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Save Yourself from Tension Headaches!

Detailed, readable self-help for stubborn tension headaches, especially those muscle pain in the neck and shoulders

updated
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

There are two main kinds of common headaches — tension headaches and migraines.1 Migraines are mostly much worse than tension headaches,2 but not necessarily: even “just” a tension headache can be amazingly nasty.

photo by Daniel Oldfield some rights reserved
photo by Daniel Oldfield some rights reserved

What’s happening in a classic tension headache is simpler than the physiology of migraine. Most tension headaches are cervicogenic headaches (“from the neck”), and probably consist mostly of muscle pain3 — neck and jaw muscles that are painfully tight, and full of “trigger points” (knots)4 that are radiating pain all over your head, and sometimes down into your neck, shoulders and even arms as well.

Although tension headache pain can come from several locations (discussed below), the most classic source the suboccipitals muscle group underneath the back of the skull. This is not necessarily obvious, and for a surprising number of people, treating tension headaches can be as simple as learning about this one “perfect spot” for massage.

Safety first, please: severe headaches often need medical investigation

There are many other types of less common headaches,5 and some of them have serious medical causes. You need medical assessment before treating your headaches as tension headaches if your headache has not already been diagnosed and it is:

And a headache can be all that and still turn out to be a tension headache. So please…

Image of blue text on a black background, under a thumb’s out hitchhiking gesture: keep calm and don’t panic.

The best advice in the galaxy applies to unexplained headaches — even a lot of really serious ones.

Image of blue text on a black background, under a thumb’s out hitchhiking gesture: keep calm and don’t panic.

The best advice in the galaxy applies to unexplained headaches — even a lot of really serious ones.

What’s the worst case scenario for tension headaches?

The worst case scenario in most cases is either “just” the annoyance of chronic headaches. Tension headaches can also be amazingly severe, but even the worst ones aren’t dangerous. (This also applies to migraines, even though they can severe enough to stop normal life.)

The main thing is just to recognize — with expert help — when a headache isn’t just a tension or migraine headache. Consider the chilling but entertaining story of scientist Yvette d’Entremont:

I got the worst headache of my life and it didn’t go away. This horrible ache took residency behind my left eye and refused an eviction notice. I consulted endless doctors and it took eight months to find the first doctor who would start getting my headaches under control…

After a multi-year diagnostic journey, the headaches turned out to be caused by a combination of two fairly rare medical problems. So, again, headaches with unusual characteristics (red flags) should be taken seriously. You should be particularly concerned about any headache that came out of nowhere, with no obvious cause, and won’t go away, or a headache that keeps coming back worse than before. In such cases, please make an appointment with your doctor.

Chuckle break! A classic patient quote from Dr. Grumpy:

“I've been having headaches, you know, and like, stuff that I get with them, you know, all that stuff that happens with my headaches, like, you know, it hurts, and I don't feel good and stuff, you know, and like, can you do stuff about this? You know, like, pills or stuff or something?”

Tensions headaches and concussion

After concussions, people often suffer from headaches, a signature feature of post-concussion syndrome, “a complex disorder in which various symptoms — such as headaches and dizziness — last for weeks and sometimes months after the injury that caused the concussion” (Mayo Clinic). Post-concussion headaches cannot be directly treated by any means: they are “brain aches,” related to the trauma to the brain. Obviously this is not a tension headache. Treatment like massage might still be helpful, but only for temporary relief.

However, there might be much more involved of other tissues in many cases. The headaches may also be caused by both trauma and/or tension in the musculature of the head neck and face, for instance. To the extent that this is the case, the kinds of treatments below are much more likely to help.

photo by Aaron Broomfield some rights reserved
photo by Aaron Broomfield some rights reserved

What can I do about tension headaches?

Fortunately, there is quite lot that you can do yourself to get relief from tension headaches.

Relaxation — They are called “tension” headaches for a reason! Stress relief and relaxation is often the magic bullet with chronic headaches. Most tension headaches can be traced to mental and emotional overexertion and exhaustion, or sitting too long in front of a computer (or both). Obviously, rest helps a headache. But consider the less obvious: headaches should not happen regularly, and you should consider them an important communication from your body if they are. A returning headache could be your body saying to you, “Whatever you are doing, knock it off.” Consider changing your lifestyle: less stress, less computer, whatever it takes. Chronic headaches aren’t just annoying — they are proof that you are doing something your body really does not appreciate.

Heat or cool the head and neck — Heating or cooling can really help with tension headaches, but you have to be careful which one you choose. Ordinarily, spasmed or chronically tight muscles need heat — but in the case of headaches, heat can sometimes contribute to a very uncomfortable flushed or congested feeling that just makes it worse. Use your instincts. What will work in the case of a headache is whatever feels soothing. If cool washcloths feel soothing, use that. If steaming washcloths sound better to you, use those instead. It may vary from one time to the next. Sometimes alternating back and forth feels great. Experiment with temperature and location. Don’t forget to include your neck, face and jaw muscles, which are a very important part of the tension equation with all headaches. For lots of ideas about hydrotherapy, see Hydrotherapy. For more about choosing between hot and cold, see The Great Ice vs. Heat Confusion Debacle.

Stretching, mobilizing, and strengthening — We know from a really nice 2007 experiment that diligent strengthening of the neck is an effective self-treatment strategy for neck pain.8 If so, there’s a good chance it will work for headaches as well, which is what another study showed (from the same lab, three years later).9 They also showed that stretching alone was less effective that more dynamic and vigorous exercises for strength and endurance.

I recommend a long-term, patient exercise program, targetting not just the neck muscles but also the jaw muscles because of their frequent involvement in headaches. Skip ordinary stretching (unless you just enjoy it),10 and begin with lots of pain-free range of motion and mobilizations. Progress to endurance exercises, and then finally strength training. Although you will probably need to be disciplined and patient, strength training is remarkably efficient.11

Bioenergetic breathing exercises — Headaches are often involve psychological factors, and so vigorous breathing exercises — an easy way of blowing off steam and shifting mental state — tend to be helpful for headaches. To pursue this treatment option, you should read The Art of Bioenergetic Breathing first. Note that breathing for headaches can be as challenging as it is rewarding: they are likely to feel worse before they get better, but that is part of the process.

Postural improvements — Postural dysfunction is routinely blamed for tension headaches, particularly the common “head forward” posture, recently demonized as “text neck.” The connection is plausible, but unproven. Whether this posture is actually a problem or not is controversial — but, for example, it certainly didn’t seem to be any kind of a problem at all for 1100 Australian teens.12 The full debate is beyond the scope of this article, but correcting posture is a difficult and uncertain business, even if it does matter — please see Does Posture Correction Matter? for much more information. I want you to beware of the real possibility of wasting time with this concern.

Photo of four teens all looking down at their phones, demonstrating the “text neck” posture.

There’s no correlation between this behaviour & neck pain or headaches in teenagers.

Photo of four teens all looking down at their phones, demonstrating the “text neck” posture.

There’s no correlation between this behaviour & neck pain or headaches in teenagers.

Some postural and ergonomic factors probably offer better bang for your buck…

Invest in a telephone headset — This is a less common problem than it used to be, because of the way phones have changes, but if you spend more than fifteen minutes per day cradling a phone between your shoulder and your ear, and you get tension headaches, please do invest in a headset. This is a more severe postural strain than “text neck”… and so much easier to fix.

Improve your computer work station ergonomics — Computer work stations, even when they are properly set up, might cause headaches (in more ways than one). If you work with a computer for more than an hour per day, you should take care to ensure that it is properly set up. Again, there’s no strong evidence that workstation configuration is actually a problem, but prevention is easy enough that it’s worth experimenting. The factor that’s probably most relevant to headaches is monitor position: it should be at least two feet away from you, and the top of the screen should be at or slightly below eye level. The main goal is to prevent the head from tipping back on the neck (as it does when you’re looking up at a display), which shortens the suboccipital muscles. See my article about ergonomics, Unconventional Ergonomics, and IBM’s guide to computer work station ergonomics, Healthy Computing, for more information.

Upgrade your eyewear — It’s amazing how easy it is to forget that it may be time to upgrade your eyeglasses prescription. Don’t feel silly! This can sneak up on anyone! A related problem, and becoming increasingly common as aging people adopt computer usage, is with bifocals and trifocals: reading a computer screen with bifocals or trifocals usually demands tilting the head back to look at the screen through the narrow, bottom pane of the glasses. This causes a chronic contraction of the suboccipital muscles at the back of the skull — major culprits in the world of headaches. If you have bifocals and trifocals and you are using a computer for more than an hour per day, you should definitely invest in a pair of glasss for the computer screen only.

Massage and self-massage — Saving the most obvious for last: massage of practically any part of the head, face or neck will usually help with tension headaches, in many cases relieving the problem completely. The best bang for your buck, however, is often in the suboccipital region under the back of the skull, as mentioned in the introduction. There are several possibilities, however…

ZOOM
Anatomical illustration of the suboccipitals muscle group.

“Perfect spot” #1

The source of many tension headaches.

Chiropractic adjustment and spinal manipulation — If tension headaches come from the neck, does a spinal adjustment from a chiropractor help? It’s possible. It might relieve pain and muscle spasm by stimulating nerve endings in muscles and joints, kind of like scratching a difficult-to-reach itch. But there isn’t enough scientific evidence to know, unfortunately.1314 Meanwhile, there are serious reasons to beware of spinal adjustment in the neck without proven benefits to justify the unclear risks15 — risks that are higher in patients with unexplained headaches, which can have serious causes.

A summary of over-the-counter pain-killers

Photograph of a bottle of generic pills.

Many people with a headache reach for one of the common non-prescription pain-killers long before they think of trying anything else. There are several confusing options, and some hazards that apply to everyone — and some that apply to headache sufferers in particular. Here’s a general summary:

Over-the-counter (OTC) pain medications are fairly safe in moderation and work in different ways, so do experiment…cautiously. There are four kinds: acetominophen/paracetamol (Tylenol, Panadol), plus three non-steroidal anti-inflammatories (NSAIDs): aspirin (Bayer, Bufferin), ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn). Don’t take any of them chronically — risks go up over time, and they can even backfire and cause pain (rebound headaches). Acetominophen is good for fever and pain, and is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers and it doesn’t work well (at all?) for musculoskeletal pain. NSAIDs reduce inflammation as well as pain and fever, but at any dose they can cause heart attacks and strokes and they are “gut burners” — they can badly irritate the GI tract (even taken with food, and especially with booze). Aspirin is usually best for joint and muscle pain, but it’s the most gut-burning of them all. Voltaren® Gel is an ointment NSAID, safer for treating superficial pain.

That “analgesic rebound” thing is total deal-killer for a lot of people with chronic headaches. See the next section for more about rebound, but the main caution is very clear: don’t use any of these medications long term! It will make a bad situation worse.

Is there any scientific evidence that any of these readily available pain killers actually work? Not nearly enough, of course — a classic case of a surprisingly unstudied treatment. However, according to a major 2016 review, ibuprofen does seem to work quite well… but only for some people.16 Only about 1 in 6 people will get a good result, and you have to give (400mg) ibuprofen to 14 people to find just one who gets complete headache relief. This tends to suggest that inflammation is more relevant to some headaches than others.

Just please be cautious with those pills! They are definitely not entirely safe.

A terrible, horrible, no good headache: a cautionary tale about coffee, caffeine, addiction, pain and analgesic rebound

Photograph of a very small cute puppy holding his head with his paws, like he has a headache.

One day I developed an extraordinary headache. It was one of those can’t-wake-up days. Coffee didn’t put a dent in the mental fog. The pain started late morning. Given my biases, it seemed like it began with a trigger point: stiffness and pain sneaking up the right side of my neck muscles, and then spreading out over the back of my skull, a sickly pain, like a zombie hand.

I massaged and soaked to no avail. It got worse. It progressed so steadily that I was queezy with the pain by midafternoon.

By the evening, it was migraine-esque. It was not a migraine — it lacked the paralyzing intensity of a migraine — but it was certainly the worst tension headache I’d ever experienced. I shuffled through a visit with a friend. I excused myself at 9:30 and collapsed in bed, whimpering and defeated. I feel into a fitful sleep that helped a little.

But the headache came back steadily in the morning. A couple hours in the day it was starting to get fierce again already. It was incredibly intimidating. It was horrible to think of another whole day like that.

And then an explanation for my suffering popped into my head, fully formed, a kind of eureka moment.

Did I accidentally buy decaf coffee? Did I? Because … if I did … that would … oh my …

I don’t know what tipped me off, but I practically sprinted to the kitchen to confirm it: I had bought the wrong coffee, and I had been drinking decaf for a day and a half. I had misread the packaging.

I’m a caffeine addict. I normally drink about 32oz of strong coffee every single day, and have for years. And I had just quit caffeine cold turkey without knowing it.

Addiction and analgesic rebound

My experience was a vivid demonstration of withdrawal physiology, which is pretty much the same reason that one million Britons have headaches from overusing painkillers. Whenever your body gets artificial help of any kind in feeling better, it suffers when the help runs out. Overuse a pain-killer, and your body starts to depend on it — and not just the hard stuff.

And so even ordinary pain-killers may actually lead to more pain over time, if you keep taking them. Your body gets used to the drug supply and starts to dial down its own pain-management systems, so you end up feeling more pain when you reduce your intake. This can be a subtle vicious cycle that can go on for years without being particularly obvious — just routinely making things a little worse.

There are probably even cases of chronic headaches that are entirely the result of chronic use of pain-killers. So ironic!

When people are troubleshooting pain, they don’t usually think of their pain meds. Or coffee. We should start.

Botox for chronic daily headaches

If tension headaches are caused by muscle tension, perhaps they can be treated by paralyzing those tense muscles with one of the most potent toxins known to science: botulinum toxin A, AKA Botox.

What could possibly go wrong? Well, “a greater frequency of blepharoptosis, skin tightness, paresthesias, neck stiffness, muscle weakness, and neck pain.” That’s what could go wrong. Those adverse events were observed in a 2012 review of many scientific trials of Botox for headaches. They concluded it was only a little more beneficial than using a placebo,17 and definitely has more risks. These are not encouraging results. There seems to be little reason for patients with tension headaches to seek out this rather exotic treatment, though for some desperate patients it might go at the bottom of a list of things to try.

Grumpy migraine links

Photograph of anonymous neurologist blogger, Dr. Grumpy, who occasionally writes about migraines.

Dr. Grumpy

Three amusing migraine items from cantakerous neurologist blogger, Dr. Grumpy:


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and assistant editor of ScienceBasedMedicine.org. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

What’s New In This Tutorial?

Friday, May 27, 2016 — Added more information and a citation about causes of thunderclap headache, and “don’t panic” graphic.

Thursday, May 12, 2016 — Added citation about “text neck,” and some modernization of recommendations related to posture and ergonomics.

Saturday, May 7, 2016 — Added more detailed and evidence-based exercise recommendations. Added sidebar about osmophobia and migraine.

Wednesday, May 4, 2016 — Added citations about causes of thunderclap headaches, efficacy of ibuprofen. Added a new short section about using Botox for treatment.

Monday, April 11, 2016 — Added information about spinal adjustment, and more information about serious causes of headache and red flags.

Tuesday, November 3, 2015 — General editing; added a list of massage targets.

Tuesday, October 27, 2015 — Added more information about OTC analgesics.

Tuesday, March 17, 2015 — Added a section about post-concussion syndrome headaches.

Wednesday, May 29, 2013 — Added “A terrible, horrible, no good headache,” a cautionary tale about coffee, addiction, pain, and analgesic rebound.

Tuesday, August 4, 2009 — Updated information about migraines to clarify their differences from tension headaches.

Notes

  1. Many people mistakenly think that “migraine” is just a word for a very bad headache, and it is not uncommon for people to dramatically boast about the severity of tension headaches by calling them “migraines.” But a migraine is definitely a different kind of animal than an ordinary headache. If you can walk around talking about the fact that you have a migraine, you probably don’t have a migraine. BACK TO TEXT
  2. Although migraines can be tolerable in their early stages, and some migraines are not completely debilitating, as a general rule migraines are much more serious than the worst tension headaches. Most migraines will have their victims flat on their backs in a darkened room. The (typical) symptoms of migraines are: disabling and pulsing pain on one-side of the head, light-sensitivity, and other symptoms elsewhere in the body (like nausea). If that doesn’t describe you, it’s pretty unlikely that you have a migraine. BACK TO TEXT
  3. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol. 2009 Oct;8(10):959–68. PubMed #19747657. The idea of a headache that comes from the neck is somewhat controversial, but “a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks.” (But, of course, nerve blocks are not routine, and are not required for diagnosis.) BACK TO TEXT
  4. Muscle knots — myofascial “trigger points” — are a factor in most of the world’s aches and pains. Their biology is still mostly mysterious: conventional wisdom says they are tiny spasms, but they might also be a more pure neurological problem. Regardless, they can cause strong pain that often spreads in confusing patterns, and they grow like weeds around other painful problems and injuries, making them quite interesting and tricky. Although they are well known to many specialists and researchers, most doctors and therapists know little about them, so misdiagnosis is epidemic. BACK TO TEXT
  5. Literally hundreds of them. For instance, there are over a hundred reported causes just of sudden and severe headaches — not counting the slow-motion ones! BACK TO TEXT
  6. Thunderclap headaches have literally dozens of possible causes — see Devenney et al — some scary, some not at all. For instance, the classic scary cause is brain bleeding (subarachnoid hemorrhage, and it’s important to rule this out… and in many cases it is ruled out. Many cases are never explained and never amount to anything. BACK TO TEXT
  7. Zanchin G, Dainese F, Trucco M, et al. Osmophobia in migraine and tension-type headache and its clinical features in patients with migraine. Cephalalgia. 2007 Sep;27(9):1061–1068. PubMed #17681021. BACK TO TEXT
  8. Ylinen J, Häkkinen A, Nykänen M, Kautiainen H, Takala EP. Neck muscle training in the treatment of chronic neck pain: a three-year follow-up study. Europa Medicophysica. 2007 Jun;43(2):161–9. PubMed #17525699. This study found that a year of regular neck strength or endurance training meaningfully reduced pain and disability. These benefits were sustained for three years in over a hundred women, even though many people didn’t continue training after the first year. Although good news, it’s important to keep in mind that not all patients improved completely, and even those who did achieve lasting had to exercise diligently for a year (although six months might have done the trick, we can’t tell from this data). So strengthening is not a reliable or easy fix for neck pain (the efficacy vs. effectiveness problem strongly applies, see Beedie). BACK TO TEXT
  9. Ylinen J, Nikander R, Nykänen M, Kautiainen H, Häkkinen A. Effect of neck exercises on cervicogenic headache: a randomized controlled trial. J Rehabil Med. 2010 Apr;42(4):344–9. PubMed #20461336. BACK TO TEXT
  10. Stretching doesn’t do what people assume: it doesn’t warm you up, prevent soreness or injury, enhance peformance, or physically change muscles. Flexibility’s value is dubious, and no other clear benefit has ever been discovered. Stretching might help some muscle pain, but that’s quite speculative. Stretching is inefficient and many key muscles are actually impossible to stretch. For more information, see Quite a Stretch: Stretching science shows that a stretching habit isn’t doing much of what people hope. BACK TO TEXT
  11. Research shows strength training is much more efficient form of exercise than most people realize, and almost any amount of it is much better than nothing. You can gain strength and all its health benefits fairly easily. For more information, see Strength Training Frequency: Less is more than enough: go to the gym less frequently but still gain strength fast enough for anyone but a bodybuilder. BACK TO TEXT
  12. 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 May 12. PainSci #53482.

    This paper presents indirect but strong evidence that the “text neck” posture does not cause neck pain and headaches in young people. Reseachers took photos of more than 1100 Australian teenagers’ necks, and surveyed their neck problems with a questionnaire. They found some correlations between neck posture and sex, weight, height, and depression… but not pain. Which “challenges widely held beliefs about the role of posture in adolescent neck pain.”

    And long-term follow-up would be nice, of course. However, correlations that are non-existent in the short term are unlikely to be strong in the long run.

    BACK TO TEXT
  13. Fernandez-de-las-Penas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC. Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache. Journal of Orthopaedic & Sports Physical Therapy. 2006;36(3):160–169.

    “There are few published randomized controlled trials analyzing the effectiveness of spinal manipulation and/or mobilization for TTH, CeH, and M in the last decade.”

    BACK TO TEXT
  14. Posadzki P, Ernst E. Spinal manipulations for cervicogenic headaches: a systematic review of randomized clinical trials. Headache. 2011;51(7):1132–9. PubMed #21649656. “There are few rigorous RCTs testing the effectiveness of spinal manipulations for treating cervicogenic headaches. The results are mixed and the only trial accounting for placebo effects fails to be positive. Therefore, the therapeutic value of this approach remains uncertain.” BACK TO TEXT
  15. ScienceBasedMedicine.org [Internet]. Homola S. Cervicogenic Headache and Cervical Spine Manipulation; 2016 Apr 12 [cited 16 Apr 16]. “While upper neck manipulation might sometimes be an effective treatment for a cervicogenic headache, care must be taken to avoid upper cervical manipulative techniques that may pose risk of stroke by damaging vertebral and internal carotid arteries.” BACK TO TEXT
  16. Derry S, Wiffen PJ, Moore RA, Bendtsen L. Ibuprofen for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev. 2015;7:CD011474. PubMed #26230487. BACK TO TEXT
  17. Jackson JL, Kuriyama A, Hayashino Y. Botulinum toxin A for prophylactic treatment of migraine and tension headaches in adults: a meta-analysis. JAMA. 2012 Apr;307(16):1736–45. PubMed #22535858. BACK TO TEXT