Cervicogenic headache in a musculoskeletal setting

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Cervicogenic headache in a musculoskeletal setting [Darren Hopes/Ikon Imges/Science Photo Library]

Fiona Lucas, senior physiotherapist for Southern Health NHS Trust and Nuffield Health Bournemouth, shares her highlights from evaluating the effect of targeted training on the management of cervicogenic headache (CGH) in a musculoskeletal setting.


Current evidence advocates physiotherapy treatment for the management of CGH.  A reasoned assessment and clear knowledge of red flags is essential.

The purpose of this study was to:

  • evaluate participant’s knowledge of red flag and signs and symptoms of CGH headache, preceding and following training.
  • examine treatments used by participants for patient cases, against current best practice after training.
  • review patient treatment outcomes, of patient cases after training.


An MSK physiotherapy team, comprising clinicians with varying levels of experience, from southern England, received two face-to-face training sessions for CGH (six hours in total).  

Topics included: 

  • assessment
  • evidence based treatment
  • clinical reasoning
  • red flags 

Physiotherapists completed a questionnaire on headache red flags and signs and symptoms, preceding and following training. The training questionnaire was completed by nine participants. Section 1 consisted of 13 possible red flags. Section 2 listed 11 possible signs and symptoms of CGH. The questionnaire was completed again after training. Data was collected as an average percentage of correct answers.

Data was collected from June 2016 to August 2017. During this time 10 patient cases were examined, exploring treatments against current best practice after training. Patients completed a Bournemouth pain questionnaire on initial assessment and at discharge. Average outcome scores were collected.


  • training needs were identified. 
  • training was found to be beneficial in improving knowledge of headache red flags and signs and symptoms of CGH. 
  • implementation of focused training strategies can provide a powerful educational tool, facilitating best practice and effective
  • patient screening and outcomes. 
  • this project led to the production of an online training webinar. 
  • the number of patients within the evaluation was limited to ten. This may have been due to a lack of patients presenting with CGH at that time. Due to workload restraints, some physios may have felt unable to include suitable cases. As the primary care setting was spread over many sites, lack of communication could have also reduced compliance.
  • future studies exploring knowledge of red flags and CGH assessment/treatment were recommended. 

Notes and funding

Top three learning points

  1. The questionnaire before and after training served as an excellent facilitator for participants’ engagement   and achievement of learning outcomes.
  2. Patient improvement outcomes were much better than anticipated. This was positive feedback for the MSK teams involved.
  3. It would be useful to explore training outcomes further, to see if the knowledge gained was retained over a longer period post training.  

Author’s reflections

Having completed this project, I have been given the opportunity to raise awareness of red flags for headaches and to discuss treatment findings with other MSK physiotherapists. This has included presenting at MSK study days and at Physiotherapy UK 2018. 

I have produced a webinar for Nuffield Health learning and development on headaches, treatments and red flags. Following publication on the Innovations Database, other physiotherapists have contacted me for more information and to request to use the questionnaire as part of their in service training sessions. My top piece of advice for someone interested on completing a similar project would be to keep it simple. 

Focus on a few key elements when considering the questions you want to address.


  • Prior to training, the red flag average correct scores were 58 per cent. 
  • Following training, the score improved to an average of 87 per cent. 
  • Prior to training, the signs and symptoms questionnaire for CGH had an average correct score of 64 per cent. After training the average score increased to 91 per cent.
  • Patient outcomes post treatment improved significantly. 
  • 40 per cent of patients experienced 100 per cent improvement. 
  • Treatments utilised were indicated in the current literature. 
  • All treatments were chosen in combination.

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