Tension-type headache (TTH)

A 2019 clinical practice guideline1 made the following recommendations:

  • Episodic TTH (symptoms > 3 months post-injury)
    • Consider home and clinic-based interventions such as low-load craniocervical and cervicoscapular exercises max of 8 sessions over 6 weeks
    • Do NOT offer spinal manipulative therapy (SMT) of the cervical spine
  • Chronic TTH (symptoms > 3 months post-injury)
    • Consider home and clinic-based interventions:
      1. General exercise (warm-up, neck and shoulder stretching and strengthening, aerobic exercises) max of 25 sessions over 12 weeks;
      2. Low-load endurance craniocervical and cervicoscapular exercises max of 8 sessions over 6 weeks;
      3. Multimodal care that includes spinal mobilization, craniocervical exercises and postural correction max 9 sessions over 8 weeks; or
      4. Clinical massage on shoulders, upper back, connecting area of neck and shoulders, shoulder tips, back of head, middle line of head, face max of 8 sessions (45 mins per) over 4 weeks
    • Do NOT offer SMT of the cervical spine

Cervicogenic headache (CGH)

  • Home and clinic-based interventions:
    1. Low-load endurance craniocervical and cervicoscapular exercises; or
    2. Manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine max of 10 sessions over 6 weeks
  • Do NOT offer multimodal program of care that combines SMT, mobilization, and low-load endurance exercises.

Systematic Reviews (by classification)

Cervicogenic headache (CGH)

A 2016 review2 to determine the effectiveness of manual therapy (MT) for CGH (studies not assessed for quality) found 10 RCTs evaluating manipulation or mobilization. Six included studies found statistically significant improvements in symptoms (such as pain intensity, frequency, duration, disability or ROM) for participants in the manipulation group compared to control. However, the active treatments and control interventions varied, creating heterogeneity in synthesizing the findings; therefore, the authors concluded uncertainty in the effectiveness of manipulation of the cervical spine as a treatment for CGH.


A 2019 meta analysis3 included 6 RCTs and found that SMT (treatment duration ranged from 2-6 months) reduced migraine days and migraine pain or intensity with an overall small effect size and did not impact migraine disability compared to control interventions. The magnitude of the effect was not determined due to the variation in study quality.


A 2015 systematic review4 evaluating the effectiveness of physiotherapy interventions (exercise, manual therapy, soft-tissue techniques, or strength and endurance training) on the duration, frequency and intensity of TTH, CGH and migraine. Based on a low-level evidence, statistically significant effects were found with:

  • PT on intensity of TTH and CGH
  • PT on frequency of CGH
  • PT on Duration of migraine and CGH
  • MT (mobilization) for frequency and duration of TTH and for all outcomes for CGH
  • Trigger point treatment reduced intensity of TTH and CGH
  • Physical and psychological treatment with aerobic exercise reduced duration of migraine

One 2017 systematic review5 assessed the effect of self-management compared to usual care in patients with migraine or TTH. The authors included 16 studies and reported that preliminary evidence suggests a small effect favoring self-management techniques such as mindfulness and cognitive behavioral therapy. Outcomes included pain intensity, headache-related disability, quality of life, and a moderate effect on mood; however, no effect on frequency. A larger treatment effect was found when it included explicit education, mindfulness and had group delivery (vs. one-on-one).

A systematic review6 was conducted to update the Neck Pain Task Force findings and evaluate the effectiveness of non-pharmacological treatments for headaches associated with neck pain (Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Associated Disorders). Results included:

  • Episodic TTH
    • One trial randomized participants into a group receiving cervical manipulation or a group receiving inert laser (both combined with deep friction massage. No clinically important differences between the groups was found.
  • Chronic TTH
    • One trial reported multimodal care (cervical and thoracic mobilization, craniocervical exercise, and postural correction) superior to usual primary care in reducing intensity and frequency. Participants receiving multimodal care were also more likely to report improved or much improved and less likely to use additional healthcare services or take sick leave.
  • Chronic CGH
    • Two trials’ evidence suggests that manual therapy (manipulation and mobilization) and low load endurance exercises are effective for patients suffering from CGH.


  1. Côté P, Yu H, Shearer HM, et al. Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. Eur J Pain (United Kingdom). 2019;23(6):1051-1070. FREE FULL TEXT
  2. Garcia JD, Arnold S, Tetley K, et al. Mobilization and manipulation of the cervical spine in patients with cervicogenic headache: Any scientific evidence? Front Neurol. 2016;7:40. FREE FULL TEXT
  3. Rist PM, Hernandez A, Bernstein C, et al. The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta-Analysis. Headache. 2019;59(4):532-542. FREE FULL TEXT
  4. Luedtke K, Allers A, Schulte LH, et al. Efficacy of interventions used by physiotherapists for patients with headache and migraine – Systematic review and meta-analysis. Cephalalgia. 2016;36(5):474-492.
  5. Probyn K, Bowers H, Mistry D, et al. Non-pharmacological self-management for people living with migraine or tension-type headache: A systematic review including analysis of intervention components. BMJ Open. 2017;7(8):e016670. FREE FULL TEXT
  6. Varatharajan S, Ferguson B, Chrobak K, et al. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016;25(7):1971-1999. FREE FULL TEXT