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


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.

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Fig. 1
Fig. 2



Tension-type headache


Cervicogenic headache


Forward head posture


Rectus capitis posterior minor


Central sensitisation


Diffuse noxious inhibitory control




Autonomic nervous system


Periaqueductal grey matter


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.

    PubMed  Article  Google 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.

    Article  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.

    PubMed  Article  Google Scholar 

  5. 5.

    Martin P. Classification of headache disorders: extending to a multiaxial system. Headache. 2016;56:1649–52.

    PubMed  Article  Google 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.

    PubMed  Article  Google Scholar 

  7. 7.

    de Tommaso M, Fernández-de-Las-Penas C. Tension type headache. Curr Rheumatol Rev. 2016;12(2):127–39.

    PubMed  Article  Google Scholar 

  8. 8.

    Olesen J. Problem areas in the international classification of headache disorders, 3rd edition (beta). Cephalalgia. 2014;34(14):1193–9.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    Article  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.

    CAS  PubMed  Article  Google Scholar 

  12. 12.

    Bogduk N. The neck and headaches. Neurol Clin. 2014;32(2):471–87.

    PubMed  Article  Google 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.

    PubMed  PubMed Central  Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    CAS  PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  PubMed Central  Article  Google 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.

    Article  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.

    PubMed  Article  Google Scholar 

  21. 21.

    Bezov D, Ashina S, Jensen R, Bendtsen L. Pain perception studies in tension-type headache. Headache. 2011;51(2):262–71.

    PubMed  Article  Google 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.

    Article  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.

    PubMed  PubMed Central  Article  CAS  Google 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.

    PubMed  Article  Google 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.

    CAS  PubMed  Article  Google 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.

    Article  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.

    CAS  Article  Google Scholar 

  28. 28.

    Fernández-de-Las-Peñas C, Cuadrado ML. Physical therapy for headaches. Cephalalgia. 2016;36(12):1134–42.

    PubMed  Article  Google Scholar 

  29. 29.

    McGill SM, Brown S. Creep response of the lumbar spine to prolonged full flexion. Clin Biomech. 1992;7(1):43–6.

    CAS  Article  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.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  Article  Google Scholar 

  34. 34.

    Sluka KA. Pain mechanisms involved in musculoskeletal disorders. J Orthop Sports Phys Ther. 1996;4(4):240–54.

    Article  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.

    PubMed  Article  Google 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.

    Article  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.

    CAS  PubMed  Article  Google 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.

    CAS  PubMed  Article  Google 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.

    Article  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.

    CAS  PubMed  Article  Google 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.

    CAS  PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    CAS  PubMed  Google Scholar 

  44. 44.

    Peterson BW. Current approaches and future directions to understanding control of head movement. Prog Brain Res. 2004;143:369–81.

    PubMed  Google 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.

  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.

    CAS  PubMed  PubMed Central  Article  Google 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.

    PubMed  Article  Google 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.

    Article  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.

    Article  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.

    PubMed  Google 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.

    PubMed  Article  Google 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.

    Article  Google Scholar 

  56. 56.

    Cady RK. The convergence hypothesis. Headache. 2007;47:S44–51.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  PubMed Central  Article  Google 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.

    Article  CAS  Google Scholar 

  63. 63.

    Glass JJ, Glaros AG. Autonomic dysregulation in headache patients. Appl Psychophysiol Biofeedback. 2013;38:257–63.

    Article  Google Scholar 

  64. 64.

    Mosek A, Novak V, Opfer-Gehrking TL, Swanson JW, Low PA. Autonomic dysfunction in migraineurs. Headache. 1999;39:108–17.

    CAS  PubMed  Article  Google Scholar 

  65. 65.

    Benarroch EE. Pain-autonomic interactions. Neurol Sci. 2006;7:S130–3.

    Article  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.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    PubMed  Article  Google 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.

    CAS  PubMed  Article  Google 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.

    CAS  PubMed  Google 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.

    Article  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.

    CAS  PubMed  Article  Google 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.

    Article  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.

    PubMed  Article  Google 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.

    PubMed  Article  Google Scholar 

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Correspondence to Sarah Mingels.

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Mingels, S., Dankaerts, W. & Granitzer, M. Is There Support for the Paradigm ‘Spinal Posture as a Trigger for Episodic Headache’? A Comprehensive Review. Curr Pain Headache Rep 23, 17 (2019).

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  • Physiotherapy
  • Spinal posture
  • Neuroanatomy
  • Biopsychosocial
  • Profile
  • Episodic headache