Cervical Spine Involvement in Tension Type Headaches…from evidence to practice

Senior woman massaging temples while suffering from headache at home

Tension type headache (TTH) is a primary headache characterized by a bilateral pattern, with pain reported as pressing or tightening in quality, of mild to moderate intensity, and lasting minutes to days. TTH does not worsen with routine physical activity and has no association with nausea, however, phonophobia or photophobia may be present. The estimated prevalence of TTH in the general population is 26%, but almost 90% of adults will experience TTH at some time during their life.
The mechanisms of TTH are not yet completely understood (similar to most headaches!). There is a hypothesis that multiple forms of headache may originate in the cervical spine via the trigemino-cervical nucleus caudalis. In this nucleus, nociceptive afferents from C1-C3 converge onto second-order neurons that also receive afferents from the first division of the trigeminal nerve through the trigeminal spinal tract. This nucleus allows inputs from the upper cervical segments and first (ophthalmic) branch of the trigeminal nerve to interchange. Thus, every structure that is innervated by the upper cervical spine and the trigeminal nerve could elicit referred pain to the head.
There is increasing evidence showing that musculoskeletal (MSK) disorders of the cervical spine are also present in individuals with migraine and TTH, not just those patients with cervicogenic headaches.

This position paper discussed contemporary clinical and evidence-based data relating to the cervical spine’s involvement in TTH.

Comment from Dr. Thistle:

From a clinical perspective, the cervical spine can be involved in all three of these common headache types – tension, migraine and (of course) cervicogenic. The treatment of all three types can include manual therapy (including manipulation/mobilization and soft tissue therapy), dry needling, and exercise prescription, among other things. The fact that neck issues can relate to numerous headache types is not news to us as chiropractors, but I think at the same time, we need to remain realistic and acknowledge that not all headache patients experience relief via treatment of the neck. In my experience, a course of care for headaches is reasonable (let’s stick to the three common classifications for the sake of example) – assuming there are ‘treatable’ findings in the neck (there usually are!). Then, after a course of care, see how they respond. As always, adapt care as necessary and look for ways they can influence their own headache frequency and severity – things like daily movement/exercise, stress management, appropriate vision assessment and care, hydration etc. Chiropractic care certainly has a lot to offer for most headache patients, including those with TTH, but it is often not the only intervention required. It is our job as clinicians to identify and implement the right combination of treatments for each patient.

RESEARCH REVIEW: Cervical Spine Involvement in Tension Type Headaches

This paper was published in Musculoskeletal Science and Practice 2023

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