Is There Support for the Paradigm ‘Spinal Posture as a Trigger for Episodic Headache’? A Comprehensive Review

  • Sarah MingelsEmail author
  • Wim Dankaerts
  • Marita Granitzer
Hot Topics in Pain and Headache (N. Rosen, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Hot Topics in Pain and Headache


Purpose of Review

The International Classification of Headache Disorders provides an extensive framework to classify headaches. Physiotherapy is indicated if neuromusculoskeletal dysfunctions are involved in the pathophysiology. Maladaptive postures seem a dominant trigger in tension-type and cervicogenic headache. Yet, outcomes following physiotherapy vary. The absence of protocol studies to identify determinants concerning the role of spinal posture in headache might explain such variability. Hence, multi-dimensional profiling of patients with headache based on interactions between spinal posture, psychosocial and lifestyle factors might be essential. Therefore, the aim of this paper was to perform a comprehensive review to find support for the paradigm of spinal posture triggering episodic headache based on a multi-dimensional view on tension-type and cervicogenic headache including modern pain neuroscience.

Recent Findings

A review was conducted to support spinal posture-induced episodic headache. Pubmed, Web of Science, Pedro and the Cochrane database were explored based on the following ‘Mesh’ or ‘Topics’: ‘Headache’, ‘Posture’, ‘Spine’, ‘Psychosocial’, ‘Lifestyle’. The contemporary review of neuroanatomical, biomechanical and non-nociceptive pathways, with integration of modern pain neuroscience in tension-type and cervicogenic headache, supports spinal posture as a trigger for episodic headache. Maladaptive postures can activate C1-C3 nociceptors. Convergence with trigeminal afferents at the trigeminocervical nucleus could explain spinal headache. Interactions with psychosocial and lifestyle factors might contribute to peripheral and central sensitisation.


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 in headache and the effect of specific interventions.


Physiotherapy Spinal posture Neuroanatomy Biopsychosocial Profile Episodic headache 



Tension-type headache


Cervicogenic headache


Forward head posture


Rectus capitis posterior minor


Central sensitisation


Diffuse noxious inhibitory control




Autonomic nervous system


Periaqueductal grey matter


Compliance with Ethical Standards

Conflict of Interest

Sarah Mingels, Wim Dankaerts, and Marita Granitzer declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Stovner L, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27(3):193–210.PubMedGoogle Scholar
  2. 2.
    World Health Organization. Lifting The Burden. Atlas of headache disorders and resources in the world. 2011. Accessed 20 May 2018.
  3. 3.
    Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629–808.Google Scholar
  4. 4.
    Smitherman TA, Davis RE, Walters AB, Young J, Houle TT. Anxiety sensitivity and headache: diagnostic differences, impact, and relations with perceived headache triggers. Cephalalgia. 2015;35(8):710–21.PubMedGoogle Scholar
  5. 5.
    Martin P. Classification of headache disorders: extending to a multiaxial system. Headache. 2016;56:1649–52.PubMedGoogle Scholar
  6. 6.
    Suhr J, Spickard B. Pain is a highly subjective sensation with a complex and often non-linear relationship between nociceptive input and pain perception. Clin Neuropsychol. 2012;26(7):1128–41.PubMedGoogle Scholar
  7. 7.
    de Tommaso M, Fernández-de-Las-Penas C. Tension type headache. Curr Rheumatol Rev. 2016;12(2):127–39.PubMedGoogle Scholar
  8. 8.
    Olesen J. Problem areas in the international classification of headache disorders, 3rd edition (beta). Cephalalgia. 2014;34(14):1193–9.PubMedGoogle Scholar
  9. 9.
    Farmer PK, Snodgrass SJ, Buxton AJ, Rivett DA. An investigation of cervical spinal posture in cervicogenic headache. Phys Ther. 2015;95(2):212–22.PubMedGoogle Scholar
  10. 10.
    Fernandez-de-las-Penas C, Alonso-Blanco C, Cuadrado ML, Pareja JA. Forward head posture and neck mobility in chronic tension-type headache: a blinded, controlled study. Cephalalgia. 2005;26:314–9.Google Scholar
  11. 11.
    Watson DH, Trott PH. Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia. 1993;13:272–84.PubMedGoogle Scholar
  12. 12.
    Bogduk N. The neck and headaches. Neurol Clin. 2014;32(2):471–87.PubMedGoogle Scholar
  13. 13.
    Moore CS, Sibbritt DW, Adams J. A critical review of manual therapy use for headache disorders: prevalence, profiles, motivations, communication and self-reported effectiveness. BMC Neurol. 2017;17(1):61.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Mesa-Jiménez JA, Lozano-López C, Angulo-Díaz-Parreño S, Rodríguez-Fernández ÁL, De-la-Hoz-Aizpurua JL, Fernández-de-Las-Peñas C. Multimodal manual therapy vs. pharmacological care for management of tension type headache: a meta-analysis of randomized trials. Cephalalgia. 2015;35(14):1323–32.PubMedGoogle Scholar
  15. 15.
    Liebert A, Rebbeck T, Elias S, Hawkins D, Adams R. Musculoskeletal physiotherapists' perceptions of non-responsiveness to treatment for cervicogenic headache. Physiother Theory Pract. 2013;29(8):616–29.PubMedGoogle Scholar
  16. 16.
    • Luedtke K, Boissonnault W, Caspersen N, Castien R, Chaibi A, Falla D, et al. International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: a Delphi study. Man Ther. 2016;23:17–24 A very good critical view on current physical therapy techniques applied in headache and their limitations. PubMedGoogle Scholar
  17. 17.
    Jones GT. Psychosocial vulnerability and early life adversity as risk factors for central sensitivity syndromes. Curr Rheumatol Rev. 2016;12(2):140–53.PubMedGoogle Scholar
  18. 18.
    • Adams LM, Turk DC. Psychosocial factors and central sensitivity syndromes. Curr Rheumatol Rev. 2015;11(2):96–108 An important contribution that stimulates including psychosocial variables during patient examination. PubMedPubMedCentralGoogle Scholar
  19. 19.
    Villanueva L. Diffuse noxious inhibitory control (DNIC) as a tool for exploring dysfunction of endogenous pain modulatory systems. Pain. 2009;3:161–2.Google Scholar
  20. 20.
    Drummond PD, Knudsen L. Central pain modulation and scalp tenderness in frequent episodic tension-type headache. Headache. 2011;51(3):375–83.PubMedGoogle Scholar
  21. 21.
    Bezov D, Ashina S, Jensen R, Bendtsen L. Pain perception studies in tension-type headache. Headache. 2011;51(2):262–71.PubMedGoogle Scholar
  22. 22.
    Mongini F, Rota E, Evangelista A, Ciccone G, Milani C, Ugolini A, et al. Personality profiles and subjective perception of pain in head pain patients. Pain. 2009;44:125–9.Google Scholar
  23. 23.
    Loyen A, van der Ploeg HP, Bauman A, Brug J, Lakerveld J. European sitting championship: prevalence and correlates of self-reported sitting time in the 28 European Union member states. PLoS One. 2016;11(3):e0149320.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Malinska M, Bugajska J. The influence of occupational and non-occupational factors on the prevalence of musculoskeletal complaints in users of portable computers. Int J Occup Saf Ergon. 2010;16:337–43.PubMedGoogle Scholar
  25. 25.
    Westgaard RH, Winkel J. Guidelines for occupational musculoskeletal load as a basis for intervention: a critical review. Appl Ergon. 1996;27(2):79–88.PubMedGoogle Scholar
  26. 26.
    Pooriput W, Bala R, Prawit J. Internal oblique and transversus abdominis muscle fatigue induced by slumped sitting posture after 1 hour of sitting in office workers. Saf Health Work. 2016;7(1):49–54.Google Scholar
  27. 27.
    Black KM, McClure P, Polansky M. The influence of different sitting positions on cervical and lumbar posture. Spine (Phila Pa 1976). 1996;21(1):65–70.Google Scholar
  28. 28.
    Fernández-de-Las-Peñas C, Cuadrado ML. Physical therapy for headaches. Cephalalgia. 2016;36(12):1134–42.PubMedGoogle Scholar
  29. 29.
    McGill SM, Brown S. Creep response of the lumbar spine to prolonged full flexion. Clin Biomech. 1992;7(1):43–6.Google Scholar
  30. 30.
    Fernandez-de-las-Penas C, Cuadrado ML, Pareja JA. Myofascial trigger points, neck mobility, and forward head posture in episodic tension-type headache. Headache. 2007;47:662–72.PubMedGoogle Scholar
  31. 31.
    Caneiro JP, O’Sullivan P, Burnett A, Barach A, O’Neil D, Tveit O, et al. The influence of different sitting postures on head/neck posture and muscle activity. Man Ther. 2010;15:54–60.PubMedGoogle Scholar
  32. 32.
    Van Houdenhove JB, Oostendorp RA. Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice. Man Ther. 2010;15(2):135–41.PubMedGoogle Scholar
  33. 33.
    Smart KM, Blake C, Staines A, Doody C. Clinical indicators of 'nociceptive', 'peripheral neuropathic' and 'central' mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians. Man Ther. 2010;15(1):80–7.PubMedGoogle Scholar
  34. 34.
    Sluka KA. Pain mechanisms involved in musculoskeletal disorders. J Orthop Sports Phys Ther. 1996;4(4):240–54.Google Scholar
  35. 35.
    Hack GD, Hallgren RC. Chronic headache relief after section of suboccipital muscle dural connections: a case report. Headache. 2004;44(1):84–9.PubMedGoogle Scholar
  36. 36.
    Kahkeshani K, Ward PJ. Connection between the spinal dura mater and suboccipital musculature: evidence for the myodural bridge and a route for its dissection—a review. Clin Anat. 2010;25:415–22.Google Scholar
  37. 37.
    Choi JC, Chung M, Lee YD. Modulation of pain sensation by stress-related testosterone and cortisol. Anaesthesia. 2012;67(10):1146–51.PubMedGoogle Scholar
  38. 38.
    Peck D, Buxton DF, Nitz A. A comparison of spindle concentrations in large and small muscles acting in parallel combinations. J Morphol. 1984;180:243–52.PubMedGoogle Scholar
  39. 39.
    Hallgren RC, Rowan JR, Bai P, Pierce SJ, Shafer-Crane GA, Prokop LL. Activation of rectus capitis posterior major muscles during voluntary retraction of the head in asymptomatic subjects. J Manip Physiol Ther. 2014;37(6):433–40.Google Scholar
  40. 40.
    Richmond F, Singh K, Corneil B. Marked non-uniformity of fiber-type composition in the primate suboccipital muscle obliquus capitis inferior. Exp Brain Res. 1999;125(1):14–8.PubMedGoogle Scholar
  41. 41.
    Liu J, Thornell L, Pedrosa-Domellöfet F. Muscle spindles in the deep muscles of the human neck: a morphological and immunocytochemical study. J Histochem Cytochem. 2003;51(2):175–86.PubMedGoogle Scholar
  42. 42.
    Corneil BD, Olivier E, Munoz DP. Neck muscle responses to stimulation of monkey superior colliculus. I. Topography and manipulation of stimulation parameters. J Neurophysiol. 2002;88(4):1980–99.PubMedGoogle Scholar
  43. 43.
    Hirai T, Hongo S, Sasaki S, Yamashita M, Yoshida K. Neck muscle afferent input to spinocerebellar tract cells of the central cervical nucleus in the cat. Exp Brain Res. 1984;55(2):286–300.PubMedGoogle Scholar
  44. 44.
    Peterson BW. Current approaches and future directions to understanding control of head movement. Prog Brain Res. 2004;143:369–81.PubMedGoogle Scholar
  45. 45.
    Field S, Treleaven J, Jull G. Standing balance: a comparison between idiopathic and whiplash induced neck pain. Man Ther. 2008;(3, 3):183–91.Google Scholar
  46. 46.
    Leistad RB, Stovner LJ, White LR, Nilsen KB, Westgaard RH, Sand T. Noradrenaline and cortisol changes in response to low-grade cognitive stress differ in migraine and tension-type headache. J Headache Pain. 2007;8(3):157–66.PubMedPubMedCentralGoogle Scholar
  47. 47.
    Hallgren RC, Greenman PE, Rechtien JJ. Atrophy of suboccipital muscles in patients with chronic pain: a pilot study. J Am Osteopath Assoc. 1994;12:1032–8.Google Scholar
  48. 48.
    Khayatzadeh S, Kalmanson OA, Schuit D, Havey RM, Voronov LI, Ghanayem AJ, et al. Cervical spine muscle-tendon unit length differences between neutral and forward head postures: biomechanical study using human cadaveric specimens. Phys Ther. 2017;97(7):756–66.PubMedGoogle Scholar
  49. 49.
    Luedtke K. Does the rectus capitis posterior minor muscle contribute to the pathogenesis of chronic headache? Cephalalgia. 2017;37(11):1025–6.Google Scholar
  50. 50.
    •• Palomeque-del-Cerro L, Arraez-Aybar LA, Rodrıguez-Blanco C, Guzman-Garcıa R, Menendez-Aparicio M, Oliva-Pascual-Vaca A. A systematic review of the soft-tissue connections between neck muscles and dura mater. Spine. 2016;2(1):49–54 A very good view of possible pathophysiological mechanisms for cervicogenic headache. Google Scholar
  51. 51.
    Meyer RA, Campbell JN, Raja SN. Peripheral neural mechanisms of nociception. Textbook of pain. 3rd ed. London: Curchill Livingstone; 1995.Google Scholar
  52. 52.
    Nijs J, Torres-Cueco R, van Wilgen CP, Girbes EL, Struyf F, Roussel N, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014;17:447–57.PubMedGoogle Scholar
  53. 53.
    Nijs J, Apeldoorn A, Hallegraeff H, Clark J, Smeets R, Malfleit A, et al. Low back pain: guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain. Pain Physician. 2015;18(3):333–46.Google Scholar
  54. 54.
    Chua NHL, van Suijlekom HA, Vissers KC, Arendt-Nielsen L, Wilder-Smith OH. Differences in sensory processing between chronic cervical zygapophysial joint pain patients with and without cervicogenic headache. Cephalalgia. 2011;31(8):953–63.PubMedGoogle Scholar
  55. 55.
    Yunus MB. Role of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain. Best Pract Res Clin Rheumatol. 2007;1(3):481–9.Google Scholar
  56. 56.
    Cady RK. The convergence hypothesis. Headache. 2007;47:S44–51.PubMedGoogle Scholar
  57. 57.
    Richards KV, Beales DJ, Smith AJ, O'Sullivan PB, Straker LM. Neck posture clusters and their association with biopsychosocial factors and neck pain in Australian adolescents. Phys Ther. 2016;96(10):1576–87.PubMedGoogle Scholar
  58. 58.
    Lundy-Ekman L. Neuroscience fundamentals for rehabilitation. 5th ed. St. Louis: Elsevier; 2018.Google Scholar
  59. 59.
    Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133(4):581–624.PubMedGoogle Scholar
  60. 60.
    Gallagher L, McAuley J, Moseley GL. A randomized controlled trial of using a book of metaphors to reconceptualise pain and decrease catastrophizing in people with chronic pain. Clin J Pain. 2013;29:20–5.PubMedGoogle Scholar
  61. 61.
    Rahim-Williams B, Riley JL, Williams AK, Fillingim RB. A quantitative review of ethnic group differences in experimental pain response: do biology, psychology, and culture matter? Pain Med. 2012;13(4):522–40.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Paananen M, O'Sullivan P, Straker L, Beales D, Coenen P, Karppinen J, et al. A low cortisol response to stress is associated with musculoskeletal pain combined with increased pain sensitivity in young adults: a longitudinal cohort study. Arthritis Res Ther. 2015;10(17):355.Google Scholar
  63. 63.
    Glass JJ, Glaros AG. Autonomic dysregulation in headache patients. Appl Psychophysiol Biofeedback. 2013;38:257–63.Google Scholar
  64. 64.
    Mosek A, Novak V, Opfer-Gehrking TL, Swanson JW, Low PA. Autonomic dysfunction in migraineurs. Headache. 1999;39:108–17.PubMedGoogle Scholar
  65. 65.
    Benarroch EE. Pain-autonomic interactions. Neurol Sci. 2006;7:S130–3.Google Scholar
  66. 66.
    Nair S, Sagar M, Sollers J, Consedine N, Broadbent E. Do slumped and upright postures affect stress responses? A randomized trial. Health Psychol. 2015;34(6):632–41.PubMedGoogle Scholar
  67. 67.
    Wilson VE, Peper E. The effects of upright and slumped postures on the recall of positive and negative thoughts. Appl Psychophysiol Biofeedback. 2004;29:189–95.PubMedGoogle Scholar
  68. 68.
    Wijma AJ, van Wilgen CP, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: the first step in pain neuroscience education. Physiother Theory Pract. 2016;32(5):368–84.PubMedGoogle Scholar
  69. 69.
    Hall T, Robinson K. The flexion-rotation test and active cervical mobility–a comparative measurement study in cervicogenic headache. Man Ther. 2004;9(4):197–202.PubMedGoogle Scholar
  70. 70.
    Sjaastad O, Bakketeig L. Tension-type headache: comparison with migraine without aura and cervicogenic headache. The Vaga study of headache epidemiology. Funct Neurol. 2008;23(2):71–6.PubMedGoogle Scholar
  71. 71.
    Castien RF, van der Windt DA, Blankenstein AH, Heymans MW, Dekker J. Clinical variables associated with recovery in patients with chronic tension-type headache after treatment with manual therapy. Pain. 2012;3(4):893–9.Google Scholar
  72. 72.
    Askew R, Kibelstis C, Overbaugh S, Walker S, Nixon-Cave K, Shepard KF. Physical therapists’ perception of patients’ pain and its effect on management. Physiother Res Int. 1998;3(1):37–57.PubMedGoogle Scholar
  73. 73.
    Overmeer T, Linton SJ, Boersma K. Do physical therapists recognise established risk factors? Swedish physical therapists’ evaluation in comparison to guidelines. Physiother. 2004;90(1):35–41.Google Scholar
  74. 74.
    Lee CH, Lee S, Shin G. Reliability of forward head posture evaluation while sitting, standing, walking and running. Hum Mov Sci. 2017;55:81–6.PubMedGoogle Scholar
  75. 75.
    McDonnell MK, Sahrmann SA, Van Dillen L. A specific exercise program and modification of postural alignment for treatment of cervicogenic headache: a case report. J Orthop Sports Phys Ther. 2005;35(1):3–15.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Sarah Mingels
    • 1
    • 2
    Email author
  • Wim Dankaerts
    • 2
  • Marita Granitzer
    • 1
  1. 1.REVAL Rehabilitation Research Centre, Biomedical Research Institute, Faculty of Rehabilitation SciencesHasselt UniversityHasseltBelgium
  2. 2.Musculoskeletal Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation SciencesLeuven UniversityLeuvenBelgium

Personalised recommendations