PainScience.com • Good advice for aches, pains & injuries

Complete Guide to Headaches

Detailed, readable, science-based self-help for tension headaches and other common musculoskeletal headaches

Paul Ingraham, updated

Close-up photograph of a face squinting in pain from a headache, cropped to show just some forehead, an eye, and bridge of the nose.

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

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 be shockingly fierce. Some people who are sure they have migraines turn out to have severe tension headaches, which is not necessarily good news.

This tutorial is mostly about tension headaches, but with plenty of comparing and contrasting them with migraine and other kinds of headaches. It’s also about troubleshooting unexplained headaches that may or may not have anything to to with “tension.” There’s a thorough discussion of diagnosis and when to worry about headaches, exploration of the causes of headaches, and reviews of all the best and most popular treatment options (not always the same thing).

Tension Headache vs Migraine: What’s the Difference?
Tension Headache Migraine
musculoskeletal pain neurological “brain ache”
mostly less awful often worse … but not always!
usually both sides usually 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?

If you ever end up in a conversation with a curious child who just keeps asking for clarification on this point, you’re going to hit a brick wall surprisingly quickly. “Tension headache” is not a clear concept. It’s a weird, traditional catch-all term for any unexplained headache that isn’t a migraine and doesn’t seem to be scary in other way. A better name would be musculoskeletal headache, or just undiagnosed headache, rather than blaming “tension,” which is painfully unclear. The moment there’s a better and more specific explanation for a headache than “tension,” it ceases to be a tension headache. But until then…

The concept of a tension headache comes from a simple fact, which most of us know all too well from experience: headaches are strongly linked to stress.4 Stress either causes pain directly and/or it causes other things to go wrong that hurt, usually assumed to be musculoskeletal problems — trouble with bones, joints, and meat (as opposed to the neurological “brain ache” of migraine, or the pathological and traumatic causes of some other headaches, like inflamed arteries, brain damage, drug side effects, and so on).

How stress makes heads ache

Is there such a thing as a pure stress headache, where literally the only problem is with your feelings? A completely sensory phenomenon, where there is no physical stress or mechanism of any kind? Probably, yes: we humans are quite good at transmogrifying emotional distress more or less directly into discomfort (somatization). Either headache or abdominal pain is probably the best example.

But there's probably also an intermediate step: feelings cause something which, in turn, causes a headache. But what? “Muscle tension” is the primary suspect — not a well-established fact scientifically, but seemingly obvious to everyone.5 Most of the time, for most people, a “tension headache” feels like muscular tightness around the head, neck, and face, and shoulders, especially sore, stiff suboccipital muscles under the back of the skull, and the jaw muscles, especially in the temple.

It’s possible that muscle tension is inherently a bit uncomfortable, and is the primary mechanism by which stress causes headache. But muscles can probably get into worse trouble than “tense.” The neck, jaw, and shoulder muscles are routinely sore, full of (hypothetical) “trigger points” (knots)6 that are radiating pain all over your head, and sometimes down into your neck, shoulders and even arms as well.7 These sensitive spots in muscle are either literally tense (contracted), or it just feels like it,8 which is one of the reasons we call it a “tension” headache. The problem is that these sensitive spots are barely understood, and their role in headache is unconfirmed.

Despite all the scientific uncertainty, treating many unexplained headaches can be as simple as just learning about these “perfect spots” for massage. I will discuss muscle pain much more later on in the tutorial.

But it’s not all about tension

Feelings of muscle tightness may be just another symptom of other kinds of headaches. A lot of unexplained headaches are probably caused by other musculoskeletal problems, simpler than the exotic physiology of migraine, but you would be surprised how murky the nature of musculoskeletal pain is. Many headaches are probably cervicogenic headaches (“from the neck”), but even that simple idea has been amazingly controversial.9

Part 2

Diagnosis of headache

When to worry about headache (and when not to)

Safety first, please: severe and strange headaches often need medical investigation. There are many other types of non-tension 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:

The worst , sneaky common cause of headaches is probably torn vertebral arteries. Headache is the only symptom of up to half of these cases in the first few days, but it is usually a “weird” headache. More on this later.

And a headache can be all that and still turn out to be a tension or musculoskeletal headache. So please, don’t panic.

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

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

What’s the worst case scenario for tension headaches?

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.

Tension headache vs. migraine

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.

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 disturbances14 that develop over 5-20 minutes and last for about an hour. Migraine auras are a warning sign that a migraine headache may follow, but not all migraines have auras … and not all auras are followed by migraines.

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

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

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

Tension Headache vs Migraine: What’s the Difference? More detail!
Tension Headache Migraine
musculoskeletal pain, especially spreading into the head from the jaw and neck 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

Other primary headache types: cluster, exertional, thunderclap, hypnic, and more

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 be 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 like15
  • 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

The common secondary headaches (when headache is a symptom or complication of something else)

I don’t need to explain that hangovers can cause headaches. But did you know that your brain might be leaking? Or that there’s a kind of stroke that results in only a headache? Some headache causes are quite sneaky.

For instance, long ago a man hid a little wad of marijuana up his nose, and then lost it up there and then forgot it for almost twenty years — oops! — until it started causing severe headaches:

Through the years he suffered recurring sinus infections and had trouble breathing out of the right side of his nose. But he didn’t connect the problems to his lost cannabis. It wasn’t until 18 years later — when he was struggling with headaches and had a CT scan of his brain — that doctors finally discovered the petrified pot.

Nothing common about that… but it is a perfect, bizarre example of a secondary headache.

Almost anything can give you a headache, but here’s more detail about conditions where the cause of a headache could easily be overlooked or misunderstood. A headache that has a clear cause is secondary to that cause, a symptom rather than the disease. There’s a big murky gray zone between primary and secondary headaches.

Aneurysm, a torn artery in the neck, is the most worrisome common cause of headaches that can pass for a tension headache, especially in the first couple days. In addition to the large carotid artery, small arteries in the side of the neck supply the brain with blood, the vertebral arteries. These arteries are somewhat vulnerable to being pinched off or even torn. If the artery actually tears, which can cause brain damage due to the loss of blood supply to the brain, it’s called vertebral artery “dissection,” or VAD.

Alarmingly, VAD may only cause neck/head pain — no other symptoms — which is disturbingly little indication of a dangerous injury. It’s not clear how common these pain-only disasters are, but they aren’t rare — at least one in ten16 — and the chance of mistaking it for an ordinary headache is probably highest at first. As time goes on, the symptoms are likely to get too strong and weird to pass for tension headache. But it is still the stuff of hypochondriac nightmares, because it’s a serious problem that can almost perfectly mimic an ordinary, common one. But it’s not a perfect mimic: the pain is usually severe, one-sided, with an unfamiliar quality (usually throbbing and constrictive). It is an injury, and it probably feels like it if you stop and think about it. For more information, see When to Worry About Neck Pain … and when not to!.

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.

Jaw trouble is strongly linked to headaches (temporomandibular joint syndrome and bruxism, teeth grinding). Jaw pain is obviously the primary problem for most patients, and unlikely to be missed. But, for a small percentage — probably less than 5% — their main symptom is actually headache, and the connection doesn’t get made. I devote a chapter to

Eye strain is also strongly linked to headaches. As with jaw trouble, it’s usually obvious that the headache is secondary — but not always.

Cerebrospinal spinal fluid leaks — literally a leak in the membrane that contains your brain and spinal cord — are often subtle, causing mainly headaches and face, neck, and arm pain, although there’s a laundry list of other odd symptoms. The dead giveaway that it might be a CSF leak is that it’s worse when you’re upright. Despite this fairly clear signature symptom, CSF leaks often go undiagnosed. If you have chronic headaches that usually feel better on your back, and especially if your health feels a bit fragile in general, definitely look into this: Upright Headache? Think CSF Leak! For many patients, just the words “upright headache” will spark a revelation.

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. However, it may be possible to have a relatively minor case bad enough to cause pain but not severe enough to be easily diagnosed.

Post-concussion syndrome [Mayo] involves a lot of headaches. PCS is “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 direct trauma to the brain. Obviously that is not a tension headache. However, the pain may cause tension headaches as a complication, which might partly explain why recovery time from post-concussion syndrome is so notoriously unpredictable.17 And there could be involvement of other tissues in many cases, such as trauma to musculoskeletal structures throughout the head and neck (especially whiplash), causing cervicogenic headache. And so even though the pain of post-concussion syndrome headaches can’t be directly treated, it may come with other types of headache that can be.

Analgesic rebound and drug side effects. Drug side effects (and side effects of some food additives, like possibly MSG, but see below) 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 be 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 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!

A few other possibilities:

  • Ear infections (usually fairly obviously an ear problem)
  • Irritation from hats, helmets, goggles and even ponytails
  • Glaucoma (damage optic nerve, often caused by high eyeball pressure)
  • Dehydration is probably an over-hyped cause of headaches (read more below)
  • Monosodium glutamate is another over-hyped cause of headaches (read more below)
  • There are a few possible causes of headache related to exotic neck problems, like chiari malformation, tethered cord syndrome, and atlantooccipital instability (read more)

Part 3

Causes of headache

Major factors in tension headaches and unexplained headaches

This part of the tutorial discusses the causes of headache, but it can also be seen as “diagnosis continued.”

For this topic, diagnosis is hard to separate from etiology (the nature of the beast). In most of my books, I talk about the nature of a problem before I talk about how to confirm the diagnosis. But it’s the other way around here, because you can’t talk about headache causes until it’s clear what kind of headache we’re talking about — and so it seemed important to explain and eliminate a whole bunch of other possibilities first.

And yet even “tension” headache is not one thing, not even remotely. It breaks down into many possible specific causes that make the label of “tension” irrelevant. And every one of thoses causes has distinct diagnostic implications. So this isn’t just about the causes of tension headaches, but the causes of any kind of headache that can’t easily be diagnosed, and digging into them will suggest more diagnostic possibilities.

One of the best examples is using a cervical nerve block — injecting a numbing agent to see if the pain is coming from the neck. If the pain goes away, bingo, you’ve discovered that a neck issue is the cause of your headache — not tension. A nerve block is not a big deal, but a needle deep in the upper neck isn’t a trivial procedure either. For most patients, it will never even be on the radar as an option.

So cause and diagnosis are basically impossible to separate with headache. Every major cause needs its own diagnostic approach. So we’ll continue the diagnosis/cause discussion with the mother of all plausible, common “tension” headache causes: the cervicogenic or neck-powered headache.

From the neck or not? The cervicogenic headache debate

“Jane” was a nurse, just 23 years old, and she’d had the same headache since she was 20, a constant throb on the right right side of her head. She worked in a radiology department, and had to wear a lot of lead aprons. She blamed those heavy aprons for the headache, always dragging her down.

She had an acutely sensitive spot on the back right side of her neck, though, just a handful of inches south of the pain. And she had more pain every time she turned her neck that way.…

END OF FREE INTRODUCTION

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Plus …

Part 3.2

Appendices

Related Reading

What’s new in this article?

This article was originally published in 2004, and evolved slowly for more than a decade before I got more serious about updating it in 2016. Updates have been fairly regular and logged ever since. The article will be converted into a book and put behind the paywall by about mid-2019.

Sixty 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.

DecemberBook launch: The headache guide has been free since I first introduced it in the early 2013. Six years and hundreds of hours of development later, it joins my inventory of full-blown books. It’s the second addition in 2019 (after frozen shoulder this summer), after years without any new ones. It is now for sale for $20 USD. All existing boxed set customers will have access automatically — someone who bought a set in 2009 is getting a new book out of that purchase a decade later.

DecemberNew chapter: [Section: Soothing the jaw: managing jaw clenching, grinding, and chronic pain.]

NovemberNew chapter: [Section: The role of the jaw (and the muscle most likely to put the “tension” into a tension headache).]

NovemberNew chapter: [Section: Muscle relaxants (Robaxin, Robaxacet, etc), psychoactives, and sedatives.]

NovemberNew chapter: [Section: The cannabinoids: marijuana and hemp, THC and CBD — “it’s complicated!”.]

NovemberAdded colour: Added a minor but very amusing anecdote about a bizarre cause of headaches. [Section: The common secondary headaches (when headache is a symptom or complication of something else).]

NovemberNew chapter: [Section: Interlude: Nora’s headache story — blurring the line between tension headache and migraine.]

NovemberScience update: Added references to support “arthritis isn’t wear-and-tear.” Substantial additional editing and clarifications throughout the chapter. [Section: Subluxation: can your neck be “out”? What goes wrong with neck joints anyway?]

NovemberMajor upgrade: Much more detailed discussion of spinal manipulative therapy. [Section: Chiropractic and spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

OctoberMinor maintenance: Updated about a dozen broken links.

OctoberNew section: No notes. Just a new section. [Section: More exotic cervicogenic headaches.]

OctoberExpanded: Added digital motion X-ray, homeopathy, supplements, electroacupuncture, and Epsom salts baths to the hall of treatment shame, making it more or less complete for now. [Section: Hall of treatment shame: the most bogus headache treatments.]

OctoberNew section: No notes. Just a new section. [Section: Hall of treatment shame: the most bogus headache treatments.]

OctoberNew chapter: [Section: Aquatic therapies: aquajogging, water aerobics, floatation, and wet yoga.]

OctoberScience update: Added a really huge footnote providing patient and physician guidance on the topic of diagnostic nerve blocks, with several references. [Section: From the neck or not? The cervicogenic headache debate.]

OctoberNew intro: Added a substantive intro the nature-of-the-beast chapters of the tutorial. [Section: Causes of headache: Major factors in tension headaches and unexplained headaches.]

OctoberNew chapter: [Section: Red wine and other triggers (not just for migraines).]

SeptemberAdded more: Covered CSF leaks, or “upright headache.” [Section: The common secondary headaches (when headache is a symptom or complication of something else).]

SeptemberAdded more: Covered aneurysms that masquerade as tension headaches, and important safety-first update. [Section: The common secondary headaches (when headache is a symptom or complication of something else).]

SeptemberNew chapter: [Section: Headache, neck pain, and ‘cricks’.]

SeptemberMore information: Added more detail, with an actual citation about ponytail headaches (and the implications), and much more thorough coverage of computer display position. [Section: Hats off! Eliminate minor sources of physical stress that cause headache.]

AugustScience update: Added a citation to build the case that headaches are linked to muscle soreness. [Section: Muscle “knots”: myofascial trigger points are a major suspect in the case of cervicogenic headaches.]

AugustClarifications: Revised for clarity, added a reference. [Section: The nature of the beast: what is a “tension” headache?]

JulyAdded more: Added jaw pain and eye strain, and also (more significantly) recruited both topics into later chapters in service of other points. [Section: The common secondary headaches (when headache is a symptom or complication of something else).]

JuneHuge expansion: Before the update: just a few paragraphs about massage for headache. After: a 2000-word whirlwind tour of the world of trigger point therapy, spelling out the relevance to headache in detail and plenty of specific advice. [Section: Massage, self-massage, and other trigger point therapies for headache.]

JuneScience update: An “update” with an old citation, but a good one. [Section: Chiropractic and spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

JuneExpanded: A deeper exploration of cervicogenic headache has begun, based mainly on Bogduk. I added a nice case study, more detail to both the arguments for and against, and a nomenclature note. [Section: From the neck or not? The cervicogenic headache debate.]

JuneRewritten: Completely revised the introduction to the definition of a tension headache. I now discuss the two main interpretations of this very vague term. Another major goal was to change the scope of the article, so that it will include cervicogenic headache in the future. While it will never be a guide to all kinds of headache, it’s clear that “tension headache” alone was too limiting. What I’m really interested in is helping readers troubleshoot any non-migraine, non-ominous headache… which covers a lot more ground than just “tension” headaches. [Section: The nature of the beast: what is a “tension” headache?]

MayUpgrade: Added table of contents, plus widespread minor edits. Shuffled some chapters around for clarity.

MayNew chapter: [Section: Muscle “knots”: myofascial trigger points are a major suspect in the case of cervicogenic headaches.]

MarchNew chapter: [Section: “Primary” instead of “functional” pain: unexplained headaches avoid the stigma of psychomatic illness (well, mostly).]

MarchAddition: Added discussion of MSG. [Section: The common secondary headaches (when headache is a symptom or complication of something else).]

FebruaryElaborated: Added much more information about stress reduction and breathing exercises [Section: Relaxation and stress relief.]

FebruaryMajor improvements: Re-organized and chapterized treatment recommendations and reviews, added more of an introduction. Many small additions.

JanuaryUpgraded: Substantial upgrade to review of evidence for over-the-counter medications. [Section: Pills, pills, pills: treating headache with over-the-counter pain-killers.]

JanuaryNew chapter: [Section: Reducing vulnerability: tackling the things that make all kinds of pain worse.]

2018New info: 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. [Section: What’s the worst case scenario for tension headaches?]

2018New chapter: [Section: From the neck or not? The cervicogenic headache debate.]

2018Elaboration: Added more detailed and evidence-based exercise recommendations. [Section: Corrective exercise for headache: stretching, mobilizing, and strengthening with specific therapeutic goals.]

2017Improved: Improvements to the discussion of cervical myodural bridges. [Section: The common secondary headaches (when headache is a symptom or complication of something else).]

2017Edited: A fairly thorough editing of the whole document, lots of minor improvements.

2017Expanded: Added important red flag information about artery tears with pain as the only symptom. [Section: Diagnosis of headache: When to worry about headache (and when not to).]

2017Elaborated: Significantly beefed up discussion of other causes of headaches. [Section: Other primary headache types: cluster, exertional, thunderclap, hypnic, and more.]

2016Elaborated: Added table contrasting tension headache with migraine — quite useful for many visitors, I hope. [Section: Tension headache vs. migraine.]

2016Science update: Cited Chaibi et al on spinal manipulative therapy for migraine. [Section: Chiropractic and spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2016: Added a mobile-only article summary.

2016Science update & elaboration: More and better references and detail about spinal manipulation for headache. Conclusion? Meh. [Section: Chiropractic and spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

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

2016Elaborated: Added an explanation of why we call it a “tension” headache, and a few other small changes. [Section: The nature of the beast: what is a “tension” headache?]

2016New chapter: [Section: Other primary headache types: cluster, exertional, thunderclap, hypnic, and more.]

2016New section: No notes. Just a new section. [Section: Does dehydration cause headaches?]

2016Edited: General editing, a new citation, more information about general exercise. [Section: Corrective exercise for headache: stretching, mobilizing, and strengthening with specific therapeutic goals.]

2016Science update: Added two footnotes. [Section: Botox for chronic daily headaches.]

2016Improvements: Added more information and a citation about causes of thunderclap headache, and “don’t panic” graphic. [Section: Diagnosis of headache: When to worry about headache (and when not to).]

2016Upgraded: Added citation about “text neck,” and some modernization of recommendations related to posture and ergonomics. [Section: Postural correction for headache.]

2016New section: No notes. Just a new section. [Section: Botox for chronic daily headaches.]

2016Science update: Added citations about causes of thunderclap headaches. [Section: Diagnosis of headache: When to worry about headache (and when not to).]

2016Additions: Added more information about spinal adjustment. [Section: Chiropractic and spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2016Additions: Added more information about red flags. [Section: Diagnosis of headache: When to worry about headache (and when not to).]

2015Addition: Added sidebar about osmophobia and migraine. [Section: Tension headache vs. migraine.]

2004Publication.

Acknowledgements

Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends (see the origin story). Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

Notes

  1. Many people mistakenly think that “migraine” is just a word for a very bad headache, and it is not uncommon for people to dramatically boast about the severity of tension headaches by calling them “migraines.” But a migraine is definitely a different kind of animal than an ordinary headache. If you can walk around talking about the fact that you have a migraine, you probably don’t have a migraine. BACK TO TEXT
  2. 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.  “” BACK TO TEXT
  3. Although migraines can be tolerable in their early stages, and some migraines are not completely debilitating, as a general rule migraines are much more serious than the worst tension headaches. Most migraines will have their victims flat on their backs in a darkened room. The (typical) symptoms of migraines are: disabling and pulsing pain on one-side of the head, light-sensitivity, and other symptoms elsewhere in the body (like nausea). If that doesn’t describe you, it’s pretty unlikely that you have a migraine. BACK TO TEXT
  4. 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
  5. The closest thing to persuasive evidence of a link between headache and muscular tension is a 1991 survey of headache patients (see Lebbink et al) which found quite a strong link: much higher prevalence of neck muscle tension in headache sufferers especially, plus other links. More about these results later. BACK TO TEXT
  6. Muscle knots — AKA “trigger points” — are small unexplained sore spots in muscle tissue associated with stiffness and soreness. No one doubts that they are there, but they are unexplained and controversial. They can be surprisingly intense, cause pain in confusing patterns, and they grow like weeds around other painful problems and injuries, but most pros know very little about them, so misdiagnosis is epidemic. BACK TO TEXT
  7. 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.”

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  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. “Not tonight, honey, you’ll give me a headache.” BACK TO TEXT
  16. Headache-only VAD might be anywhere from 10 and 50% of cases. The uncertainly is probably because it matters when you ask: the symptoms can evolve over several days, as with any injury. Arnold 2006, Kerry 2009, and Maruyama 2012 all propose lower numbers. Bogduk, a particularly expert source cited a lot in this guide, goes much higher:

    Sixty percent of patients with aneurysms of the vertebral artery or the internal carotid artery present with headache as the sole feature. Within a matter of a few days, aneurysms typically declare themselves by the onset of neurovascular features. However, during this period, the headache may be misdiagnosed as common cervicogenic headache, unless the practitioner is alert to the possibility of aneurysm.

    BACK TO TEXT
  17. More from the Mayo Clinic resource page on post-concussion syndrome: “In most people, post-concussion syndrome symptoms occur within the first seven to 10 days and go away within three months, though they can persist for a year or more.” BACK TO TEXT

There are 135 more footnotes in the full version of the book.


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