Sensible advice for aches, pains & injuries
Close-up photograph of a face squinting in pain from a headache, cropped to show just some forehead, an eye, and bridge of the nose.

Almost every second human being has had a tension headache & one in ten have had a migraine, putting headaches in the top 10 most disabling conditions (top 5 for women).

Complete Guide to Tension Headaches

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

updated (first published 2004)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of for several years. 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


Headaches are one of the top 10 most disabling conditions and tension headaches afflict almost half of all people. This article compares tension hadaches to migraines and other kinds of headaches in detail. (Safety first: unusually severe, persistent, sudden, or strange headaches need medical investigation.) Headaches have dozens of major causes and complications but “simple” tension headaches are strongly associated with stress, fatigue, and neck pain, and are usually caused by pain radiating from sensitive structures in the neck, face, jaw, and scalp, especially the suboccipital muscle group — self-massage in this “perfect spot” is the most neglected easy treatment option. Others include relaxation, insomnia treatment, heat and ice, breathing exercises, and both general and specific exercise (especially neck strength training). Vision correction is sometimes an overlooked opportunity. There are some over-rated treatment ideas: dehydration is often suspected but trivial and easy to fix; poor posture probably doesn’t matter much and it’s hard to fix (although a few ergonomic factors can be important); the evidence on chiropractic therapy (spinal manipulation) is discouraging; pain-killers barely work, and even backfire with chronic use (analgesic rebound). Botox injection is an exotic and sketchy option, but possibly worth pursuing for serious chronic cases.

full article 8500 words

There are two main kinds of common headaches, tension-type headaches and migraines.1 Almost every other human being has had a tension headache, and one in ten have had a migraine, and more women — making headaches one of the top 10 most disabling conditions, and the top 5 for women.2 That’s a lot of aching heads.

Migraines are usually worse than tension headaches, but not necessarily:3 some migraines are surprisingly tame, but “just” a tension headache can shockingly fierce. Some people who are sure they have migraines turn out to have severe tension headaches, which is not necessarily good news. This article is mostly about tension headaches, but with plenty of comparing and contrasting them with migraine and other kinds of headaches.

Tension Headache vs Migraine: What’s the Difference?
Tension Headache Migraine
musculoskeletal pain neurological “brain ache”
mostly less awful often worse (but not always!)
usually both sides usually just one side
pressure, tightness throbs pulse
noise sensitivity light sensitivity
few weird symptoms weirdness par for the course

The nature of the beast: what is a tension headache?

Most tension headaches are assumed to be a musculoskeletal problem — bone, joint, and meat — as opposed to the neurological “brain ache” of migraine. They are probably simpler than the exotic physiology of migraine, but you might be surprised how murky the nature of musculoskeletal pain is. For instance, many tension headaches are probably cervicogenic headaches (“from the neck”) — but it’s controversial.4 No one knows exactly what’s hurting.

Muscle pain is a strong candidate, but that’s controversial too. Neck and jaw muscles may be painfully tight, full of (hypothetical) “trigger points” (knots)56 that are radiating pain all over your head, and sometimes down into your neck, shoulders and even arms as well. These sensitive spots in muscle are either literally tense (contracted), or it just feels like it,7 which is one of the reasons we call it a “tension” headache.

Emotional tension is the other reason: tension headaches are strongly associated with stress.8

If your headaches feel more like an extension of neck pain, especially a “stuck” feeling neck, you may want to switch to reading about that: Save Yourself from Neck Pain!

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

About footnotes. There are 41 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.

and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942. ← That symbol means a link will open in a new window.
Try one!

Safety first, please: severe headaches often need medical investigation

There are many other types of less common headaches — literally hundreds of them — and some of them have serious medical causes. Headaches can be their own problem (primary), or they can be a symptom of something else. You need medical assessment if your headaches are:

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.

What’s the worst case scenario for tension headaches?

The worst case scenario in most cases is “just” the “annoyance” of chronic headaches … plus their worst common consequence, insomnia, which in turn has even more serious consequences, especially other kinds of pain. People with bad, chronic headaches are in significant long term danger of poor health.

Although tension headaches can be amazingly severe — again, they actually can be worse than migraines — even the worst ones aren’t dangerous in the short term. (This also applies to migraines, even though they can severe enough to destroy all activity and hope.)

The main thing is just to recognize — with expert help — when a headache isn’t just a 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.

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?”

How do you know that a headache is just a tension headache? Clinching the tension diagnosis

The odds favour it — tension-type headaches are more common than all other types put together, by a long shot. But heads can ache in many ways and confirming a headache type can be difficult or impossible. Here’s are some key features of the many other kinds of common headaches.

Tension and migraine headaches are the main primary headaches — headaches that are the primary problem, rather than a symptom of some other problem, like a dehydration/hangover headaches, which are secondary.

Migraines have many distinctive features, because they affect brain function. As mentioned above, although migraines are often severe, they aren’t synonymous with “severe headache.” They usually stick to one side of the head (except in kids), typically in front or near the temple. They last for at least a few hours and as long as (ugh!) three days. The pain is related to brain blood vessels, so migraines are often pound in sync with your pulse (or possibly alpha brain waves—it’s complicated). Light sensitivity is common and can be severe. Migraines may be caused or aggravated by physical exertion, or triggered by foods and smells, most famously (and depressingly) wine and chocolate. And there needs to be a pattern of at least several attacks for an official diagnosis.

And finally, the most distinct feature of migraines, the infamous “aura”: weird visual, auditory, and other neurological disturbances13 that develop over 5-20 minutes and last for about an hour. Migraine auras are a warning sign that a migraine headache may follow, but not all migraines have auras…and not all auras are followed by migraines.

It’s also possible to have a variety of other migraine warning symptoms for up to a day or two beforehand: fatigue, mental fog, neck stiffness, constipation, strong food cravings.

If any of this weird migraine stuff sounds like you, then you probably do not have tension headaches. Or not just tension headaches, at any rate — people who get migraines can also get tension headaches.

Here’s a more detailed version of the tension headaches vs. migraine table:

Tension Headache vs Migraine: What’s the Difference? More detail!
Tension Headache Migraine
musculoskeletal pain, especially from the jaw and neck (cervicogenic) neurological “brain ache”, formerly classified as a “vascular” headache but no more (“it’s complicated”)
mostly less awful, but severe tension headaches are just as bad as any migraine often worse, but they actually can be milder than tensions headaches (or even painless, consisting only of non-pain neurological symptoms)
often on both sides usually just one side
feels like pressure, tightness feels like throbbing with pulse
noise sensitivity light sensitivity and visual disturbances common
smell intolerance (osmophobia) never occurs with tension headache occurs in ~40% of case
no weird symptoms, though they can be bad enough to cause malaise many weird symptoms, particularly sensory disturbances, auras and prodromal symptoms

Cluster headaches are cousins to migraines, but are more severe, distinctive, eye-o-centric, and a hundred times less common. While migraines can be mistaken for tension headaches, cluster headaches cannot: they are way too serious and odd. The extreme pain is almost always around and/or above one eye and/or the temple, and the eye may droop, leak, and swell. Victims often pace miserably, agitated and restless. These headaches are called “cluster” headaches because they usually occur in clusters of many headaches over a few weeks or months (and then nothing for weeks, months, or even years).

Other primary headaches (though several of these could also by symptoms of other conditions):

Other kinds of secondary headaches (when headache is a symptom or complication of something else)

Almost anything can give you a headache, but I’ll go into a little more detail with some conditions where headache is a particularly prominent symptom and the underlying cause might be missed (I’m sure I don’t need to explain that hangovers can cause headaches):

Anxiety is a potent driver of practically every conceivable kind of pain, but headaches are right at the top of the list (along with chest pain). Even ordinary stress can do this, but when worries are severe and prolongued (rational or not), headaches are an extremely common symptom. Headaches are almost standard with panic attacks.

Temporal arteritis [healthline] is an inflammation of arteries in the temple, with a lot of symptoms: severe headache, fever, scalp tenderness, jaw pain, vision trouble, and ringing in the ears are all possible symptoms, along with neck pain. It’s almost unheard of in people younger than 50, and it usually occurs in people with other diseases or infections.

Post-concussion syndrome,[Mayo] is a common cause of tension headaches. 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.” Post-concussion headaches cannot be directly treated by any means: they are “brain aches” caused by trauma. Obviously this is not a tension headache. However, the pain may cause tension headaches as a complication. And there could be involvement of other tissues in many cases, such as trauma to musculoskeletal structures throughout the head and neck (especially whiplash), which could also cause tensions headaches. And so even though the pain of post-concussion syndrome headaches can’t be directly treated, it may come with a heaping helping of tension headaches that can.

Analgesic rebound and drug side effects. Drug side effects (and side effects of some food additives, like monosodium glutamate) are a very common sneaky cause of headaches, but the most surprising one of all is that headaches are a side effect of pain-killers, which seems extremely unfair. When you take a lot of pain killers, they may pre-empt the production of your body’s own pain-fighting molecules. Endorphin production, for instance, will drop. This can have disastrous consequences when you stop taking the drugs, resulting in worse pain than ever. This is part of the phenomenon of the well-known serious withdrawal symptoms from some drugs; it is a less well-known problem with over-the-counter pain-killers. Given how extremely common analgesic usage is, it’s likely that people with recurrent headaches may suffering primarily from bouts of rebound pain, occurring in the occasional gaps between erratic but generally intensive self-prescribing of pain killers. Definitely something to watch out for!

Chronic sinus inflammation is probably a surprisingly common cause of “tension” headaches. Acute sinusitis is not subtle, but chronic inflammation from chronic infection or allergies can be surprisingly hard to nail down, and remarkably similar to tensions headaches. Or you could have both, because having chronically painful sinuses is stressful!

Cervical myodural bridges are an obscure anatomical feature of the neck. They are variable connections between the spinal cord wrapping (dura mater) and the muscles of the upper neck. Exactly what is connected and how tightly is unknown and is probably quite different from person to person, like all anatomy.15 The clinical implications are unclear, but they surely exist.16 CMBs probably explain why some people can flex their upper neck more comfortably than others, and it probably causes some headaches in some people: a good specific example of a cervicogenic headache. Obviously there’not much to be done about it,17 but you can at least get some sense of whether or not this might be a problem for you just by strongly flexing your upper neck (tuck your chin down firmly): if it’s uncomfortable, there’s a chance you have pesky myodermal bridges! Or just trigger points18 — hard to tell the difference, unfortunately. I’m including this because it’s interesting, subtle, and probably quite common.

A few other causes of headaches:

What can I do about tension headaches?

Fortunately, there is quite lot that you can do yourself to get relief from tension headaches. Obviously there are many stubborn cases that don’t yield easily, but don’t assume yours is a tough case until you’ve given all the options a good try.

Relaxation and stress relief — They are called “tension” headaches for a reason! Stress relief and relaxation can be the magic bullet that kills chronic headaches. Many 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. If it suits you, take up yoga and/or meditation; if it doesn’t, trying more vigorous breathing exercises and blow off some steam (more on this below); or just wear yourself out with exercise. Beating stress is a very personal challenge, of course. For a much deeper dive into that challenge, see Help for Anxiety.

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. Cranky neck muscles usually prefer heat — but in the case of headaches, heat can sometimes contribute to an uncomfortable flushed or congested feeling that makes the headache worse. Trust your instincts: what will work in the case of a headache is whatever feels soothing to you. If cool washcloths feel soothing, do 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. For lots of ideas about hydrotherapy, see Hydrotherapy. For more about choosing between hot and cold, see The Great Ice vs. Heat Confusion Debacle.

Specific exercise (stretching, mobilizing, and strengthening) — Exercise is amazingly potent medicine for many musculoskeletal conditions, but attempts to prove a benefit for headaches specifically have been unimpressive.19 We do know from a really nice 2007 experiment that determined, long-term strengthening of the neck is an effective self-treatment strategy for neck pain.20 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).21 They also showed that stretching alone was less effective than 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),22 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.23

General exercise — just getting the heart rate up any old way — is a no-brainer treatment option for all stubborn painful problems, but it’s probably extra worthwhile for tension headaches because (1) it’s so good at improving mood and sleep, both of which are probably particularly important factors in most cases of chronic tension headaches; and (2) if you have a little migraine mixed in with your tension headaches, as many probably do, then fitness is even more relevant, in theory.24

Vigorous breathing exercises — Headaches are often involve psychological factors, and so strong breathing exercises — an easy way of blowing off steam and shifting mental state — tend to be helpful for headaches. That’s just one theory about why breathing exercises seem to have a lot to do with 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 may feel worse before they get better, but that may be part of the process.

Postural improvements seem like an obvious opportunity, but it’s an over-rated approach, unfortunately. Postural dysfunction is routinely blamed for tension headaches, particularly the common “head forward” posture, recently demonized as “text neck.” The connection is unproven, and not for lack of trying. Whether this posture is truly a problem or not is controversial — but it certainly didn’t seem to be any kind of a problem at all for 1100 Australian teens.25 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.

However, some postural and ergonomic factors probably offer better bang for your buck. There are some postural strains that are more likely to be a factor in headaches, and are quite easy to fix, so why not?

Invest in a telephone headset or ear buds — This is a less common problem than it used to be, because of the way phones have changed, but if you spend more than fifteen minutes per day cradling a phone between your shoulder and your ear, please do fix that. This is a much more serious postural strain than “text neck”… and dead easy 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, which just means that it should be comfortable. Again, there’s no strong evidence that workstation configuration is truly 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, 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 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 shortens the suboccipital muscles at the back of the skull — the muscles most likely to cause headaches. If you have bifocals and trifocals and you are using a computer for more than an hour per day, please invest in a pair of glasses specifically for computer use.

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 to some degree, sometimes getting rid of them entirely. The no-brainer best place to work is the suboccipital region under the back of the skull, and there are several other high-priority locations:

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. Anything is 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. The evidence to support this is technically inadequate and inconclusive, but that’s quite damning — there should be better science on this by now. Three recent-ish reviews (2004, 2006, 2011) are all sad clones of each other:262728 small reviews of mostly poor quality trials, none of which clearly showed anything, which is fishy.29

There is a single more recent trial of seemingly respectable quality and reasonably positive results — but less so if you check the fine print.30 Cherry-picking one of the best results from that paper, one group of patients started with an average pain intensity of 4.85 (varying by up to 2 points), and ended up with a score of 1.5 on follow-up, which we can file under “not bad.” Of course, the control group — people who literally just lay down on a table for a while — also saw a drop in their pain score, from 5.27 to 3.85, which is almost half as much for the no-treatment group. And that’s one of the very best results in a complicated study. Conclusion: technically positive, but not very compelling.

Does spinal adjustment work for migraine? That would be encouraging! It might work in the same way for tension headaches (by helping with the same kind of neck issues that may be a trigger for both kinds of headaches). Alas, it doesn’t seem to work: a 2016 study was big and good enough to just about be the last word on the topic, and it found that spinally manipulated migraine patients got only tiny benefits at best.31

Meanwhile, it’s not like spinal manipulation is free or even cheap. And there are serious reasons to beware of spinal adjustment in the neck without proven benefits to justify the unclear risks32 — risks that are higher in patients with unexplained headaches, which can have serious causes that make the neck more vulnerable.

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: acetaminophen/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). Acetaminophen 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. The NSAIDs are a better bet (Derry 2015): they 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 popular treatment. According to a major 2016 review of what little evidence we have, ibuprofen does seem to work… but only for some people.33 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, pounding viciousness 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 fell into a fitful sleep that helped just a little.

But the headache came back steadily in the morning. A couple hours into the day it was getting fierce again. It was intimidating to look ahead at 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 and drink 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 indeed bought the wrong coffee, and I had been drinking decaf since the previous morning.

I’m a caffeine addict. I normally drink about 32oz of strong coffee every single day, and have for year. And I had just quit caffeine cold turkey by accident.

Addiction and analgesic rebound

My experience with accidental coffee quitting 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.

Speaking of coffee…

Hydration and headaches: don’t get too thirsty, but don’t worry about it too much either

Coffee does not dehydrate anyone: that’s a classic myth. (It’s only a mild diuretic — although you pee more, there’s still a substantial net fluid “profit.”34) We are drowning in myths about water and hydration, especially the fear that mild chronic dehydration insidiously undermines our health. It doesn’t.35

There’s no question that dehydration can cause headaches when it’s bad enough. Unlike coffee, alcohol really can cause dehydration, which is of course a major factor in hangovers.36 But mild dehydration — the kind that sneaks up on you, dehydration without obvious thirst — is probably a minor factor in a chronic headache problem.

It’s also a just about the easiest possible treatment to test: just drink a couple glasses of water! The blood pressure changes that should make a difference take place quite quickly. If your headache is dehydration-powered to any significant degree, you’ll feel a lot better fast, within 20 minutes.

Is there any scientific evidence about hydration and headaches?

Not much. A 2012 study, the only one of its kind ever done as far as I can find, produced a perception of improvement with an extra 1.5L of water per day, and the way it’s summarized by the researchers you could easily mistake this for a positive result. Unfortunately, uh oh, there was actually no objective effect on anything that mattered,37 and the perceived improvement was almost certainly just wishful thinking on the part of the experimental subjects, who had “significantly more positive expectations.” So this is actually evidence that hydrating does not help headaches.

Another 2012 study, funded in part by a giant corporation that sells bottled water, supposedly shows that surprisingly mild dehydration can make you a bit pissy and headachey.38 But we probably can’t take it too seriously, because the results were so trivial…and yet pitch-perfect for a study funded by a water bottling company! The data could be perfectly good, or it could be hopelessly corrupted. We just can’t tell without more information. We’ll simply never know what’s true without more research…which will probably be hard to get anyone but another water bottling company to pay for!

My watery conclusion: sure, drink a bit extra just in case — it might actually matter for some kinds of headaches — but don’t expect it to make a difference.

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,39 and definitely has more risks. These are not encouraging results, and others have concluded as recently as 2012 that there’s nowhere near enough good research to support this treatment: we simply can’t know if it works.40 A 2014 review was a little less pessmistic, but still far from conclusive.41

All we do know is that it’s risky. There seems to be little reason for patients with tension headaches to seek out this rather exotic treatment, though for some desperate patients it could go on a list of experimental treatments to try. Probably not the top of the list.

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 I was the assistant editor at for several years. 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 or Twitter.

What’s new in this article?

Twenty-four updates have been logged for this article since publication (2004). All updates are logged to show a long term commitment to quality, accuracy, and currency. more When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.

I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

JulyImprovements to the discussion of cervical myodural bridges.

JuneA fairly thorough editing, lots of minor improvements.

AprilAdded important red flag information about artery tears with pain as the only symptom.

JanuarySignificantly beefed up discussion of other causes of headaches.

2016Added table to intro concisely contrasting tension headache with migraine — simple but quite useful for many visitors, I hope. Also added a more detailed version later in the tutorial.

2016Science update — cited Chaibi et al on spinal manipulative therapy for migraine.

2016Added a mobile-only article summary.

2016Science update. More and better references and detail about spinal manipulation for headache. Conclusion? Meh.

2016Substantial editing: many improvements and minor corrections to the first half of the tutorial.

2016Added an explanation of why we call it a “tension” headache, and a few other small changes. There are now 30 footnotes, so I added the footnote intro.

2016Large new diagnostic section, explaining the distinctive features of primary non-tension headaches.

2016New section about water and hydration.

2016Edited the exercise advice section, added a citation, and created a small new section about the value of general exercise.

2016Added two footnotes about Botox.

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

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

2016Added more detailed and evidence-based exercise recommendations. Added sidebar about osmophobia and migraine.

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

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

2015General editing; added a list of massage targets.

2015Added more information about OTC analgesics.

2015Added a section about post-concussion syndrome headaches.

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

2009Updated information about migraines to clarify their differences from tension headaches.



  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. Stovner L, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007 Mar;27(3):193–210. PubMed #17381554. “On the World Health Organization's ranking of causes of disability, this would bring headache disorders into the 10 most disabling conditions for the two genders, and into the five most disabling for women.” BACK TO TEXT
  3. 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
  4. 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
  5. 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
  6. Fernández-de-Las-Peñas C, Simons D, Cuadrado ML, Pareja J. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Current Pain & Headache Reports. 2007 Oct;11(5):365–72. PubMed #17894927.

    This review of the scientific literature, unfortunately, has little scientific literature to review: not much research has been done on the relationship between trigger points and neck pain, and — as is so often the case in musculoskeletal health care — “additional studies are needed.” However, the authors suggest that “it seems that the pain profile of neck and head syndromes may be provoked referred pain from TrPs in the posterior cervical, head, and shoulder muscles” and that there is some evidence “that both tension headache and migraine are associated with referred pain from trigger points.”

  7. This is a bit sneaky of me, a convenient dodge around the controversy about the nature of trigger points. If the feeling of tension either is a literal contraction, or it just feels that way, I’ve covered all my bases. My money is on literal contraction, but I realize that there’s a lot of scientific uncertainty about that. The subjective sensation of contraction and tightness, however, is indisputable: most of the human race knows that feeling, and doesn’t hesitate to describe it like it’s a contraction. And the simplest explanation for the sensation would probably be that trigger points hurt even if they aren’t actually little contractions, and our brains interpret “uncomfortable movement” as “tightness.” I go into considerable detail about the sensation of tightness in another article: You’re Really Tight: The three most common words in massage therapy are pointless. BACK TO TEXT
  8. Martin PR. Stress and Primary Headache: Review of the Research and Clinical Management. Curr Pain Headache Rep. 2016 Jul;20(7):45. PubMed #27215628. “…although some researchers have questioned whether stress can trigger headaches, overall, the literature is still supportive of such a link.” BACK TO TEXT
  9. Devenney E, Neale H, Forbes RB. A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based? J Headache Pain. 2014;15:49. PubMed #25123846. PainSci #53381. Thunderclap headaches have literally dozens of possible causes, some scary, some not scary. The classic scary cause is brain bleeding (mostly subarachnoid hemorrhages), and it’s important to rule this out… and in many cases it is ruled out. Most cases are never explained and never amount to anything. BACK TO TEXT
  10. Severe throbbing or constrictive neck and/or head pain may be the only symptom of an artery tear (see Arnold, Kerry, Maruyama) with a high risk of a stroke, but it is almost always a strange pain: Arnold et al reported that most patients “considered the pain to be unique and unusual compared with previously experienced headache or neck pain episodes. Nevertheless, pain was often interpreted initially as migraine or musculoskeletal in nature by the patient or the treating doctor.” See scary causes of neck pain for more detailed red flag information about this. BACK TO TEXT
  11. Especially weakness, disturbed vision, or any other neuro-ish symptom. Obviously it’s an emergency if you detect any of the big-three stroke signs: face drooping, arm weakness, speech difficulty. BACK TO TEXT
  12. 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
  13. Seeing shapes, bright spots, flashes. Hearing noises or music. Jerking or twitching. Pins and needles in an arm or leg. Trouble speaking. Just about anything hallucinatory or brain-disturbed. People with migraine auras sometimes think they are have a stroke. BACK TO TEXT
  14. “Not tonight, honey, you’ll give me a headache.” BACK TO TEXT
  15. Palomeque-Del-Cerro L, Arráez-Aybar LA, Rodríguez-Blanco C, et al. A Systematic Review of the Soft-Tissue Connections Between Neck Muscles and Dura Mater: The Myodural Bridge. Spine (Phila Pa 1976). 2017 Jan;42(1):49–54. PubMed #27116115. BACK TO TEXT
  16. Enix DE, Scali F, Pontell ME. The cervical myodural bridge, a review of literature and clinical implications. J Can Chiropr Assoc. 2014 Jun;58(2):184–92. PubMed #24932022. PainSci #53727. BACK TO TEXT
  17. Surgery in that region is serious business, and could be worse than the disease in most cases. You probably shouldn’t even think about it, especially because it’s nearly certain that many or most CMBs cause no trouble at all. And yet! There is a published case study of a patient who “experienced relief from chronic headache after surgical separation of the myodural bridge from the suboccipital musculature.” BACK TO TEXT
  18. Trigger points are are also sensitive to stretch, so it’s probably impossible to tell the difference between a neck that is sore because of “trigger points” and one that is sore because of a CMB. Some people might get suboccipital trigger points because of the CMB, so “all of the above” is definitely a possibility. How many massages have tried to rub away CMB discomfort? Poking at our suboccipital muscles in vain, hoping to “release” trigger points that either aren’t there at all, or are effectively untreatable because a CMB is delivering an infinite source of minor irritation? BACK TO TEXT
  19. Kay TM, Gross A, Goldsmith CH, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2012;8:CD004250. PubMed #22895940.

    “Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain… and headaches.” This is promising, but not based on any high quality evidence, only six of the 21 experiments they looked at were of decent quality, and they were spread thin over different kinds of exercise, many ways of measuring success, a lot of apples to oranges comparisons. So overall the results were mostly mixed, confusing, unimpressive and highly subject to interpretation … and therefore also subject to the huge bias in favour of therapeutic exercise. And there’s been no real improvement since the first version of this review in 2005. I don’t trust any conclusions here.

  20. 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
  21. 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
  22. 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
  23. 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
  24. Irby MB, Bond DS, Lipton RB, et al. Aerobic Exercise for Reducing Migraine Burden: Mechanisms, Markers, and Models of Change Processes. Headache. 2016 Feb;56(2):357–69. PubMed #26643584. PainSci #53462. In theory, exercise normalizes cardiovascular function, and migraines are related to vascular dysfunction. This hardly guarantees that exercise will work, but it’s certainly a reasonable assumption, especially given how much exercise seems to help practically everything else. Irby et al: “regular exercise is recommended as an intervention for managing and preventing migraine, and yet empirical support is far from definitive.” BACK TO TEXT
  25. 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.

  26. Lenssinck ML, Damen L, Verhagen AP, et al. The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review. Pain. 2004 Dec;112(3):381–388. PubMed #15561394. PainSci #56057. This review of two higher quality trials and six not-so-high quality ones “concluded” that “there is insufficient evidence to either support or refute the effectiveness of… manipulation in patients with [tension headache.]” BACK TO TEXT
  27. Fernández-de-Las-Peñas 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. In addition, the methodological quality of these papers is typically low.” BACK TO TEXT
  28. Posadzki P, Ernst E. Spinal manipulations for cervicogenic headaches: a systematic review of randomized clinical trials. Headache. 2011;51(7):1132–9. PubMed #21649656.

    A review from particularly credible authors (Dr. Edzard Ernst and Dr. Paul Posadzki), with a classic more-study-needed-but-we’re-not-holding-our-breath conclusion: “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.”

  29. Such review are only good for one thing: the absence of good news is probably bad news. Genuinely effective treatments should pass tests with flying colours. This is similar to being “damned with faint praise,” but worse: damned with insufficient evidence. True absence of evidence is different. This is a case of crappy evidence, produced by researchers who were probably biased and yet still couldn’t show a clear benefit. BACK TO TEXT
  30. Espí-López GV, Gómez-Conesa A. Efficacy of manual and manipulative therapy in the perception of pain and cervical motion in patients with tension-type headache: a randomized, controlled clinical trial. J Chiropr Med. 2014 Mar;13(1):4–13. PubMed #24711779. PainSci #53362.

    This is one of the only trials of spinal manipulation for tension headache in recent history (since discouraging reviews in the past). It’s positive, but — considering the source — the risk of bias here seems rather high. The same authors wrote a review that came to positive conclusions on this topic, but no one else has (see Posadzki 2011, Lenssinck 2004, Fernández-de-Las-Peñas 2006). The abstract reports only the statistical significance of their positive results, rather than their clinical significance (an effect large enough to actually matter to anyone). Browsing their data, I think it’s an ambiguous mix: some the outcomes they measured (quite a few) show modest but probably meaningful benefits… while several others struck me as clinically trivial.

  31. Chaibi A, Benth JŠ, Tuchin PJ, Russell MB. Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial. Eur J Neurol. 2016 Oct. PubMed #27696633.

    Clearly negative results from a good quality test of the efficacy of three months of regular chiropractic therapy for migraine, with follow-up for a year afterwards. Over one hundred patients received spinal manipulative therapy (SMT), a sham, or just their standard meds. Spinal manipulation for migraine was no better than the sham by any measure. On two secondary outcomes, it was trivially better than the control group only (not the sham), but too little to care. Therefore, the authors reasonably concluded that “the effect of chiropractic spinal manipulative therapy observed in our study is probably due to a placebo response.”

  32. [Internet]. Homola S. Cervicogenic Headache and Cervical Spine Manipulation; 2016 Apr 12 [cited 16 Jul 6]. “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
  33. 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
  34. Killer SC, Blannin AK, Jeukendrup AE. No evidence of dehydration with moderate daily coffee intake: a counterbalanced cross-over study in a free-living population. PLoS One. 2014;9(1):e84154. PubMed #24416202. PainSci #53892.

    Many people believe that coffee is dehydrating. To test this popular idea, 50 men drank four cups (200ml) of either coffee or water each day for three days while their diet and activity were controlled. There were no differences in their body mass, urine volume, and signs of hydration in the blood and urine (pee clarity, basically). If you can drink almost a litre of coffee a day and have no measurable effect on hydration, then it is not “dehydrating” to any meaningful degree. The authors reasonably concluded that coffee “provides similar hydrating qualities to water.”

  35. PS Ingraham. Water Fever and the Fear of Chronic Dehydration: Do we really need eight glasses of water per day? 3802 words. BACK TO TEXT
  36. Hangovers are complicated, and the misery has many causes, but dehydration is primarily responsible for the headache. Your body tries to maintain blood pressure by narrowing most blood vessels — less fluid, less space. But the brain must have oxygen, so it dilates its blood vessels, causing swelling, which painfully stretches the linings of compartments in and around the brain. BACK TO TEXT
  37. Spigt M, Weerkamp N, Troost J, van Schayck CP, Knottnerus JA. A randomized trial on the effects of regular water intake in patients with recurrent headaches. Fam Pract. 2012 Aug;29(4):370–5. PubMed #22113647. PainSci #53287. “Drinking more water did not result in relevant changes in objective effect parameters, such as days with at least moderate headache or days with medication use. There was no significant effect modification for headache intensity at baseline, age, gender, migraine, migraine with aura and tension type headache.” In other words, it just didn’t work. *sad trombone* BACK TO TEXT
  38. Armstrong LE, Ganio MS, Casa DJ, et al. Mild dehydration affects mood in healthy young women. J Nutr. 2012 Feb;142(2):382–8. PubMed #22190027. BACK TO TEXT
  39. 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
  40. Gerwin R. Botulinum toxin treatment of myofascial pain: a critical review of the literature. Curr Pain Headache Rep. 2012 Oct;16(5):413–22. PubMed #22777564. BACK TO TEXT
  41. Zhou JY, Wang D. An update on botulinum toxin A injections of trigger points for myofascial pain. Curr Pain Headache Rep. 2014 Jan;18(1):386. PubMed #24338700.

    Previous reviews of Botox injection (Ho 2007, Jackson 2012, Gerwin) for myofascial pain have been disappointingly negative or inconclusive. This review (albeit in a much more obscure journal) is more optimistic…but only a little more. Zhou and Wang believe that “there are well-designed clinical trials to support the efficacy of trigger-point injections with BTX-A for MPS.” But they emphasize that it’s not conclusive, and that we need (among other improvements) more studies “minimizing placebo effect” … which is exactly how promising results tend to evaporate in follow-up studies.

    Just two years earlier, in 2012, Gerwin was more critical of the state of the evidence: “few studies have been designed to avoid many of the pitfalls associated with a trial of botulinum toxin treatment of trigger points.”