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Cervicogenic and Tension-Type Headaches

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About Cervicogenic and Tension-Type Headaches

Headaches are broadly categorized as primary – not attributed to a distinct pathology – or secondary – linked to an underlying physical, psychiatric, or systemic condition. Tension-type headache (TTH) is the most common primary headache type, while cervicogenic headache arises from neck disorders and is thus secondary. Individuals may experience multiple headache types simultaneously, and one headache (e.g., migraine) can be triggered by another (e.g., cervicogenic headache).

The diagnosis of these headaches is primarily clinical – most serious pathologies can be excluded by a thorough history and physical examination. Further diagnostic testing may be needed if specific findings or red flags suggest another underlying condition.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Cervicogenic and Tension-Type Headaches Care Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent
  • Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
  • Key Aspects:
    • Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
    • Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time. 
    • Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
    • Patient understanding and agreement:
      • Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
      • Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
      • Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
    • Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.
3. Health History
  • Apply cultural awareness and trauma-informed care principles.
  • Sociodemographic information: Age, gender, sex, race/ethnicity.
  • 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 review: Neurologic, cardiovascular, genitourinary, gastrointestinal, musculoskeletal, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
  • Health, lifestyle, and 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, social isolation.
  • Previous treatments and responses: Document prior treatments, effectiveness and any adverse effects. 
  • Beliefs and expectations: Assess patient understanding of their condition, treatment goals, and outcome expectations.
  • Flag considerations: Identify red, yellow, and orange flags for potential referrals.

​​Outcomes Assessments: Prioritize approaches that align with the patient’s specific goals and clinical presentation.

  • Pain: Use pain scales (e.g., NRS) and diagrams.
  • Function and participation: Evaluate impact on daily activities (PSFS, WHODAS, HIT6, HDI, NDI).
  • Recovery: Use Self-rated recovery scales.
  • Quality of life: Assess using tools such as SF-12.
  • Work/school status: Monitor return to activities.
  • Sleep quality: Assess using tools such as PSQI.
4. Red Flags : Differential Diagnosis Requiring Medical Referral

ACTION: Refer immediately to emergency care:

  • Meningitis: Neck stiffness, severe headache worsening with neck flexion, fever, vomiting, rash, altered mental status, photophobia, flexed hip/knee posturing, positive Brudzinski/Kernig signs.
  • Spinal infection: Progressive neck pain (worse at night), constitutional symptoms (e.g., fever/chills), recent infection/surgery, immunosuppression, TB history, IV drug use, poor living conditions, tenderness on palpation or tap test.
  • Intracranial/brain lesion: Sudden intense headache (thunderclap) or progressive headache (± neck pain), dizziness, visual changes, nausea/vomiting, focal neurological signs. Worse in the morning, with coughing/straining, or forward bending; cranial nerve abnormalities, motor and sensory deficits in limbs, papilledema, positive Romberg test (coordination and balance issues), signs of increased intracranial pressure (e.g., Cushing’s triad: hypertension, bradycardia, irregular respirations). 
  • Vertebral/carotid artery dissection: Severe neck pain, “worst headache ever”, double vision, difficulty swallowing/speaking/walking, dizziness, facial numbness/sensory deficits, drop attacks, nausea, nystagmus, contralateral trunk sensory deficits, focal neurological signs.
  • Traumatic spinal fracture: Severe localized pain following trauma (e.g., pedestrian struck, high-speed collision, rollover, ejection from motor vehicle, fall ≥3 feet/5 stairs, axial load to head), age ≥65, extremity weakness/tingling/burning, inability to rotate neck 45° left/right, midline cervical spine tenderness (Canadian C-Spine Rule).
  • Acute narrow-angle glaucoma: Severe unilateral eye pain, blurred vision, light halos, nausea/ vomiting; exam may reveal optic nerve cupping and visual field deficits.
  • Cervical myelopathy: Gait disturbances, hand clumsiness, non-dermatomal numbness/weakness (upper/lower extremities), bowel/bladder dysfunction, hyperreflexia, hypertonia, pathological reflexes (e.g., positive L’Hermitte sign, finger escape sign).
  • Giant cell arteritis: Typically, age >60 years (often with polymyalgia rheumatica). Presents with new temporal headache, scalp tenderness, jaw claudication, vision changes (including loss), tender/nodular temporal artery, bruits over carotid/temporal artery, abnormal fundoscopy (e.g., optic disc edema).

ACTION: Refer to appropriate medical provider:

  • Non-traumatic spinal fracture: Sudden severe pain, osteoporosis, corticosteroid use, female, age >60, spinal fracture/cancer history, point tenderness over vertebra, inability to rotate neck 45°, extremity neurological signs.
  • Spinal malignancy: Progressive headache (worse at night or with exertion/unrelieved by rest), cancer history, constitutional symptoms (e.g., fatigue, weight loss, night sweats), localized tenderness, neurological deficits. 
  • Inflammatory arthritides: Neck and joint pain/stiffness, morning stiffness >1-hour, systemic symptoms (e.g., fatigue, weight loss, fever), joint swelling/tenderness/deformity.
    • Spondyloarthropathies (e.g., ankylosing spondylitis): Pain/stiffness radiating to shoulders/upper back, improves with activity, may include uveitis/psoriasis.
    • Rheumatoid arthritis: Symmetrical joint involvement, joint deformities.
    • Systemic lupus erythematosus (SLE): Butterfly rash, photosensitivity, organ involvement (e.g., kidney or pleuritis).
  • Migraine: Moderate to severe unilateral (can be bilateral) throbbing pain, worsened by activity, often with nausea/vomiting, photophobia, phonophobia; possible aura; neurologic exam is typically normal.
5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

  • Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.   
  • Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
  • Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

  • Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

  • Triage: Ensure primary management by medical/psychiatric providers.
  • Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)
6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

  • Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
  • Social: Lack of family/social support, limited connections.
  • Socioeconomic: Employment status, financial stress, litigation/compensation.
  • Environmental/cultural: Social inequality, unsafe/unsupportive environments.
  • Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
  • Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers: 

  • Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).  
  • Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
  • Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
    • PHQ-9 (depressive symptoms)
    • GAD-7 (anxiety symptoms)
    • FABQ (fear related to physical activity/work) 
    • PCS (catastrophic thoughts) 
    • ORT (opioid risk)

7. Physical Examination
  • Observation: Evaluate abnormalities, asymmetries, posture, balance, gait, movements, facial expression.
  • Vitals: Assess blood pressure, heart rate, respiratory rate, temperature. May include eye exam (e.g.., visual acuity, pupil response, fundoscopic examination).
  • Range of motion (ROM): Assess active, passive, and resisted cervical spine ROM in flexion, extension, lateral flexion, and rotation. Note regional or segmental hypo-/hypermobility and aberrant movements.
  • Palpation: Examine for tenderness, swelling, tightness, or temperature changes in bones, joints, and soft tissues of the head and neck region. 
  • Neurological Examination: 
  • Motor strength testing: Assess for asymmetry or weakness indicating nerve root involvement:
    • C5: Shoulder abduction
    • C6: Wrist extension
    • C7: Wrist flexion and finger extension
    • C8: Finger flexion
    • T1: Finger abduction/adduction
  • Sensory testing: Assess for sensory deficits in dermatomal distributions:
    • C5: Lateral arm
    • C6: Lateral forearm, thumb, index finger
    • C7: Middle finger
    • C8: Ring and small finger, medial forearm
    • T1: Medial arm
    • T2: Axilla
  • Reflex testing: Assess for asymmetry, diminished/absent reflexes:
    • C5: Biceps
    • C6: Brachioradialis
    • C7: Triceps
  • Upper motor neuron signs: Assess for increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate central nervous system disorders (e.g., myelopathy, multiple sclerosis, stroke).
  • Lower motor neuron signs: Assess for muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate systemic neurological conditions (e.g., radiculopathy, peripheral neuropathy, ALS).
  • Cranial nerves tests:
  • Special/Orthopedic Tests: Perform as clinically indicated. 
  • Advanced Diagnostics: Radiography is generally not recommended without red flags or specific individual factors (e.g., contraindications to treatment).

8. Clinical Presentations for Cervicogenic and Tension-Type Headaches

Cervicogenic Headache (secondary to cervical spine disorders)

  • Definition: Headache arising from disorders of the cervical spine or soft tissues, typically provoked by cervical ROM or other neck-specific tests (e.g., cervical flexion-rotation, myofascial trigger points).
  • Prevalence: Accounts for 15–20% of all chronic recurrent headaches.
  • Pain location: Usually unilateral, originating in the nuchal region and extending to the oculofrontal area.
  • Duration: May fluctuate or be continuous.
  • Signs/Symptoms: Moderate, non-throbbing, often episodic. Headache onset and cervical disorder develop in a similar time frame.
  • Examination: Normal upper extremity and cranial nerve exam.

Tension-type Headache (TTH) 

  • Definition: A primary headache not attributable to another pathology requiring medical intervention (e.g., infection, tumor).
  • Prevalence: The most common primary headache globally (≈26%); peak prevalence at ages 35–39.
  • Pain location: Bilateral, pressing/tightening, non-throbbing (“band-like”), mild to moderate intensity.
  • Duration:
    • Episodic
      • Infrequent: At least 10 episodes/year occurring on <1 day/month on average (<12 days/year), lasting 30 minutes to 7 days.
      • Frequent: At least 10 episodes on 1–14 days/month over >3 months (≥12 and <180 days/year), lasting 30 minutes to 7 days.
    • Chronic
      • ≥15 days/month for >3 months (≥180 days/year), episodes last hours or may be continuous.
  • Signs/Symptoms: 
    • May include only one of photophobia, phonophobia, or mild nausea; not associated with moderate/severe nausea or vomiting.
    • May involve scalp/neck muscle tenderness.
    • Does not worsen with routine activity.

Examination: Normal upper extremity and cranial nerve exams.

9. Treatment Considerations for Cervicogenic and Tension-Type Headaches

Approach to Treatment

The treatments outlined in this section reflect core domains of care consistently identified across high-quality clinical practice guidelines and established clinical practices. These include interventions shown to improve patient-important outcomes such as pain, function, and quality of life. Management plans should be tailored to the individual’s needs, goals, and preferences, taking into account clinical presentation, response to care, and contextual factors.

Not all domains need to be included in every care plan or at every stage of recovery. Clinicians are expected to apply professional judgment in selecting the most relevant components based on the clinical context.

This pathway is not prescriptive, nor does it list every possible intervention. Readers are encouraged to consult individual guidelines for specific treatment protocols, dosage, and condition-specific considerations.

While a range of other interventions may be in use, such as passive physical modalities, these have mixed or limited evidence of clinical benefit and are therefore not recommended for routine use. If applied, such therapies should be used as adjuncts to the core, evidence-based components of care, and not as standalone treatment.

  1. Education and Self-Management (Bussières et al., 2016; Côté et al., 2016; Côté et al., 2019)
    These interventions address modifiable prognostic factors for recovery [see Section 10].
    • Education & reassurance: Clarify pain’s biopsychosocial dimensions and set realistic expectations. Reassure patients that tension-type and cervicogenic headaches typically do not stem from serious pathology. Use tailored, evidence-based information in various formats (written, digital, visual) to empower individuals. Limited evidence suggests no single superior type of education for improving patient outcomes, but consistent reinforcement improves understanding and engagement.
    • Self-care: Encourage regular exercise, nutrition, sleep hygiene, stress management, weight maintenance, and avoidance of smoking/substance abuse. Employ SMART goals and Brief Action Planning for sustained engagement.
    • Daily activities: Promote continued movement and daily activity participation; discourage prolonged rest, immobilization, or the use of neck collars. Maintaining normal activity reduces recovery time and prevents disability.
    • Social & work engagement: Encourage participation using pacing strategies and workplace accommodations to support social functioning and productivity.
  2. Exercise Therapy (Bussières et al., 2016; Blanpied et al., 2017; Côté et al., 2016; Côté et al., 2019)
    • Tailor individualized programs to improve strength, mobility, and aerobic capacity.
    • Exercise reduces pain, improves quality of life, and enhances function. No single type is superior; selection should align with patient preferences and needs.
    • Monitor psychological responses to exercise; refer to medical/mental health providers if signs of distress or aversion arise.
  3. Manual Therapy (Bussières et al., 2016; Blanpied et al., 2017; Côté et al., 2016; Côté et al., 2019)
    • Incorporate spinal manipulation (for cervicogenic headache), mobilization, and soft tissue techniques to reduce pain and improve function. 
    • Manual therapy should be integrated as part of a broader care plan to maximize effectiveness.
  4. Psychosocial and Psychological Support (Bussières et al., 2016; Côté et al., 2016; Côté et al., 2019) 
    • Address barriers: Screen for psychosocial barriers (e.g., fear of movement, low recovery expectations, anxiety) using tools (e.g., FABQ, PHQ-9, GAD-7, ORT, PCS). Addressing these factors improves engagement and recovery. Provide education and strategies within the scope of care to support recovery (e.g., stress management, self-efficacy building, social/occupational engagement) [see Sections 5 and 6].
    • Resources & instruction: Offer resources (e.g., online tools, written materials, mindfulness programs). Refer mind-body practitioners (e.g., yoga, meditation) for further support when conservative care is insufficient.
    • Medical/mental health referral: Refer people with severe, persistent, or impairing symptoms to qualified medical/mental health providers or community support services to address psychological and social barriers to recovery [see Sections 5 and 6].
  5. Medication (Côté et al., 2016)
    • Short-term use of analgesics, NSAIDs, or muscle relaxants may be considered for pain relief, in consultation with a medical provider. 
    • Long-term opioid use is discouraged due to dependency risk.
  6. Multimodal Care (Bussières et al., 2016; Côté et al., 2016; Côté et al., 2019)
    • Integrate physical, psychological, and social interventions tailored to individual needs, particularly for persistent headache, to support function, work, and community engagement through predominantly non-pharmacologic care.

10. Risk and Prognostic Factors
  • Risk Factors: 
    • Cervicogenic headache (Huguet et al., 2016; Kazeminasab et al., 2022): Female, having sustained an injury that limits neck movement, unemployed. 
    • Tension-type headache (Huguet et al., 2016; Lyngberg et al., 2005): Younger age, female, poor self-rated health, inability to relax after work, sleeping few hours per night.
  • Prognosis: Cervicogenic and tension-type headaches can be episodic, chronic, or recurrent. 
  • Negative Prognostic Factors:
    • Cervicogenic headache (Fleming 2007; Probyn et al., 2017; Shearer et al., 2021): Depression, anxiety, poor sleep, stress, medication overuse, younger age, unemployment, headache not provoked or relieved by movement, passive coping strategies, higher initial pain level, poor recovery expectations, persistent symptoms, work-related factors, functional limitations, previous neck pain, arm pain. 
    • Tension-type headache (Bendtsen & Jensen, 2006; Castien et al., 2012; Huguet et al., 2016; Probyn et al., 2017): Female, chronic TTH, coexisting migraine, sleep problems, not being married, depression, anxiety, poor sleep, stress, medication overuse, poor self-efficacy, multiple-site pain, reduced cervical range of motion, higher headache intensity. Children: negative emotional states (anxiety, depression, mental distress).

11. Ongoing Follow-up
  • Monitor progress: Reassess symptoms, functional status, and patient-reported outcomes at appropriate intervals. Confirm that care remains aligned with the patient’s goals, values, and expectations.
  • Adjust treatment plan: Continuously realign the management plan based on evolving goals, treatment response, clinical findings, and professional judgment. Modify interventions, dosage, frequency, or focus as needed to support meaningful improvement.
  • Support self-management: Reinforce the patient’s understanding of home strategies, activity recommendations, and behavioural approaches. Encourage adherence and address barriers that may affect progress.
  • Recognize plateaus or change in status: Identify when the patient is improving, stable, or worsening. Reassess for contributing factors such as comorbidities, psychosocial influences, or new functional limitations.
  • Referral and co-management: Consider referral or co-management with an appropriate provider when there is limited or no significant improvement within an expected timeframe (for example 6 to 8 weeks), when new or concerning findings emerge, or when additional expertise is required to support optimal care.
  • Documentation: Record follow-up assessments, changes to the plan, patient feedback, reassessment of goals, and any referral or co-management decisions.
12. Criteria for Discharge
  • Discharge criteria: Establish clear criteria for concluding active care. These may include achieving the patient’s initial goals, demonstrating meaningful improvement in symptoms or function, reaching a plateau in progress, or transitioning to self-management as the primary approach. Consider patient preferences, functional demands, and clinical judgment when determining readiness for discharge.
  • Clinical reassessment: Prior to discharge, complete a focused reassessment to confirm stability of symptoms, functional status, and the patient’s confidence in managing their condition. Address any remaining concerns and ensure no new issues require further evaluation.
  • Post-discharge planning: Discuss ongoing self-management strategies, including activity recommendations, home exercises, behavioural or lifestyle modifications, and symptom monitoring. Provide guidance on when to return for follow-up, when to seek additional care, and what indicators should prompt medical evaluation.
  • Future care needs: Clarify options for episodic care, preventive visits, or re-engagement with the provider if symptoms recur or functional demands change. Encourage ongoing communication if new concerns arise.
  • Documentation: Record the rationale for discharge, the patient’s status at the time of discharge, self-management recommendations provided, and the agreed-upon follow-up plan

References