Neck Pain and Headache

The Clinically Organized Relevant Exam (CORE) Neck Tool and Headache Navigator was developed to assist primary care providers in differentiating and assessing neck pain or headache. The CORE Neck Tool and Headache Navigator provides discrete approaches to neck pain and headache management.

Question #1: A patient with 2 or more symptoms of the following – nausea, light sensitivity or interference with activities – is most likely experiencing a:

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Question #2: Pain that is most intense over the trapezius, sub-occipital, paraspinal, or parascapular regions is a common presentation of:

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CORE Neck Tool and Headache Navigator
CORE Neck Tool and Headache Navigator
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Primary care providers told us that headache and neck pain are challenging to treat, especially when presented together. The Clinically Organized Relevant Exam (CORE) Neck Tool and Headache Navigator was developed to assist primary care providers in differentiating and assessing neck pain or headache.

Because neck pain and headache often have overlapping presentation of symptoms, this tool uses discrete approaches that help rule out other underlying conditions.

The Clinically Organized Relevant Exam (CORE) Neck Tool guides providers to recognize common mechanical neck pain and screen for other conditions.

The CORE Neck Tool has been divided into four components:
1. History    2. Physical Examination     3. Management Matrix     4. Referrals

The Headache Navigator is based on the Primary Care Management of Headache in Adults clinical practice guideline and quick reference algorithm that was produced by Towards Optimized Practice (TOP). It assists primary care providers in managing primary headache disorders.

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Project Overview

 Primary care providers say that headache and neck pain are challenging to treat, especially when presented together. The Clinically Organized Relevant Exam (CORE) Neck Tool and Headache Navigator was developed to assist primary care providers in differentiating and assessing neck pain or headache.

Because neck pain and headache often have overlapping presentation of symptoms, this tool uses discrete approaches that help rule out other underlying conditions.

Development Process

The CORE Neck Tool and Headache Navigator is one of several resources developed as part of the 2014 to 2017 Knowledge Translation in Primary Care Initiative. This multi-year initiative was a collaboration between the Centre for Effective Practice (CEP), Ontario College of Family Physicians (OCFP), and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health and Long-Term Care, this initiative supported primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

As part of this initiative, CEP conducted a Primary Care Needs Assessment to determine topics of interest to primary care providers. In this survey providers identified the need for more effective resources to help patients with chronic non-cancer pain.

The CORE Neck Tool and Headache Navigator was developed using CEP’s integrated knowledge translation development methods. CEP ensures that health care providers are engaged throughout the tool development process, using a User Centered Design methodology to test the usability of tools from a provider perspective. For the CORE Neck Tool and Headache Navigator project, CEP worked with clinical leads, Drs. Julia Alleyne and Arun Radhakrishnan, and a clinical working group.  In addition, experts were engaged to provide input into terminology, physical assessment, and management components for neck pain and headache.

The project team reviewed and evaluated evidence from clinical practice guidelines and relevant studies. The information and recommendations included in the final version of the Toolkit reflect current best available evidence.

Meet the Team

 The need for a more effective approach to managing to neck pain and headache was identified by Ontario primary care providers as part of the Knowledge Translation in Primary Care Initiative. The Centre for Effective Practice enlisted the collaboration of clinical leads and a clinical working group.

Clinical Leads

Jan. 2016 JMA - Julia AlleyneJulia Alleyne, MD, CAC (SEM), FCFP

Dr. Julia Alleyne is a family physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. In addition, she trained as a physiotherapist and maintained an active license for 30 years.  She is appointed at the University of Toronto, Department of Family and Community Medicine as an associate clinical professor.

In 2009, she completed her Masters with a focus in Health Professions Education. Since that time, she has been active as an educational curriculum consultant including acting as the clinical lead for Ontario’s Low Back Pain Strategy and program designer for the MSK Initiative in British Columbia.  In 2013, she was appointed as the first Family Physician to be chair of Bone and Joint Canada.

In addition, Dr. Alleyne’s work in the area of back care includes being an educational consultant for curriculum and tool development for provincial MSK initiatives in Ontario and British Columbia. She has co-authored a series of spine related articles for Current Concepts in Care and is the co-chair for the Spine Quality Based Pathway.  Dr. Alleyne has worked with the Centre for Effective Practice for a decade in the area of Primary Care Musculoskeletal tool development and education.

ArunArun Radhakrishnan, MSc, MD, CM CCFP

Dr. Arun Radhakrishnan is a family physician with a focused practice in chronic pain and is the current co-chair of the Collaborative Mental Health Network and the Medical Mentoring for Addictions and Pain Network at the Ontario College of Family Physicians. He is also an adjunct assistant professor with the Department of Family and Community Medicine at the University of Toronto.

In 2013 Arun completed a Master’s degree at the University of Toronto in Health Services Research focusing on the value of information and communication technologies to enable knowledge translation activities in the areas of pain, mental health and addictions to support community physicians. His interests also include teaching and curriculum development around the integration of technology into the clinical encounter.

Acknowledgements

A clinical working group comprised of family physicians, chiropractors, primary care nurse practitioners and a pharmacist oversaw the development of this tool. Members include:

  • Michelle Acorn, Nurse Practitioner
  • John Axler, Family Physician
  • Craig Bauman, Chiropractor
  • Kerri Deir, Kinesiologist
  • David Dos Santos, Chiropractor
  • Dale Guenter, Family Physician
  • Bruce Hobson, Family Physician
  • Jessica Munro, Nurse Practitioner
  • Steve Radke, Family Physician
  • Hema Rajawat, Pharmacist
  • Inge Schabort, Family Physician
  • Murray Townsend, Chiropractor
  • Kathy Tripp, Nurse Practitioner
  • Xu Wang, Family Physician
  • Jennifer Young, Family Physician

Thank you to all of our members for their work.

Expert Opinion

In addition to our clinical working group, CEP sought expert input to inform specific aspects of the Neck Pain and Headache Tools including terminology, physical assessment and the management components. We are grateful to the following individuals for their time and expertise.

  • Pierre Côté DC, PhD
  • Jonathan Gladstone, MD
  • Hamilton Hall MD, FRCSC
  • Christine Lay, MD
  • Raja Rampersaud, MD, FRCSC

Supporting Material

Here are some additional resources and sources of information. These supporting materials are hosted by external organizations and we cannot guarantee the accuracy and accessibility of their links. CEP will make every effort to keep these links up to date.

Supporting Materials

CORE Neck Tool

Opioid Risk Tool
This tool identifies patients who may be at risk for opioid dependency so that appropriate medication management can be planned.
https://thewellhealth.ca/wp-content/uploads/2016/07/4._opioid_risk_tool_eng.pdf

The Keele STarT Back Screening Tool
This screening tool categorizes patients by risk of persistent symptoms (low, medium or high), which allows the clinician to tailor interventions appropriately.
https://thewellhealth.ca/wp-content/uploads/2016/07/7._startback_tool_eng_bw.pdf

Neck Pain Information and Exercise Sheet
The exercise sheet includes images to help identify correct and incorrect posture positions, and lying positions, as well as flexion/extension, rotation, side flexion, and retraction exercises.
http://www.arthritisresearchuk.org/health-professionals-and-students/reports/hands-on/hands-on-spring-2011-exercise-sheet.aspx

Headache Navigator

Headache Diary Sheets
These can be completed by patients to help with headache diagnosis.
http://www.ihe.ca/download/ambassador_headache_diary_short_form_06_nov_2013.pdf

Patient Education Resources

General headache information
A resource that provides answers to patients’ commonly asked questions about headache.
http://www.ihe.ca/download/ambassador_headache.pdf

Medication overuse headache
A resource that provides answers to patients’ commonly asked questions about medication overuse headache.
http://www.ihe.ca/download/ambassador_medication_overuse_headache.pdf

Acute migraine management
A resource that provides answers to patients’ commonly asked questions about migraine management.
http://www.ihe.ca/download/ambassador_migraine_headache.pdf

Migraine prophylaxis
A resource that provides answers to patients’ commonly asked questions about migraine preventive medications.
http://www.ihe.ca/download/ambassador_migraine_preventive_medications.pdf

Tension headache management
A resource that provides answers to patients’ commonly asked questions about managing tension-type headaches.
http://www.ihe.ca/download/ambassador_tension_type_headache.pdf

Treating frequent headaches with pain relievers
Provides tips to help manage frequent headaches and discourages patients from taking pain relievers too often.
http://www.choosingwiselycanada.org/wp-content/uploads/2015/10/Headaches-EN.pdf

References

CORE Neck Tool References

  1. Kopjar B, Tetreault L, Kalsi-Ryan S, Fehlings M. Psychometric properties of the modified Japanese orthopaedic association scale in patients with cervical spondylotic myelopathy. Spine. 2014. 40(1): E23-28.
  2. Hall H. Effective spine triage: Patterns of pain. Ochsner J. 2014 Spring; 14(1): 88-95.
  3. Stiell IG, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct; 286(15):1841-8
  4. Concussions Ontario [Internet]. 2015 [cited 2016 May 30]. Available from: http://concussionsontario.org/
  5. British Columbia Ministry of Health, British Columbia Medical Association. Rheumatoid arthritis: diagnosis, management and monitoring [Internet]. 2012 Sep [cited 2016 Mar 8]. [Figure], Differentiate inflammatory from non-inflammatory arthritis; p. 2. Available from: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/rheumatoid-arthritis
  6. New Zealand Guidelines Group. New Zealand acute low back pain guide: Incorporating the guide to assessing psychosocial yellow flags in acute low back pain [Internet]. 2004 Oct [cited 2015 Nov 25]. Available from: http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_communications/documents/guide/prd_ctrb112930.pdf
  7. Kroenke K, Spitzer RL, Williams JBW, Lowe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics [Internet]. 2009 Nov-Dec [cited 2015 Nov 20]; 50(6): 613-621. Available from: http://www.psychiatrictimes.com/all/editorial/psychiatrictimes/pdfs/scale-PHQ4.pdf
  8. Nicholas MK. The pain self-efficacy questionnaire: Taking pain into account. Eur J Pain. 2007 Feb; 11(2): 153-63.
  9. Cervical and thoracic spine disorders. In Hegmann KT, editor. Occupational medicine practice guidelines. Evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2011.
  10. National Institute for Health and Clinical Excellence. Neck pain – non-specific. Clinical Knowledge Summaries. 2015 Apr.
  11. Canadian Association of Radiologists. Section D: Musculoskeletal system. Diagnostic Imaging Referral Guidelines. 2012. Available from: http://www.car.ca/en/standards-guidelines/guidelines.aspx
  12. Canadian Association of Radiologists. Section J: Trauma. Diagnostic Imaging Referral Guidelines. 2012. Available from: http://www.car.ca/en/standards-guidelines/guidelines.aspx
  13. Cook C, Hegedus E. Orthopedic physical examination tests: An evidence-based approach. Upper Saddle River, N.J.: Pearson Education, 2013.
  14. Yung E, Asavasopon S, Godges JJ. Screening for head, neck, and shoulder pathology in patients with upper extremity signs and symptoms. J Hand Ther. 2010 Apr-Jun; 23(2): 173-85.
  15. Wainner RS, et al. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003 Jan 1; 28(1): 52-62.
  16. Cote P, et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Management (OPTIMa) Collaboration. Eur Spine J. 2016 Mar 16.
  17. Rampersaud YR, Alleyne J, Hall H. Managing leg dominant pain. J Current Clinical Care. 2013 Jan; Educational Suppl.: 32-39.
  18. National Institute for Health and Clinical Excellence. Neck pain – cervical radiculopathy. Clinical Knowledge Summaries. 2015 Apr.
  19. National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain [Internet]. 2010 [cited 2016 May 30]. Available from: http://nationalpaincentre.mcmaster.ca/opioid/
  20. Childs JD, et al. Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. 2008. J Orthop Sports Phys Ther. 38(9):A1-A34.
  21. Hall H, Alleyne J, McIntosh G, Cote P. A pain in the neck. Journal of Current Clinical Care. 2015; 5(1):24-34.

Headache Navigator References

  1. Headache Imaging Pathway. Developed as part of the Diagnostic Imaging Appropriateness (DI-APP) Tools in Primary Care project by University Health Network, Health Quality Ontario, Ministry of Health and Long-Term Care. 2015.
  2. Toward Optimized Practice. Guideline for primary care management of headache in adults. Edmonton, AB: Toward Optimized Practice. 2012 July. Available from: www.topalbertadoctors.org
  3. National Institute for Health and Clinical Excellence. Headaches: Diagnosis and management of headaches in young people and adults. Clinical guideline 150: Methods, evidence and recommendations. 2012 Sep.
  4. Choosing Wisely Canada, Canadian Association of Radiologists. Imaging tests for headaches: When you need them – and when you don’t. 2014. Available from: http://www.choosingwiselycanada.org/
  5. Canadian Association of Radiologists. Section A: Central nervous system. Diagnostic Imaging Referral Guidelines. 2012. Available from: http://www.car.ca/en/standards-guidelines/guidelines.aspx

Copyright & Disclaimer

CEP fully supports the use of CORE Neck Tool and Headache Navigator by providers, educators, decision-makers and others. Please read the following information prior to use of the Tool to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative CommonsCORE Neck Tool and Headache Navigator is a product of the Centre for Effective Practice.  Permission to use, copy and distribute this material for all non-commercial and research purposes is granted, provided that all copies, modifications, and distributions contain full reproductions of this Creative Commons License and the following Disclaimer along with appropriate citation.  Use of the CORE Neck Tool and Headache Navigator for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with Centre for Effective Practice (Email: info@effectivepractice.org)

For statistical and bibliographic purposes, please notify the Centre for Effective Practice (info@effectivepractice.org) of any use or reprinting of the tool.

Please use this citation when referencing the tool: Reprinted with Permission from Centre for Effective Practice (July 2016). CORE Neck Tool and Headache Navigator. Toronto: Centre for Effective Practice.

Disclaimer

CORE Neck Tool and Headache Navigator (the “Tool”) contains links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations.  These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective Their Party Resource(s).

This Tool was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice.  Primary care providers and other health care professionals are required to exercise their own clinical judgment in using this Tool.

Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, the contributors to this Tool, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this Tool; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this Tool by any individual including, but not limited to, primary care providers, or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this Tool, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any of the Third Party Resources, that are owned or operated by third parties, including any information or advice contained therein.