Evaluation of treatments and outcomes, red flags and signs and symptoms for cervicogenic headache in a musculoskeletal setting


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

An MSK physiotherapy team from southern England received training sessions for CGH. Topics included assessment, evidence based treatment, clinical reasoning and red flags. Physiotherapists completed a questionnaire on headache red flags and signs and symptoms, preceding and following training.

10 patient cases were examined, exploring treatments, against current best practice, after training. Effectiveness was evaluated using patient outcomes before and after intervention.

The purpose/objectives 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 10 CGH patient cases, against current best practice after training.
  • Review patient treatment outcomes, of the 10 CGH patient cases after training.


The training questionnaire, was completed by 9 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 % of correct answers.


Data was collected from June 2016 to August 2017. Treatments utilised during each session, were recorded and given an average score.

Patients included, completed a Bournemouth pain questionnaire on initial assessment and at discharge. Average outcome scores were collected.

Prior to training, the red flag average correct scores were 58%. Following training, the score improved significantly to an average of 87%. Similarly, the signs and symptoms questionnaire for CGH had an average correct score of 64%. After training the average score increased to 91%.

Patient outcomes post treatment improved significantly. 40% of patients experienced 100% improvement. 70% of patients had an 80%+ improvement. 30% of patients reported an improvement of between 30% and 43%.

Acupuncture was the most utilised treatment at 40.61%, followed by manual therapy at 12.18%. Advice and exercise, balance therapy and soft tissue massage were included. All treatments were chosen in combination.


It was concluded that training needs were identified. Training was found to be beneficial in improving knowledge of headache red flags and signs and symptoms of CGH.

Treatments utilised were indicated in the current literature. Post treatment effective patient care outcomes were achieved.

Future studies exploring knowledge of red flags and CGH assessment/treatment were recommended.

Patients included were limited to 10. Due to workload restraints, some physiotherapists may have felt unable to include suitable cases. The setting was over many sites. Lack of communication may have reduced compliance.

Having explored current NICE guidelines for the management of headaches, MSK physiotherapist should consider all red flags when treating headaches and cervical spine symptoms.
Implementation of focused training strategies can provide a powerful educational tool, facilitating best practice and effective patient screening and outcomes.

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.  

Funding acknowledgements

This work is not funded.

Additional notes

This work was presented at Physiotherapy UK 2018.

For further information about this work contact Fiona Lucas.