Tension-Type Headaches

Tension type headaches


  • Headaches are a common symptom in patients with primary neck pain, with over 60% reporting concurrent headaches.
  • Differentiated into primary (e.g., migraines, tension-type, cluster headaches) and secondary (caused by another condition, such as TMJ dysfunction or neck pain).


  • Tension-type headaches (TTH) are the most common form in adults worldwide, with a mean prevalence of 42%.
  • TTH can be infrequent episodic, frequent episodic, or chronic.

Clinical Picture

  • Diagnosis requires at least two of the following – bilateral location, pressing/tightening quality (not pulsating), mild to moderate intensity, not aggravated by physical activity; no nausea/vomiting, and at most one of photophobia or phonophobia.


  • Differences in provocation, cervical range of motion, neck muscle endurance, and forward head position compared to healthy controls.
  • Provocation tests recreate familiar pain, indicating nociception in cervical structures. Watson test for referred pain
  • Neck Flexor Endurance Test
  • Flexion-Rotation Test for upper cervical rotation
  • Assessment of Forward Head Posture (FHP).


  • Craniocervical Flexion Training (CCFT): Van Ettekoven et al. (2006) found CCFT combined with physiotherapy reduced headache frequency, duration, and intensity compared to physiotherapy alone.
  • Manual Therapy (MT): Castien et al. (2011, 2013) showed MT, including spinal mobilization/manipulation, posture correction, and craniocervical exercises, significantly reduced headache frequency and improved cervical function.
  • Isometric Neck Flexor Strength: Castien et al. (2015) correlated increased isometric strength of neck flexors with decreased pressure-pain thresholds, indicating reduced peripheral and central sensitization in chronic TTH patients.
  • Manual Pressure Techniques (MTP): Demonstrated to decrease pain and increase upper cervical range of motion. Techniques target rectus capitis posterior major and upper cervical joints, providing nociceptive stimuli to reduce pain through neurological pathways.

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Caneiro, J. P., O’Sullivan, P., Burnett, A., Barach, A., O’Neil, D., Tveit, O., & Olafsdottir, K. (2010). The influence of different sitting postures on head/neck posture and muscle activity. Manual therapy15(1), 54-60.

Castien, R. F., Van Der Windt, D. A., Grooten, A., & Dekker, J. (2011). Effectiveness of manual therapy for chronic tension-type headache: a pragmatic, randomised, clinical trial. Cephalalgia31(2), 133-143.

Castien, R., Blankenstein, A., Van Der Windt, D., Heymans, M. W., & Dekker, J. (2013). The working mechanism of manual therapy in participants with chronic tension-type headache. journal of orthopaedic & sports physical therapy43(10), 693-699.

Castien, R., Blankenstein, A., & De Hertogh, W. (2015). Pressure pain and isometric strength of neck flexors are related in chronic tension-type headache. Pain physician18(2), E201-E205.

Van Ettekoven, H., & Lucas, C. (2006). Efficacy of physiotherapy including a craniocervical training programme for tension-type headache; a randomized clinical trial. Cephalalgia26(8), 983-991.

Fernandez-de-Las-Penas, C., Alonso-Blanco, C., Cuadrado, M. L., & Pareja, J. A. (2006). Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study. Cephalalgia26(3), 314-319.

Hall, T., Briffa, K., Hopper, D., & Robinson, K. (2010). Long-term stability and minimal detectable change of the cervical flexion-rotation test. journal of orthopaedic & sports physical therapy40(4), 225-229.

Hall, T. M., Briffa, K., Hopper, D., & Robinson, K. (2010). Comparative analysis and diagnostic accuracy of the cervical flexion–rotation test. The journal of headache and pain11(5), 391-397.

Harman, K., Hubley-Kozey, C. L., & Butler, H. (2005). Effectiveness of an exercise program to improve forward head posture in normal adults: a randomized, controlled 10-week trial. Journal of Manual & Manipulative Therapy13(3), 163-176.

Lee, C. H., Lee, S., & Shin, G. (2017). Reliability of forward head posture evaluation while sitting, standing, walking and running. Human Movement Science55, 81-86.

Mingels, S., Dankaerts, W., & Granitzer, M. (2019). Is there support for the paradigm ‘spinal posture as a trigger for episodic headache’? A comprehensive review. Current Pain and Headache Reports23, 1-8.

Nemmers, T. M., Miller, J. W., & Hartman, M. D. (2009). Variability of the forward head posture in healthy community-dwelling older women. Journal of geriatric physical therapy32(1), 10-14.

Ogince, M., Hall, T., Robinson, K., & Blackmore, A. M. (2007). The diagnostic validity of the cervical flexion–rotation test in C1/2-related cervicogenic headache. Manual therapy12(3), 256-262.

Olesen, J. (2018). International classification of headache disorders. The Lancet Neurology17(5), 396-397.

Stovner, L. J., Hagen, K., Jensen, R., Katsarava, Z., Lipton, R. B., Scher, A. I., … & Zwart, J. A. (2007). The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia27(3), 193-210.

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