The cervical spine in tension type headache

Review written by Dr Julia Treleaven info

Key Points

  1. Cervical impairments may or may not be present, and if present may or may not be related to headache.
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Neck pain in tension type headache (TTH) can be due to several potential mechanisms. It may be due to referred pain from the head to the neck via the trigeminocervical nucleus; due to cervical musculoskeletal impairments and related to headache; or be comorbid. Neck pain might also be related to peripheral sensitization. These different causes of neck pain have recently been identified in individuals with migraine, where only approximately 39% exhibited a pattern of cervical musculoskeletal impairment consistent with individuals with a cervical musculoskeletal disorder (1).

This paper was a position piece included in the recent special edition on Headache and Neck pain for the Musculoskeletal Science and Practice Journal. The objective was to discuss the latest clinical and evidence-based data about the cervical spine and TTH. This is important as TTH is estimated to occur in 26% of the adult population (2) and associated neck pain reported in up to 90% (3). Consequently, many patients with TTH seek treatment for their neck.

Tension type headache is estimated to occur in 26% of the adult population and associated neck pain reported in up to 90%.
Physiotherapy should be multimodal including “bottom up” (tissue based), such as manual therapy and specific exercise and “top down” (central nervous system), such as general exercise, relaxation and cognitive behaviour therapy.


The paper firstly discussed the evidence for clinical cervical musculoskeletal impairments in those with TTH. There is evidence of increased forward head posture, decreased cervical range of motion and altered cervical motor control, such as increased co-contraction of agonists (e.g.

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