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).
The two main kinds of common headaches are tension-type headaches and migraines.1 Almost half of the population has experience with tension headaches, and one in ten get migraines, 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.
|musculoskeletal pain||neurological “brain ache”|
|mostly less awful||often worse … but not always!|
|usually both sides||usually one side|
|pressure, tightness||throbs with pulse|
|noise sensitivity||light sensitivity|
|few weird symptoms||weirdness standard|
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
Although tension headache pain can arise from several locations (discussed below), the most classic source is the suboccipital 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.
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:
- unusually severe, more 8+ on a 10-scale show
This is Pain Level 8 as depicted by Allie Brosh in her hilarious article about severe pain, Boyfriend Doesn't Have Ebola. Probably. Pain Level 8 is pretty bad.
- unusually persistent, more than a day at higher pain levels, more than a week at moderate pain levels)
- unusually sudden, a so-called “thunderclap” headache, which comes on in seconds to minutes9
- unusual in any other way10
- associated with other worrisome symptoms11
And a headache can be all that and still turn out to be a tension headache. So please …
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?
In the fall of 2017, I had a mild tension headache for several weeks, almost non-stop (just one piece of my own chronic pain problem). It would surge up to moderate severity in the evenings, and there were a few patches that were impressively bad, but it was the grind of constant pain, regardless of severity, that I think really took its toll on me.
And I think that’s a thing — a thing that many people with a tension headache problem can relate to. Here’s what an old friend of mine had to say about it, and he has a lot more experience with that grind:
I find low level chronic pain much worse than infrequent acute pain. It is a weird thing (maybe not for someone with your knowledge base) that I can easily shrug off significant pain like getting kicked in the face in martial arts … but steady low level stuff like headaches mentally breaks me pretty quickly.
I don’t think I properly appreciated this phenomenon until I’d felt it. There is clearly nothing “mild” about mild pain when it persists for six weeks. As is so often the case, one must live with a problem to really get it. More and more, I wonder how I could possibly publish a good website about pain if I didn’t also suffer from it. “Fortunately” for this enterprise, I have that experience.
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.
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 dehydration/hangover headaches, which are secondary. The primary-ness of a headache is only a function of our ignorance of the specific cause. “Primary” headache is really just another way of saying “unexplained” headache. The moment a specific cause for a headache is identified, in a •poof• of nomenclatural smoke, the headache ceases to be primary and is now merely a symptom of whatever we know to be causing the problem.
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:
|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):
- stabbing headache — nasty intermittent stabbing pains mainly in eye, temple, and side of the head
- cough headaches — caused by coughing (duh), but also straining on the toilet and holding the breath strongly (valsalva maneuver)
- exertional headaches — non-migraine headaches that occur only during/after exercise, and the first time one of these happens it’s critical to make sure it’s not related to a brain bleed
- sex headaches — exactly what it sounds like14
- thunderclap headaches — also exactly what it sounds like, and just as bad (I have personal experience with these)
- hypnic (sleep) headaches — these wake people from sleep
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 it probably varies,16 like all anatomy. The clinical implications are unclear, but they surely exist.17 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,18 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 points19 — 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:
- Dehydration is probably an over-hyped cause of headaches that I discuss in detail below.
- Dental problems, temporomandibular joint syndrome
- Chiari malformation (herniation of brain tissue through the hole in the bottom of your skull)
- Ear infections (usually fairly obviously an ear problem)
- Irritation from hats, helments, goggles and even pony tails
- Glaucoma (damage optic nerve, often caused by high eyeball pressure)
From the neck or not? The cervicogenic headache debate
We can put a man on the moon, but we still don’t really know whether headaches can come from the neck. As a former massage therapist, it never even occurred to me question this. Through my entire clinical career and well into my years as a health science writer, I regarded it as “obvious” that some headaches are cervicogenic. I had seen countless patients where the link was blatant, and I also had plenty of personal experience with headaches that seem obviously “necky.” (I am extremely prone to aches and pains, which is one of the reasons I study the topic professionally.)
There’s a good chance my confidence was always justified. But everything gets more complicated when you start trying to get serious and specific about it. There is a legitimate debate about this. So why would anyone be skeptical?
On the one hand, there are a bunch of clinical and research clues that cervical pain can cause headaches.2021 For example, nerve blocks in the neck have been shown to stop headache pain. Clues like this are perfectly good, several fine examples of plausible links between neck and head pain — good enough it might seem foolish to ignore them.
On the other hand, even if that’s all true,
And so what is the actual problem with your head in that scenario? Very broadly speaking, it would be the phenomenon of “sensitization” — excessive pain in response to relatively minor stimuli,23 a well-known neurological complication that explains an awful lot of chronic pain. While well understood in general, it’s role in headache specifically has barely been touched by researchers.
No one knows. Because this is my website, I will presume to issue an opinion though: I suspect all of the above in widely varying proportions!
“Primary” instead of “functional” pain: unexplained headaches avoid the stigma of psychomatic illness (well, mostly)
So a “primary” headache is basically an unexplained headache, and primary is standard terminology, appropriately neutral.
But unexplained primary pain problems in other parts of the body are routinely called “functional pain disorders”… and this term is not neutral. In fact, it’s kind of an asshole of a term with a lot of shameful historical baggage. If terms were people, this one would be your racist uncle.
Originally tamer, over the last several decades “functional pain” gradually became obnoxious doctor-code for “probably psychosomatic”: because if we don’t know how to explain it, it must be all in your head, right? Obviously! This classic argumentum ad ignorantiam — argument from ignorance — got enshrined in jargon and became one of the great shames of medicine. It really needs to go away.15
Why would that be? Probably because unexplained headaches are so common that they frequently afflict the self-same doctors that would otherwise get condescending and dismissive! And so, although primary headaches are often considered an example of a “functional pain disorder,” they are rarely called that.
Unexplained headache free of judgemental baggage? Surely you jest!
But some readers are now hollering at the screen:
Are you *#%[email protected]^% kidding me? I had a neurologist tell me that I have migraines because I’m an excessively ‘willful’ woman! Right to my face! In 2019!
That diagnostic crime isn’t yet extinct. Headache/migraine haven’t entirely avoided the same fate as the other primary pain disorders. While it’s refreshing that the term “functional” is rarely applied, the diagnostic buck has been passed to psychiatrists all too often, especially for migraine. You can bet that many female migraineurs throughout history have been told they were “hysterical,” and that is appalling.
Half truths are more dangerous than pure nonsense
The stickiest myths are the ones with a kernel of truth. A misconception is far easier to debunk if it’s entirely untrue. If it’s partly right, or God forbid as much as half right, it’s much harder to destroy. People motivated to believe it now have a compelling justification for it.
Obviously this is exactly the (frustrating) case with primary headache. With all the primary pain conditions, really.
There almost certainly is a strong emotional component in headache in many cases. Certainly not all, and probably rarely exclusively. But the mind does matter, especially when it comes to chronic pain. In no way does this excuse patronizing dismissal of primary headache as “psychosomatic.” But it’s also not entirely wrong. Psychological stressors and even mental illness are definitely potentially major factors in primary headaches, and that has to be taken seriously.
Just not so seriously that all other possibilities are ignored. I believe that a large percentage of unexplained headaches — and probably most chronic pain conditions — do indeed have organic, biological explanations. Most professionals underestimate just how many possible causes of chronic pain there are, many of them devilishly hard to diagnose.
Treatment Options Reviewed
Fortunately, there is quite lot that you can do to try to get relief from tension headaches. Even if the first ten things don’t work, the eleventh might. Many stubborn cases that won’t yield easily, obviously, but don’t assume yours is truly a tough case until you’ve given all the options a good try. Studies show that most people who say they’ve “tried everything” have actually tried 4.6 treatments, three of which were kind of silly anyway.25
Hats off! Eliminate Minor sources of physical stress
What all of these suggestions have in common is that they are low-hanging fruit, the easiest factors to address that might make difference (overlapping with some of the more detailed sections below). None of them is very likely to be your magic bullet, but every single one of these aggravating factors has been a critical factor for someone out there.
Hats off! — Starting with the lowest of low-hanging fruit: chronic headache sufferers, please make sure that you minimize or eliminate the potential irritation caused by hats, helments, goggles, and even pony tails.
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 stop that. This is a much more significant postural stress 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 be a factor in causing 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… where by “proper” I just mean “comfortable,” as opposed to strict adherence to some theoretical ideal. There’s no strong evidence that workstation configuration is truly a problem (more on this below), but an ounce of prevention is easy enough that it’s worth experimenting. And “comfort” is inherently valuable anyway.
The ergonomics factor that’s the most likely to be relevant to headaches is display position. Rough guidelines: 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.
Upgrade your eyewear — It’s amazing how easy it is to forget that it might 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. Ask your optometrist for other ideas about how to ease eye strain.
Better posture seems 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 widely demonized in the form of “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.26 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.
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 stresses that are more likely to be a factor in headaches, and are quite easy to fix, so why not?
Relaxation and stress relief
They are called “tension” headaches for a reason, so reducing “tension” in your life should probably be your first stop on your tour of treatment options.
Unfortunately, stress relief is the ultimate easier-said-than-done challenge.
Stress is often the overall result of a tangled mess of life troubles, all of them reinforcing each other. It’s nearly impossible to “relax” when you need it because of the effects of poverty, tragedy, addiction, and other all-too-common severe hardships. Even for people who are gainfully employed and tragedy-free, the rat race alone generates sticky stresses: family dramas, bad bosses, noisy neighbours, commuting, and so much more.
Still, ya gotta try! 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. Obviously, rest helps most headaches (and if it doesn’t, that’s a serious headache problem, and you may be reading the wrong document).
Turns out yoga and meditation are not actually the best ways to tackle stress for many people (but if you like the idea, by all means fill your boots). Some of the more important options to consider are:
- “blow off steam” with exercise
- outlets for frustration and aggression
- fun, play, and creative expression
- cognitive behavioural therapy
- escape your most toxic relationships
- create safe zones, peaceful rituals
- big picture life changes, personal growth
- breathing exercises
- and, yes, yoga and meditation… if that’s your bag
Beating stress is a very personal challenge, of course. For a much deeper dive into the challenge, see Anxiety & Chronic Pain.
Breathing exercises, fast and slow
“Meditation” is not for everyone — difficult and unappealing for many — but I think basic slow breathing exercise are a much more important and democratic option. They are probably the most basic form of stress relief, and there’s a basic physiological reason for that: every single exhalation engages our rest and repair protocols (relaxing). Conversely, each inhalation is just a teensy bit neurologically stimulating. We normally breathe more or less symmetrically, spending roughly the same amount of time inhaling as exhaling. But if we spend more time exhaling than inhaling — three second in, six seconds out, repeat — we get more relaxed. It’s a mild but extremely reliable effect.
Basically, it’s meditating, but without any mumbo jumbo about what your mind is doing.
Fast breathing exercise are also an important option to consider. But also a much stranger one…
Vigorous, deep breathing will make you harmlessly hyperventilate, but it’s also very invigorating and cathartic. It induces heightened and altered states of awareness and sensation. It has odd psychological effects; it is messier, noisier and more emotional than slow/meditative breathing.
There’s no clear pathway to headache relief, and I’ll be honest and clear: this is a rare example of a recommendation on this website that is based much more on my own intuition and experience than any science.
I don’t make this recommendation for many other conditions. Something I’m not sure I can even articulate has convinced me that vigorous breathing is a particularly good idea for headache sufferes.
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: it could feel worse before they get better, but that may be part of the process.
Heating and/or cooling the head and neck
Heating or cooling can really help with tension headaches, but you have to be a bit careful with this.
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, Water powered rehab. For more about choosing between hot and cold, see The Great Ice vs. Heat Confusion Debacle.
Corrective exercise (stretching, mobilizing, and strengthening with specific therapeutic goals)
Exercise is good medicine for many musculoskeletal conditions, but attempts to prove a benefit for headaches specifically have been unimpressive.27 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.28 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).29 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, targeting 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),30 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.31
A trendy neck pain treatment method in the physical therapy world is a strengthening program just for the "deep cervical flexors," a group of several tiny muscles on the front of the cervical spine. The "scientific" rationale for this method is appallingly thin, but it's an interesting topic. See Deep Cervical Flexor Training: “Core” strengthening for the neck.
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:
- It’s a good stress stress outlet, and great at improving mood and sleep (both of which are important factors in many cases of chronic tension headaches).
- If you have a little migraine mixed in with your tension headaches, as many probably do, then fitness is even more relevant, in theory.32
Massage therapy and self-massage
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:
- The temples are filled with the temporalis muscle, a jaw muscle. It’s a source of pain itself, but often pain in this area is actually coming from other muscles in this list.
- Although it’s rarely the direct or main cause of a headache, the masseter muscle of the jaw is often involved, and should always be massaged along with the temporalis. See Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome.
- The trapezius muscle — the big one on top of the shoulder — is a classic source of pain in the side of the head and temples.
- The columns of muscle along the side of the cervical spine. But the muscles at the very top, under the skull, that are of the greatest interest. For much more detail about the suboccipitals, see Massage Therapy for Tension Headaches.
- The upper back is often surprisingly important: a lot of neck discomfort has clear roots in the muscles of the upper back. If your neck is causing headaches, what’s bothering them? Always look a little lower. See Massage Therapy for Upper Back Pain.
- The most exotic and not-for-beginners possibility is the scalene muscle group, in the sides of the throat. Working with the scalenes is a bit trickier, and should not be attempted until you’ve done a fair bit of experimentation with easier anatomy. See Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain.
Warning! Massage is not always harmless. “Deep tissue” (intense) massage can backfire, irritating more than soothing and causing a significant worsening of symptoms. While any vigorous massage has the potential to aggravate nearly any condition, the risk is highest with headaches.33 If you have a chronic headache problem, please do not tolerate unpleasantly intense massage, especially above the shoulders.
Strong massage also has the potential to make you feel kind of gross and wiped out for the rest of the day or even longer. This phenomenon is called post-massage soreness and malaise, and headache is a particularly consistent symptom of PMSM. Massage therapists have a habit of dismissing PMSM as an acceptable side effect caused by flushing “toxins” out of tissues, treatable by drinking extra water, which is tragically ignorant. In fact, PMSM is probably a mild form of a muscle crush injury called rhabdomyolysis which traumatically forces proteins out of damaged muscle cells into the bloodstream, which then clog up the kidneys. Its signature is brown urine … and headaches, malaise, and feverishness. For more information, see Poisoned by Massage.
But wait, there’s more! Massage therapists also often move the neck around. Although this is rarely done as vigorously as a typical chiropractic adjustment, it can come close, and that is dangerous for some vulnerable individuals — and headache is one of the warning signs of that vulnerability. See the next section for more about the risks of neck manipulation.
Chiropractic adjustment and spinal manipulation
If tension headaches come from the neck, does a spinal adjustment from a chiropractor help? 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:343536 small reviews of mostly poor quality trials, none of which clearly showed anything, which is fishy.37
There is a single more recent trial of seemingly respectable quality and reasonably positive results — but less so if you check the fine print.38 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.39
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 risks40 — risks that are higher in patients with unexplained headaches, which can have serious causes that make the neck more vulnerable.41
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, some hazards that apply to everyone, and some more hazards that apply to headache sufferers specifically. Here’s my standard summary of pain killers:
Over-the-counter (OTC) pain medications are fairly safe and somewhat effective 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 nasty rebound headaches. They are all probably equally effective for acute injuries (Hung), but benefits vary with people and issues (chronic pain, headache, arthritis, etc). Acetaminophen is good for both fever and pain, and is one of the safest of all drugs at recommended dosages, but it may not work well for musculoskeletal pain (at all?) and overdose can badly hurt livers. The NSAIDs all 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 irritate the GI tract, even taken with food). Aspirin may be best for joint and muscle pain, but it’s the most gut-burning of them all. Voltaren® Gel Review is an ointment NSAID, effective for superficial pain and safer (Derry). Athletes, puh-lease don’t take “Vitamin I” to prevent soreness — it doesn’t work!
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 can definitely make a bad situation worse.
Is there any scientific evidence that these pain killers actually help headaches?
Not nearly enough, of course — a particularly good example of how modern medicine isn’t based on nearly as much settled science as we tend to assume. There are three recent major reviews of “frequent episodic tension-type headache,” one for each of the three most common over-the-counter medications.424344 They are discouraging and based on surprisingly shabby evidence.
But it is fairly clear that your mileage will vary. These meds all seem to work quite well for a few lucky winners. For instance, ibuprofen (Advil, Motrin) seems to have a clear beneficial effect in about 1 in 6 people, especially for harsher headaches, the ones that start faster and stronger. About one in 14 people will get “complete” relief — not bad odds for the desperate.
The odds for paracetamol (acetaminophen) were only a little worse: 1 in 20 people did quite well, taking 1000mg (the only specific conclusion about that drug that was based on higher quality evidence).
The power of placebo looms here. The data for acetaminophen showed that a lot more than 1 in 20 people were pain free after 2 hours — about five times more than that — but that was true for the folks popping sugar pills! Officially, the drug can only get credit if it helps more people than placebo (and that’s where they got 1 in 20). But what does it matter to the people who felt better? If your headache is gone two hours after taking 1000mg of acetaminophen, it’s really likely it was a placebo effect, no a medicinal one… but what do you care? Your headache is gone.
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
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 queasy 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 years. And I had just quit caffeine cold turkey by accident. Oops!
Caffeine withdrawal may be more likely in your own case than you suspect. Some people dose themselves frequently enough with caffeine to create addiction, but irregularly, often motivated by good intentions not to “rely” too much on caffeine. Ironically, erratic dosing can pretty easily create erratic withdrawal. This can explain a pattern of frequent, seemingly unpredictable headaches in some people. What they haven’t noticed yet is that the headaches always happen when they are virtuously abstaining from feeding their caffeine addiction. The answer, of course, is to break the addiction entirely… or feed it more regularly.
Addiction and analgesic rebound
Frequent but irregular dosing is also a major problem with other drugs, especially the pain-killers that people often seek out when they have chronic headaches.
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
First of all, let’s get this out of the way: coffee does not dehydrate. That’s a classic myth. Coffee is only a mild diuretic — although you pee more, there’s still a substantial net fluid “profit.”45
We are drowning in myths about water and hydration, especially the fear that mild chronic dehydration insidiously undermines our health. It doesn’t.46
There’s no question that dehydration can cause headaches when it’s severe enough. Unlike coffee, alcohol really can cause dehydration, which is of course a major factor in hangovers.47 But mild dehydration? The kind that sneaks up on you, dehydration without obvious thirst? That 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.
Hydration and headache science
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,48 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.49 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,50 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.51 A 2014 review was a little less pessmistic, but still far from conclusive.52
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.
Reducing vulnerability: tackling the things that make all kinds of pain worse
The best evidence for treating persistent pain points towards improving general health, as opposed to fixing specific “issues in the tissues.”
~ Playing With Movement, by Todd Hargrove, p. 217
We tend to assume that chronic pains have specific causes — especially strained or damaged tissues — when in fact many of them may have more to do with complex general biological vulnerabilities and top-down neurological sensitization. There are several common risk factors for chronic pain that are typically ignored:
- smoking, excessive drinking
- lack of exercise, a terrible diet, obesity, metabolic syndrome
- stress, anxiety, depression, social isolation
- insomnia, which is probably king of all underestimated drivers of pain
Sleep deprivation is not a direct cause of headaches, and yet practically everyone who just lost a night of sleep has a headache. It makes us more likely to feel issues in our tissues that would have otherwise stayed quiet. Or perhaps there is no issue until we are suffering from significant fatigue, but then the joint biomechanics get a bit wonky and then the joint gets a wee bit irritable, and boom, now it’s driving a headache. Once rested again, the joint mechanics normalize, the tissue settles down, and the headache eases. The direct mechanism of that headache was a cranky intervertebral joint… but if it never would have been a problem without the sleep deprivation, was the joint really the “cause”?
When the primary complaint is pain, the treatment of pain should be primary.
~ Barrett Dorko, Physical Therapist, online discussion, 2010
If you’re suffering from chronic headaches, it probably makes more sense to work on these bigger picture issues than it does to try to chase down specific causes of headache. It’s difficult, of course. The big factors are often thoroughly entangled, all making each other worse. An impoverished single mom with a nicotine addiction and diabetes looming is going to have a tough time extricating herself from all of those stresses… and yet doing so could be her only real hope of a cure for the headaches that are also contributing to her misery.
It’s not easy, but it is simple in principle: if you really want to solve your headaches, start making yourself as healthy as possible overall. Always begin with the easiest problems to solve, which is usually improving your sleep quality, because a great deal of insomnia is an “unforced error.” See The Insomnia Guide: Serious insomnia-fighting advice from a veteran of the sleep wars.
It is more important to know what sort of person has a disease than to know what sort of disease a person has.
Grumpy migraine links
Just some amusing migraine items from cantakerous neurologist blogger, Dr. Grumpy:
- News flash: nausea makes migraines worse! And other news of the obvious.
- If only I could have more migraines …
- As rude as it sounds: “I went down on Saturday. I had to do it in front of my kids, too.”
If you found this article useful, consider making a small contribution to my income — like paying a busker.
About Paul Ingraham
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.
- PS Deep Cervical Flexor Training — “Core” strengthening for the neck
- PS When to Worry About Neck Pain … and when not to! — Tips, checklists, and non-scary possible explanations for neck pain
- PS Massage Therapy for Tension Headaches — Perfect Spot No. 1, in the suboccipital muscles of the neck, under the back of the skull.
- PS What Happened To My Barber? — Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers
What’s new in this article?
32 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.
March — New section: “‘Primary’ instead of ‘functional’ pain: unexplained headaches avoid the stigma of psychomatic illness (mostly).”
February — Re-organized and chapterized treatment recommendations and reviews, added more of an introduction. Many small additions, and added much more information about stress reduction and breathing exercises.
January — Substantial upgrade to review of evidence for over-the-counter medications.
January — New section: “Reducing vulnerability: tackling the things that make all kinds of pain worse.”
January — Careful revision of the article summary: more thorough, and yet shorter!
2018 — Added information about how massage can backfire and make headaches worse.
2018 — Expanded the “Worst case scenario” discussion with an anecdote about the impact of chronicity: even mild pain is draining when it just won’t quit.
2018 — New section: “From the neck or not? The cervicogenic headache debate.”
2017 — Improvements to the discussion of cervical myodural bridges.
2017 — A fairly thorough editing, lots of minor improvements.
2017 — Added important red flag information about artery tears with pain as the only symptom.
2017 — Significantly beefed up discussion of other causes of headaches.
2016 — Added 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.
2016 — Science update — cited Chaibi et al on spinal manipulative therapy for migraine.
2016 — Added a mobile-only article summary.
2016 — Science update. More and better references and detail about spinal manipulation for headache. Conclusion? Meh.
2016 — Substantial editing: many improvements and minor corrections to the first half of the tutorial.
2016 — 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.
2016 — Large new diagnostic section, explaining the distinctive features of primary non-tension headaches.
2016 — New section about water and hydration.
2016 — Edited the exercise advice section, added a citation, and created a small new section about the value of general exercise.
2016 — Added two footnotes about Botox.
2016 — Added more information and a citation about causes of thunderclap headache, and “don’t panic” graphic.
2016 — Added citation about “text neck,” and some modernization of recommendations related to posture and ergonomics.
2016 — Added more detailed and evidence-based exercise recommendations. Added sidebar about osmophobia and migraine.
2016 — Added citations about causes of thunderclap headaches, efficacy of ibuprofen. Added a new short section about using Botox for treatment.
2016 — Added information about spinal adjustment, and more information about serious causes of headache and red flags.
2015 — General editing; added a list of massage targets.
2015 — Added more information about OTC analgesics.
2015 — Added a section about post-concussion syndrome headaches.
2013 — Added “A terrible, horrible, no good headache,” a cautionary tale about coffee, addiction, pain, and analgesic rebound.
2009 — Updated information about migraines to clarify their differences from tension headaches.
2004 — Publication.
- 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
- 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
- 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
- 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. ❐ “Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical.” I’ll return to this topic in more detail later in the tutorial. BACK TO TEXT
- 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
- 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.”BACK TO TEXT
- 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
- 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
- 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 so 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. And there’s the cases caused by eating extremely hot chili peppers. “What could possibly go wrong?” Here’s the news story, and the case report in the British Medical Journal. BACK TO TEXT
- 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
- 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
- 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
- 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
- “Not tonight, honey, you’ll give me a headache.” BACK TO TEXT
- Schechter NL. Functional pain: time for a new name. JAMA Pediatr. 2014 Aug;168(8):693–4. PubMed #24887181. ❐
Schecter explains several problems with the term “functional pain disorder,” and particularly highlights its strong and ridiculous connotation of a psychological problem in modern use. He proposes a much tidier and more description: “primary pain disorder.”
BACK TO TEXT
Therefore, a new neutral name is proposed for this category, primary pain disorders. This term arises from the headache field, where headaches are categorized as primary (the head pain itself is the central problem) or secondary (the headache is due to other factors such as increased intracranial pressure or infection, for example). The term primary pain disorder implies that the pain itself is the disease.
- 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. ❐
This review of 26 studies found “stong evidence” and concluded that is “proved” that there are connections between some suboccipital muscles and the dura mater, while there is “limited evidence” and “controversy” about others. They conclude: “There is a continuity of soft tissue between the cervical musculature and the cervical dura mater.”BACK TO TEXT
- 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
- 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
- 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
- Becker WJ. Cervicogenic headache: evidence that the neck is a pain generator. Headache. 2010 Apr;50(4):699–705. PubMed #20456156. ❐
This review was developed as part of a debate, and takes the "pro" stance that abnormalities of structures in the neck can be a significant source of headache. The argument for this is developed from a review of the medical literature, and is made in 5 steps. It is clear that the cervical region contains many pain-sensitive structures, and that these are prone to injury. The anatomical and physiological mechanisms are in place to allow referral of pain to the head including frontal head regions and even the orbit in patients with pain originating from many of these neck structures. Clinical studies have shown that pain from cervical spine structures can in fact be referred to the head. Finally, clinical treatment trials involving patients with proven painful disorders of upper cervical zygapophysial joints have shown significant headache relief with treatment directed at cervical pain generators. In conclusion, painful disorders of the neck can give rise to headache, and the challenge is to identify these patients and treat them successfully.
BACK TO TEXT
- Bogduk N. The neck and headaches. Neurol Clin. 2014 May;32(2):471–87. PubMed #24703540. ❐
Cervicogenic headache is pain referred to the head from a source in the cervical spine or mediated by cervical nerves. Clinical features allow for no more than a diagnosis of probable cervicogenic headache. Definitive diagnosis requires evidence of a cervical source of pain. For most treatments, the evidence is limited or poor. Many patients with probable cervicogenic headache can be managed with exercise therapy, with or without manual therapy. Intractable cervicogenic headache can be investigated with controlled diagnostic blocks of the upper cervical joints and treated with thermal radiofrequency neurotomy. Other interventions are experimental or speculative.
BACK TO TEXT
- Vincent MB. Cervicogenic headache: the neck is a generator: con. Headache. 2010 Apr;50(4):706–9. PubMed #20456157. ❐
Cervicogenic headache (CeH) is a well-recognized headache syndrome, distinguishable from other primary and secondary headaches. Although in some cases a cervical lesion may be detected in connection with the headache, many CeH patients have no demonstrable lesion. Besides, most of the frequent cervical diseases, such as spondylosis and disc herniations, do not present with headache of the cervicogenic type. This suggests that the neck is not an independent headache generator. CeH may depend in addition on a central predisposition counterpart, leading to the activation of the trigeminovascular system and pain generation.
BACK TO TEXT
- Pain itself can change how pain works, so that patients with pain actually become more sensitive and get more pain with less provocation. For more information, see Sensitization in Chronic Pain: Pain itself can change how pain works, resulting in more pain with less provocation. BACK TO TEXT
- This point is argued in extreme detail in my full Epsom salts article: Does Epsom Salt Work? The science of Epsom salt bathing for recovery from muscle pain, soreness, or injury. BACK TO TEXT
- No, not really. I’m just being cute.
BACK TO TEXT
- 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.
(See more detailed commentary on this paper.)BACK TO TEXT
- Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;8:CD004250. PubMed #25629215. ❐
“Specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial,” but “when only stretching exercises were used no beneficial effects may be expected.”
However, “no high quality evidence was found” in the 26 experiment reviewed. The data was also spread thin over many different exercises and 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.
There’s been no real improvement since the first version of this review in 2005. They keep adding more low quality studies to the pool of data, but the bottom line hasn’t moved: it’s still mediocre results based on poor quality evidence. I don’t trust any conclusions here.BACK TO TEXT
- 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
- 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
- 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 has shown that this extremely popular form of exercise has almost no measurable benefits. BACK TO TEXT
- 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
- 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
- Posadzki P, Ernst E. The safety of massage therapy: an update of a systematic review. Focus on Alternative and Complementary Therapies. 2013;18(1):27–32. PainSci #53974. ❐ “Severe headache” is one of the adverse affects reported in this survey of poor massage outcomes. BACK TO TEXT
- 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.]”
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- 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.”
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- 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.”
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- 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
- 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.BACK TO TEXT
- 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.”
(See more detailed commentary on this paper.)BACK TO TEXT
- ScienceBasedMedicine.org [Internet]. Homola S. Cervicogenic Headache and Cervical Spine Manipulation; 2016 Apr 12 [cited 18 Dec 7]. “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
- See Arnold et al, Kerry et al, Maruyama et al BACK TO TEXT
- 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
- Derry S, Wiffen PJ, Moore RA. Aspirin for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev. 2017 01;1:CD011888. PubMed #28084009. ❐ BACK TO TEXT
- Stephens G, Derry S, Moore RA. Paracetamol (acetaminophen) for acute treatment of episodic tension-type headache in adults. Cochrane Database Syst Rev. 2016 Jun;(6):CD011889. PubMed #27306653. ❐ BACK TO TEXT
- 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.”BACK TO TEXT
- PS Ingraham. Water Fever and the Fear of Chronic Dehydration: Do we really need eight glasses of water per day? ❐ PainScience.com. 3990 words. BACK TO TEXT
- 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
- 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
- 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
- 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
- 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
- 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.”BACK TO TEXT