Tension-Type Headaches | Diagnosis & Treatment for Physios

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Tension type headaches

Tension-Type Headaches | Diagnosis & Treatment for Physios

Introduction & Epidemiology

Headaches can manifest on their own but are also a very common symptom in neck pain patients as more than 60% of patients with a primary neck pain complaint report having concordant episodes of headaches. Therefore it’s essential to find out what kind of headache the patient is suffering from.

To start off let’s differentiate between primary and secondary types of headaches. But what does this mean? Simply put, primary headaches are a “disease themselves” whereas, in secondary headaches, the headache is a symptom of another condition. So primary headaches would be migraines, tension-type headaches & cluster headaches. Secondary type headaches are headaches caused by tumors, hemorrhage, other trauma, TMJ dysfunction, substance overdose, or neck pain aka. The cervicogenic headache.

Now let’s take a closer look at tension-type headaches, which are primary types of headaches.


When looking at the current prevalence of different forms of headaches, TTH is the most prevalent form in the adult population worldwide with a mean prevalence of 42%, followed by migraine with 11% (Stovner et al. (2007). The following graph shows the current prevalence of different forms of headaches in different age categories (Stovner et al. (2007):


The following figure shows the prevalence of headaches on different continents around the world:

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Clinical Picture & Examination

Tension-type headaches can vary from infrequent episodic, frequent episodic, to chronic. As seen in this table.

Tension type headache episodes

While the frequency and duration differ, patients in all three categories need to report at least 2 of the following four characteristics (ICD-H-III):

    1. The headache is bilateral
    2. It has a pressing or tightening quality but NOT pulsating
    3. The intensity is mild to moderate so a patient will usually still be able to complete ADLs as
    4. The headache is not aggravated by routine physical activity such as walking or climbing stairs.

Also, there is

  1. NO nausea or vomiting
  2. No more than one of photophobia or phonophobia which is sensitivity to light and sounds respectively

Tools you can use to assess the impact of a headache on your patient are the HIT-6 questionnaire. Also note that it can be difficult for a patient to answer all of the questions on duration, intensity, and characteristics of their headache during your assessment. Therefore asking them to complete a headache diary can help in the assessment and management of the headache and you should be aware that there can be overlap between multiple headache disorders.


In comparison with healthy controls, the average patient with tension-type headaches differs on provocation, cervical range of motion, neck muscle endurance and forward head position.
The goal of provocation tests is to recreate the patient’s familiar pain. This way, you are able to confirm the location of nociception in the cervical structures, possibly leading to referred pain to the head. While provocative testing for CGH can be done with the techniques shown in the following tab, the phenomenon of referred pain to the head for tension-type headaches and migraine can be provoked with the Watson test:

Although no clear cut-off values are given, the performance time can give an indication of neck flexor endurance:

Upper cervical range of motion in the direction of rotation can be reliably and accurately assessed with the Flexion-Rotation Test (Hall et al. 2010a, Ogince et al. 2007, Hall et al 2010b). This test – if positive – can give you an indication of limited rotation on segments C1/C2. In turn, hypomobility on C0/C1 or C2/C3 can lead to this limitation in rotation on C1/C2.So in case of a positive test, we still need to perform intervertebral motion assessment of all upper cervical segments in order to find the dysfunctional segment.

Forward head posture (FHP) refers to the anterior positioning of the head relative to the torso in a reproducible upright posture. Measuring the horizontal gap between the tragus and the C7 spinous process has been reported to be the most reliable method compared to the horizontal gap between the tragus and acromion process and the craniovertebral angle between the tragus and the C7 spinous process (Lee et al. 2017). The authors report almost perfect intra-rater reliability in both sitting (comfortably or straight) and standing (comfortably or straight) positions with ICC values >0.9 in young healthy Chinese individuals.

When looking at norm values the literature is rather scarce and usually, the craniovertebral angle is described as the sole measurement. Nemmers et al. (2005) describe that a clinician could expect young healthy adults to exhibit an average normal FHP within a 10° range from 49° to 59° when the craniovertebral angle was used as a reference. In their study, the authors report an angle of 48.84° for the 65-74-year-old, 41.2° for the 75-84-year-old, and 35.6° for people in the 85+ range in healthy community-dwelling older women.

In their randomized controlled trial, Harman et al. (2005) defined a forward head posture as soon as the distance between the tragus to the posterior angle of the acromion was greater than 5cm. Fernández-de-las-Peñas (et al. 2006) found a craniovertebral angle of 45.3° in patients with chronic TTH compared to an angle of 54.1° in healthy controls.

Caneiro et al. (2010) showed that slumped sitting is associated with an increased cervical flexion and anterior translation of the head compared to upright sitting. Such postural stress might activate peripheral cervical nociceptors in upper cervical structures like the suboccipital muscles or facet joints which can lead to referred head pain (Mingels et al. 2019). Neuroanatomical, biomechanical, and non-nociceptive pathways seem to justify profiling patients based on a postural trigger. Further research is needed to determine the contribution of postural dysfunctions to headaches and the effect of specific interventions (Mingels et al. 2019).

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Van Ettekoven et al. (2006) compared a craniocervical flexion training(CCFT) program with physiotherapy to physiotherapy alone in patients with chronic tension-type headaches. They found a decrease in headache frequency, duration, and intensity in the CCFT group at 6-week follow-up compared to the physiotherapy group. At 6 months follow-up, even after the intervention program had stopped, the effect regarding decreased headache frequency still remained significant.
Castien et al. (2011) have compared manual therapy (MT) interventions including spinal mobilization / manipulation of the cervical and thoracic spine, posture correction, and craniocervical exercises with usual care by a general practitioner in a group of patients with chronic TTH. They found a significantly larger reduction of headache frequency, disability, and increased cervical function in the MT group at 8 weeks follow-up Disability and cervical function While the difference in the primary outcome headache frequency was still significant at 26 weeks, disability and cervical function were not.
2 years later the authors examined which part of their MT intervention was effective (Castien et al. 2013). They found that increased neck flexor endurance appeared to be the working mechanism behind the MT intervention. An increase in cervical ROM and improved posture did not mediate the effect of decreased headache symptoms.
The same authors went on to examine if there is a relation between isometric neck flexor strength and the decrease of pressure-pain thresholds – an indicator for peripheral and central sensitization in patients with chronic TTH (Castien et al. 2015). Their results indicate that a decrease in PPT correlates with increases in isometric strength of neck flexors in patients with chronic TTH in the short- and long term.

In the case that neck endurance is reduced, you might want to try the following exercise program:

A small part of the intervention in the study of Castien et al. (2011) consisted of manual pressure techniques abbreviated as MTP, for which only anecdotal evidence is available as a treatment in isolation. In the following video we will show you 3 manual pressure techniques that can decrease pain and increase upper cervical range of motion.


Have your patient in prone position. If possible you can lower the head part of the bench so that the patient’s head is in slight flexion. This technique targets the ipsilateral rectus capitis posterior major. This muscle runs obliquely from the spinous process of C2 to the lateral part of the inferior nuchal line at the occiput.In order to reach the muscle, we will have to shift the trapezius muscle medially to reach underneath it. You can ask your patient to slightly lift his head to see the course of the trapezius. Inevitably, we will have to palpate through the splenius, which is only a thin muscle layer that still allows you to palpate through to the rectus capitis posterior major.

Now, apply pressure to this muscle with your thumb into medial and cranial direction toward its attachment. This will result in local and then referred pain to the head in patients with tension-type headaches. Hold the pressure for 20 to 60 seconds until the referred head pain has decreased, followed by a decrease in local pain until only local pressure remains. Afterwards, repeat the technique on the contralateral side as well.

MTP 2: 

This technique combines compression of myofacial structures with a stretch of the rectus capitis posterior major.To conduct the technique have your patient in supine position and place your index or middle finger on the posterior tubercle of C1, which lies deep between the occiput and spinous process of C2. You can increase your pressure by putting another finger on top. Then gradually increase the tension in the contralateral rectus capitis posterior major by rotating the patients head towards you until submaximal pain is reported by the patient. This can again cause local and referred head pain in patients with tension-type headaches. You can fixate the rotation with your own belly or thigh, so it can be maintained in a submaximal position. Hold the pressure and the stretch 20 to 60 seconds until the referred head pain has decreased, followed by a decrease in local pain until only local pressure remains. Afterwards, repeat the technique on the contralateral side as well.


This technique is targeted at the upper cervical joints C1/C2 and C2/C3.To perform the technique for C1/C2 have your patient in supine lying position and support his head on your forearm. Then rotate the patient’s head 20 degrees away from you and place your thumb onto the ipsilateral arch of C1. Afterwards, rotate your patient’s head back until you feel the resistance on your thumb.Again, this technique will elicit local pain and referred pain to the head in patients with tension-type headaches. Hold the pressure and the stretch 20 to 60 seconds until the referred head pain has decreased, followed by a decrease in local pain until only local pressure remains.

In order to target C2/C3, rotate the patient’s head 30 degrees away from you. Then perform an upward slip movement at the ipsilateral facet joint of C2/C3 by exerting pressure on the ipsilateral arch of C2. Again, hold this position 20 to 60 seconds until first the referred head pain is diminished and the local pain has decreased as well until only local pressure remains.

Afterwards, repeat the technique on the contralateral side as well.

Unlike trigger point techniques, the manual pressure techniques are not targeted at painful taut bands in certain muscles.The goal is to elicit a nociceptive afferent stimulus to the upper cervical area that is innervated by the dorsal ramus of C2. This nociceptive stimulus has shown to activate supraspinal inhibiting systems like the periaqueductal gray (PAG) and the rostroventral medulla abbreviated as RVM. These structures can both inhibit nociception at the dorsal horn.Although pain is usually only decreased on short-term in approaches targeting the neurological system, anecdotal evidence shows that these techniques might have a long lasting effect.

Want to learn more about headaches? Then check out our following blogs & research reviews:



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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