Tension Headache

Procedure

Patient lying with knees bent and the head level. Place a pressure biofeedback unit behind the upper neck and inflate it to 20 mmHg. Ask for a gentle nodding action to raise the pressure in 2 mmHg steps (22 to 30), holding each for 10 seconds, while you watch for substitution.

Positive Finding

Unable to reach or hold the stages without substitution: superficial neck muscles tightening, chin poking, jaw clenching or the head lifting.

Interpretation

Measures control and endurance of the deep neck flexors and guides exercise. Reduced performance is common in neck pain and some headache groups, but it does not diagnose tension-type headache. The CCFT measures deep neck flexor control and endurance. It is used to guide and track exercise, not to diagnose tension-type headache. The figure previously stored was described as being "for cervical dysfunction" and could not be matched to a diagnostic study of headache, so no figure is shown. The CCFT measures deep neck flexor control and endurance. It is used to guide and track exercise, not to diagnose tension-type headache. The figure previously stored was described as being "for cervical dysfunction" and could not be matched to a diagnostic study of headache, so no figure is shown.

Procedure

Patient seated. Measure active flexion, extension, side-bending and rotation with an inclinometer or goniometer, comparing sides, and ask whether any movement brings on the headache.

Positive Finding

Reduced or painful range, or the familiar headache brought on by neck movement.

Interpretation

Neck movement can be mildly reduced in tension-type headache, but normal range is common and the findings overlap with migraine. A headache that is reliably brought on by neck movement points more towards cervicogenic headache. Refer urgently for a new or changed headache with red flags: sudden severe onset, neurological signs, fever or neck stiffness, new headache after 50, headache worse lying down or on straining, or a history of cancer or immune suppression.

Procedure

Patient seated or lying. Palpate the upper trapezius, suboccipitals, temporalis, masseter and sternocleidomastoid on both sides with steady pressure, noting tenderness and any referred head pain.

Positive Finding

Increased tenderness of the head and neck muscles, sometimes reproducing the familiar headache.

Interpretation

Increased tenderness of the pericranial muscles is a recognised feature of tension-type headache, used to sub-classify it. It is also common in migraine, so it supports rather than confirms the diagnosis.

Procedure

Patient lying on their back. Fully flex the neck passively to take the lower neck out of play, then rotate the head to each side until firm resistance or pain, and compare the range.

Positive Finding

Rotation clearly reduced to one side with a firm end-feel, or the familiar headache reproduced.

Reference: Ogince M, Hall T, Robinson K, Blackmore AM. The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache. Man Ther. 2007;12(3):256-62.

Interpretation

Tests rotation at C1–C2. A positive test suggests an upper cervical contribution, which is more typical of cervicogenic than tension-type headache. See the cervicogenic headache page for its figures. Before upper cervical techniques, screen for cervical arterial dysfunction (dizziness, double vision, difficulty speaking or swallowing, drop attacks, numbness, nystagmus) and for instability (recent trauma, rheumatoid arthritis, Down syndrome). No study of this test in tension-type headache was found (Europe PMC search, October 2026). In cervicogenic headache it was positive in 91% of cases and negative in 90% of people with migraine with aura or no headache (Ogince 2007, 58 people), so no figure is shown for tension-type headache.

Procedure

Assess passive movement at C0–C1, C1–C2 and C2–C3 with the patient lying or seated (accessory glides and physiological movements), comparing levels and sides and asking about headache reproduction.

Positive Finding

Reduced or painful movement at an upper cervical level that reproduces the familiar headache.

Interpretation

Reproduction of the familiar headache on upper cervical examination suggests the neck is contributing (a cervicogenic component) rather than pure tension-type headache. Agreement between examiners is only moderate. Before upper cervical techniques, screen for cervical arterial dysfunction (dizziness, double vision, difficulty speaking or swallowing, drop attacks, numbness, nystagmus) and for instability (recent trauma, rheumatoid arthritis, Down syndrome).

Procedure

Palpate along the course of the greater occipital nerve, a little below and to the side of the external occipital protuberance, and the lesser occipital nerve behind the ear, comparing sides.

Positive Finding

Local tenderness, or a shooting or electric pain spreading up over the back of the scalp.

Interpretation

Tenderness alone is common in tension-type headache and migraine. Brief shooting or stabbing pains in the nerve's area, with tenderness over the nerve, suggest occipital neuralgia instead.