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 migraines aren’t always nasty, and even “just” a tension headache can be amazingly severe. Tension headaches are often on both sides, the pain feels like pressure or a tightening around the head, and may include noise sensitivity. This article is mostly about tension headaches, but I’ll be comparing and contrasting them with migraine and other kinds of headaches quite a bit.
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 pain4 — neck and jaw muscles that are painfully tight, and full of “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: this type of headache is strongly associated with stress.8
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.
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…
The worst case scenario in most cases is “just” the annoyance of chronic headaches. Although tension headaches can be amazingly severe, even the worst ones aren’t dangerous. (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. 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.
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, headache biology is extremely complicated and often mysterious, and confirming a headache type can really be a challenge. 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.
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. 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 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 othe neurological disturbances11 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. (This is not the same thing as aura.)
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.
Cluster headaches are related 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, mostly quite distinctive, include:
After concussions, people often suffer from headaches, a signature feature of post-concussion syndrome,[Mayo] “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.
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.
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.12 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.13 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).14 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),15 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.16
General exercise 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.17
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.18 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.
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…
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 is technically just inadequate, but that’s quite discouraging.19 Three recent-ish reviews (2004, 2006, 2011) are all sad clones of each other:202122 small reviews of mostly poor quality trials, none of which clearly showed anything, which is fishy.
There is a single more recent trial of apparently respectable quality and reasonably positive results — but less so if you check the fine print.23 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 probably 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 has much for the no-treatment group. And that’s one of the very best results in a complicated study.
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 risks24 — risks that are higher in patients with unexplained headaches, which can have serious causes.
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. 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.25 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.
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.
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.
Speaking of coffee…
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.”26) We are drowning in myths about water and hydration, especially the fear that mild chronic dehydration insidiously undermines our health. It doesn’t.27
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.28 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.
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,29 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.30 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.
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,31 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.32 A 2014 review was a little less pessmistic, but still far from conclusive.33
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.
Three amusing migraine items from cantakerous neurologist blogger, Dr. Grumpy:
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org 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.
Seventeen updates have been logged for this article since publication (2004). All PainScience.com 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 PainScience.com 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.
— Science update. More and better references and detail about spinal manipulation for headache. Conclusion? Meh.
— Substantial editing: many improvements and minor corrections to the first half of the tutorial.
— Added 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.
— Large new diagnostic section, explaining the distinctive features of primary non-tension headaches.
— New section about water and hydration.
— Edited the exercise advice section, added a citation, and created a small new section about the value of general exercise.
— Added two footnotes about Botox.
— Added more information and a citation about causes of thunderclap headache, and “don’t panic” graphic.
— Added citation about “text neck,” and some modernization of recommendations related to posture and ergonomics.
— Added more detailed and evidence-based exercise recommendations. Added sidebar about osmophobia and migraine.
— Added citations about causes of thunderclap headaches, efficacy of ibuprofen. Added a new short section about using Botox for treatment.
— Added information about spinal adjustment, and more information about serious causes of headache and red flags.
— General editing; added a list of massage targets.
— Added more information about OTC analgesics.
— Added a section about post-concussion syndrome headaches.
— Added “A terrible, horrible, no good headache,” a cautionary tale about coffee, addiction, pain, and analgesic rebound.
— Updated information about migraines to clarify their differences from tension headaches.
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.”BACK TO TEXT
“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.BACK TO TEXT
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
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.”BACK TO TEXT
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, Fernandez-de-las-Penas 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.BACK TO TEXT
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.”BACK TO TEXT