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Headaches: A real pain in the neck.

To understand a solution to a problem, first, we must understand the problem itself. In this brief write up, I aim to explain, help you understand, and provide potential evidence-based solutions for headaches associated with neck pain, and tension-type headaches.

The classification of a headache is principally based on the evaluation of headache symptoms as well as clinical testing. It is important to distinguish between various types of headaches with a comprehensive musculoskeletal examination, this examination and subsequent diagnosis is essential not only to identify patients with headache where manual therapy is appropriate but also to form a basis for selection of the most appropriate treatment for the identified condition.


The Problem:

Headaches are the most prevalent pain disorder affecting roughly 66% of the global population. Tension-type headaches are the most common, different studies have found a lifetime prevalence of between 30% and 78% in the general population (compared to 10% with migraines). Neck pain and headaches are very common comorbidities.

In one study published in 2014 with 797 participants, the one-year prevalence of neck pain was 68.4% and higher in those with versus those without a primary headache (85.7% vs. 56.7%).


Understanding the Headache:

A tension-type headache (TTH) is very common, with a lifetime prevalence in the general population ranging in different studies of between 30% and 78%. It also has a high socio-economic impact on the individual and the wider community. While it was previously considered to be primarily psychogenic, a number of further studies since the publication of ICHD-1 strongly suggest a neurobiological basis. However, the exact mechanism of TTH is not known.

Cervicogenic headaches are typically described as headaches causally associated with cervical myofascial pain sources (myofascial trigger points) or headache caused by a disorder of the cervical spine and its component bony, disc and/or soft tissue elements, usually but not invariably accompanied by neck pain.


The Solution(s):

When managing patients with headaches associated with neck pain, clinicians should and patients should expect the clinician to:


  1. Rule out major structural or other pathologies, or migraine as the cause of headaches;

  2. Classify headaches associated with neck pain as tension-type headache or cervicogenic headache;

  3. Provide care in partnership with the patient and involve the patient in care planning and decision making;

  4. Provide additional patient education;

  5. Consider low-load endurance exercises for tension-type headaches or cervicogenic headaches >3 months duration;

  6. Consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches;

  7. Not offer manipulation of the cervical spine as the sole form of treatment;

  8. Consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration; and

  9. Reassess the patient at every visit to assess outcomes and determine whether a referral is indicated.


Helpful resources for additional information:


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