wording may be used when helpful but is not required.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change care. Adapt the examination to the patient’s presentation, comfort, consent and abilities.

• Consent and comfort: explain what you propose, provide choices about positioning, draping, pace and support, and confirm ongoing consent, especially before provocative, eye, neurological or hands-on testing.
  
• Condition-specific safety: begin with the history and observations needed to decide whether examination is appropriate. Defer or modify procedures when vascular pathology, acute neurological change, major trauma, infection, severe irritability or another safety concern requires urgent assessment.
  
• Observation and relevant vital signs: general appearance, distress, behaviour, speech, gait, balance, posture, movement and guarding; blood pressure, pulse, temperature or other observations when indicated.
  
• Focused neurological and eye examination: mental status, visual fields and eye movements, pupils, facial symmetry and sensation, speech, coordination, gait, limb strength, sensation and reflexes when the history or presentation indicates. Add fundoscopy or other examination only within competence and when the result may change action.
  
• Head, jaw and regional screen: scalp and temporal artery when indicated, temporomandibular movement and functioning, eyes, ears, sinuses, shoulders and other regional sources guided by the history.
  
• Cervical musculoskeletal examination: active movement first; note range, quality, headache or neck-symptom response and meaning for daily activity. Add passive or resisted testing, palpation, joint assessment, and craniocervical and cervicoscapular motor control and endurance when safe and relevant.
  
• Cervicogenic hypothesis: look for a coherent causal pattern rather than a single positive test. Relevant findings can include restricted movement with familiar headache provocation and change in parallel with the cervical disorder; tenderness, reduced range of motion or imaging alone does not establish cervicogenic headache (Headache Classification Committee of the International Headache Society 2018).
  
• TTH hypothesis: compare the headache pattern with ICHD-3 features and note pericranial tenderness when relevant. A normal neurological examination supports but does not by itself establish a primary headache diagnosis (Headache Classification Committee of the International Headache Society 2018).
  
• Imaging and diagnostic testing: neuroimaging is not routine for a stable TTH presentation without signs of secondary headache and is not used solely for reassurance. Cervical imaging is also not diagnostic of cervicogenic headache on its own. Testing follows the suspected condition and is used when the result is likely to change medical assessment, referral or care (National Institute for Health and Care Excellence 2025; Headache Classification Committee of the International Headache Society 2018).
  
• Repeat and adapt: repeat focused findings when needed to review progress, revisit the working presentation or decide whether further assessment or referral is appropriate.

International Classification of Headache Disorders, 3rd edition (ICHD-3)

Use the formal framework only after appropriate safety screening. A diary can help establish frequency. These criteria support diagnosis and communication but do not replace the broader clinical presentation (Headache Classification Committee of the International Headache Society 2018).

• TTH phenotype: at least 10 episodes with at least two of bilateral location, pressing or tightening quality, mild to moderate intensity, and no aggravation by routine physical activity. Episodic attacks last 30 minutes to 7 days. There is no nausea or vomiting, and no more than one of photophobia or phonophobia.
  
• Infrequent and frequent episodic TTH: infrequent episodic TTH occurs on fewer than 1 day per month on average. Frequent episodic TTH occurs on 1 to 14 days per month on average for more than 3 months.
  
• Chronic TTH: headache occurs on at least 15 days per month on average for more than 3 months. It lasts hours to days or can be continuous. No more than one of photophobia, phonophobia or mild nausea is present, and there is no moderate or severe nausea or vomiting.
  
• Cervicogenic headache: a cervical disorder or lesion known to cause headache is present, with at least two causation features: onset in temporal relation to the cervical disorder, substantial improvement or resolution as it improves, reduced cervical range and provocation by manoeuvres, or abolition by diagnostic blockade. Another ICHD-3 diagnosis must not better account for the headache.

Working clinical presentations

• Episodic TTH presentation: the TTH phenotype occurs below the chronic threshold. Frequency, impact, associated symptoms and possible coexisting migraine guide care and monitoring.
  
• Chronic or high-impact TTH presentation: headache frequency meets or approaches the chronic threshold, or the effects on functioning and participation are substantial. Review medication use, sleep, distress and alternative or coexisting headache types.
  
• Cervicogenic headache presentation: formal ICHD-3 causation criteria are met and serious, vascular, neurological and other headache causes have been assessed. Headache with neck pain or musculoskeletal findings that does not yet meet the criteria is recorded as a provisional neck-associated presentation, not confirmed cervicogenic headache.
  
• Mixed, uncertain or alternative presentation: TTH, cervicogenic and migraine features overlap; another cause is possible; or information is insufficient. Document uncertainty, safety-netting, diary or examination needs, and any referral or shared-care plan.

Presentations can overlap or change. Revisit the working clinical impression when the pattern, examination or response changes.

Base care on the presentation, safety, goals, context and response. Use adaptable principles and options rather than a ranked sequence, and repeat meaningful outcomes to guide change.

Education, self-management and participation

• Explain the working presentation and uncertainty: discuss the primary or secondary headache distinction, possible overlap, the role of the neck when relevant, and changes that need earlier assessment. Avoid implying that posture, muscle tension or imaging findings alone explain the headache (Headache Classification Committee of the International Headache Society 2018).
• Use the diary to guide decisions: review headache frequency, impact, associated symptoms, medication days and response with the patient. Pair patterns with context without assigning blame or treating a possible trigger as a proven cause (National Institute for Health and Care Excellence 2025).
• Support daily routines and participation: options include regular sleep and meals, hydration, pacing, breaks from sustained tasks, gradual return to valued activity, and feasible work, school or caregiving adaptations. Avoid blanket rest or a rigid posture rule.

Physical activity and exercise

• Headache with neck pain: individualized low-load endurance exercise for the craniocervical and cervicoscapular regions can form part of care for adults with persistent TTH or cervicogenic headache associated with neck pain. Type, amount and progression reflect capacity, goals and response (Côté et al. 2019).
• Chronic TTH: general physical activity or exercise can be combined with education and, when relevant, cervical exercise. Selection reflects patient preference, access, health status and observed benefit (Côté et al. 2019).
• Exercise resources: the Canadian Chiropractic Guidelines neck-pain exercise videos can support an individualized plan; select only exercises relevant to the patient’s presentation and review response.

Hands-on and symptom-relieving care

• Persistent cervicogenic headache: a time-limited trial of cervical or thoracic mobilization, manipulation with or without mobilization, or soft-tissue care can be an adjunct to education and active care after safety screening and informed consent. Continue only when benefit is meaningful and acceptable (Côté et al. 2019).
• TTH: multimodal care can include spinal mobilization, craniocervical exercise and postural strategies for chronic TTH with neck pain. Cervical manipulation is not a stand-alone TTH option (Côté et al. 2019).
• Acupuncture: this can form part of a medical or interdisciplinary shared decision for chronic TTH when it fits the patient’s preferences, clinician scope and local access (National Institute for Health and Care Excellence 2025).
• Culturally grounded approaches: traditional or community-based approaches identified by the patient can be incorporated when they are safe, acceptable and consistent with the clinical presentation and care goals.

Psychological, social and interdisciplinary support

• Stress, coping and sleep: relaxation with stress-coping strategies can form part of multimodal care for chronic TTH with neck pain. Psychologically informed, sleep, mental health or community support can be coordinated when distress, sleep or coping substantially affects functioning or participation (Côté et al. 2019).
• Participation support: address work or study demands, caregiving, costs, access and social context. Coordinate medical, rehabilitation, occupational, workplace, Indigenous, culturally specific or community supports when these help the patient pursue valued roles.

Médicament

• Acute TTH medication: non-opioid analgesic options can be discussed with an authorized prescriber or pharmacist, accounting for health conditions, pregnancy, other medicines, contraindications, adverse effects and patient preferences. Opioids are not a TTH treatment option (National Institute for Health and Care Excellence 2025).
• Medication-overuse risk: track headache days and acute medication days. Increasing frequency, uncertain medication safety or possible medication-overuse headache prompts pharmacist or medical review (National Institute for Health and Care Excellence 2025; Headache Classification Committee of the International Headache Society 2018).
• Medication coordination: medication decisions remain within authorized scope and do not replace urgent assessment of a new or changing headache, neurological loss, systemic illness or another red flag.

Monitoring and reassessment

Agree on a reassessment point based on the presentation, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.

Repeat the small outcome set recorded at baseline and review the diary, headache frequency and impact, associated symptoms, medication use, relevant neurological or cervical findings, functioning, participation, benefits, harms, treatment burden and progress toward patient-defined goals.

Continue what is useful and acceptable; adapt or stop what is not; and revisit the clinical presentation, differential diagnosis, referral or shared care when progress differs from expectations, the headache pattern changes or a new safety concern emerges.

• Expected course: the course is individual. Episodic TTH can recur, and chronic TTH occurs on at least 15 days per month for more than 3 months. Cervicogenic headache can fluctuate with the cervical disorder. Use the observed course and repeated outcomes rather than a universal recovery timeline (Headache Classification Committee of the International Headache Society 2018).
  
• Factors associated with a less favourable course: in chronic headache populations, depression, anxiety, poor sleep, stress, medication overuse and low confidence in headache self-management are potential markers of poorer outcome. These group-level associations do not determine an individual’s course (Probyn et al. 2017).
  
• Potential supports for recovery: an understandable working explanation, self-efficacy, feasible active care, attention to sleep and medication use, supportive relationships and workplaces, accessible care and progress toward meaningful activity may support recovery without guaranteeing it.
  
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update prognosis using the diary, repeated outcomes, relevant examination findings and response over time. Revisit the diagnosis and referral needs when the course differs materially from expectations.