• Good advice for aches, pains & injuries

Complete Guide to Headaches

Detailed, readable 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 in the cheek and 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 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

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 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 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.

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 dysfunction 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.

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 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!

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,18 like all anatomy. The clinical implications are unclear, but they surely exist.19 CMBs probably explain why some people can flex their upper neck more comfortably than others, and it probably causes some headaches in some people. Obviously there’s not much to be done about it,20 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 in a headachey way, there’s a chance you have pesky myodermal bridges! (Or it could just be trigger points21 — hard to tell the difference, unfortunately.) I’m including this because it’s interesting, subtle, and probably quite common.

A few other possibilities:

  • 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, 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)

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 elimination 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 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.

More telling still: she got perfect and pain relief by anaesthesis of the third right occipital nerve, the nerve that takes sensation from one of the uppermost neck joints. And then more lasting relief from steroid injections and neurotomy. Her headache was cured by precisely treating her neck.

Jane’s story is from a case study reported by Dr. Nikolai Bogduk (a major expert source for this chapter), who writes:22

The most extensively, and most rigorously, studied form of cervicogenic headache is pain from the C2-3 zygapophysial joint, mediated by the third occipital nerve, and therefore known as third occipital headache.

That’s awfully specific for a phantom that experts argue about. Cervicogenic headache is probably the best single example of a type of headache that is routinely lumped into the “tension” headache category, despite having quite a clear, specific cause that has nothing to do with tension. (Although tension surely results.)

Strangely uncertain science

We can put a man on the moon, but we still don’t know for sure if headaches can come from the neck. They almost certainly can, but it is tough to confirm, and a lot of the details are uncertain.

As a former massage therapist, it never even occurred to me question this. Throughout my entire clinical career, and well into my years as a health science writer, I seemed obvious to me that many headaches have their roots in the neck. I had seen countless patients where the link seemed blatant, and I also had plenty of personal experience with headaches that were plainly “necky.” (I am extremely prone to aches and pains, which is one of the reasons I study them professionally.)

But everything gets more complicated when you start trying to get serious and specific about it. There is a legitimate ongoing debate about this.

The case for cervical headache sources

There’s a good chance my confidence was always justified. It’s not like it’s a subtle phenomenon. If you have a nasty headache, and it surges every time you turn your neck to one side (just like Jane’s story above), that’s probably not a coincidence.

There are many such clinical and research clues that cervical pain can cause headaches.232425

Most definitively, nerve blocks in the neck have been shown to stop headache pain.26 See the (huge) footnote for information to show your doctor when discussing this option.

We also know exactly how it probably mainly works: sensory convergence. Threat signals in structures in the upper neck are sent to the brain on nerves that merge with other nerves that provide sensation to the head. So you've got signals from both the neck and head converging in a single nerve trunk, and the brain gets mixed up about where the information is coming from — could be head, could be neck — and so we experience some of both (in varying proportions). Sensory convergence is a well-described phenomenon in other contexts, like referred pain from organs (e.g. arm pain during a heart attack).27 And it’s well-studied in this one, with numerous studies mapping specific neck structures to head pain. Brave human volunteers have submitted to “stimulation” of many neck structures, not just demonstrating but detailed mapping of referred pain patterns.28 Big footnote there, maybe a record breaker — there’s actually quite a lot of information about this.

Jaw pain and eye strain, like neck pain, are common trouble spots that are anatomically nearby and strongly associated with headache. Both of them are usually obviously their own phenomenon, but not always: sometimes headache a major symptom in addition to eye or jaw pain, and occasionally the only obvious one. The existence of these problems tends to suggest that, yes, discomfort in other nearby anatomy can cause headaches — if eye and jaw pain can do it, and they clearly can, then it’s likely that neck pain can too.

Cervicogenic headache is essentially a headache for which a cervical source of pain needs to be shown.

~ Bogduk, 2014, Neurol Clin

The case for doubt about cervical headache sources

Clues like this are good enough it might be foolish to ignore them. That’s a lot of cervicogenic headache smoke. So why would anyone be skeptical that there’s a fire?

First, a neck lesion often cannot be found, and it’s not like there are all that many places to look. For every Jane, who gets miraculous relief from numbing one neck nerve, there is a Jack, Jill, and John who do not. Just because we can’t identify it doesn’t mean it’s not there, but the failures are damning.

Second, a stronger argument: the most common neck problems do not typically cause headaches, and suggests that “the neck is not an independent headache generator.”29 Even if the case for cervicogenic headache made above is basically correct, it’s still possible that neck-head links aren’t enough to cause a headache on their own. The true nature of the beast may be vulnerability to headache that has nothing to do with the neck.30 You wouldn’t blame a bridge collapse on the cars driving over it. In this scenario, the head really is the problem, and the neck issues are innocent bystandersor mere triggers.

And so what is the actual problem with your head in that scenario? Broadly speaking, it would be the phenomenon of “sensitization” — excessive pain in response to relatively minor stimuli,31 a well-known neurological complication that is a major factor in a 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: I suspect all of the above is true to some extent.

Headache, neck pain, and ‘cricks’

The bottom line of the cervicogenic headache question is simple: some kinds of neck pain almost certainly contribute to chronic “tension headache.” Most of the concerns experts have are about exactly how and how strong the link is. Not many of them actually think there’s no link at all.

Which means that you can’t really get serious about headache pain without including neck pain. Headaches and neck pain are clearly different topics, and yet there is great overlap — though mostly in one direction. Neck pain patients usually don’t need to know much about headache. If neck pain is their main complaint, headaches just seem like a complication — they don’t usually ask “Is this neck pain causing my headache?”

But headache patients probably do need to know about neck pain.

I have been selling a book about neck pain on since 2007, and I’ve been actively upgrading it ever since. Originally it was mainly about the peculiar, specific phenomenon of neck “cricks” — that nasty stuck feeling that often accompanies neck pain, or sometimes drives you nuts all by itself. Since then, it has evolved into a full-blown book about any kind of chronic neck pain. There is some discussion of headache as well, but nothing like the detail in this tutorial.

This tutorial must repeat some of the same information in the neck pain book, some of it nearly verbatim. There’s enough about neck pain baked in here for most readers needs, but I had to draw the line somewhere or I would have ended up copying and pasting the entire neck pain book into this document. So I've held some neck pain content back, and for readers who feel that neck pain is a more critical piece of their puzzle… the neck pain book is there for you.

Cricks and headache

A neck crick is discomfort dominated by a sense of limited movement. It usually feels like something in a joint is catching or sticking or locking when you try to move, a seemingly mechanical failure. Many neck crick sufferers insist that the problem is not exactly painful, but still extremely unpleasant — a sensation of stuckness that is “irritating” or “uncomfortable” or “stuck” or more like an “itch” or perhaps a “deep itch” than an actual pain.

Because a crick often does not hurt, per se, it is often underestimated and neglected, even by the patient. The use of that word “crick” can trivialize the problem. When it exceeds a certain degree of badness, no one calls it a “crick” anymore — the word feels too lightweight.

I have a hunch that neck cricks are more strongly associated with headache than other kinds of neck trouble. There's no hard evidence of this, because a crick is such a poorly defined phenomenon. But this is what I suspect:

  • Many neck cricks probably involve distress to the small neck joints (facet joints), which are in turn the neck structure that probably most predictably causes headaches.
  • The irritation of a neck crick, when it persistent, inevitably leads to more generalized tension and pain, casting a wider and wider net of pain over the region, making headache a more likely complication.

Estimating the contribution of neck pain

A chronic headache problem is more likely to be at least partially driven by neck pain…32

  • If you have some obvious neck pain, and if there is a sense that it is spreading from the neck to the head, like paint being smeared. This directionality of the pain is by no means always clear, but sometimes it is.
  • If your neck pain is related to a crick or reduced range of motion.
  • If your headache is triggered by neck movements, awkward neck postures, or pressure on your neck.
  • If the pain is moderate and non-throbbing. Severe throbbing isn't a deal-breaker, but it's probably unusual with cervicogenic.
  • If your neck symptoms are higher. Upper neck pain is quite a bit more likely to be related to headaches than lower neck and shoulders. That said, headaches can come be caused by the upper trapezius muscle on the top of the shoulder (we'll get into this in the next section).
  • If neck massage alone is capable of making your headache better, even if it's just brief (massage is often not a cure, but it is great for producing short term relief from some symptoms).
  • If (advanced) diagnostic anaesthesia of a neck structure relieves your headache.
  • If your symptoms are one-sided.

Muscle “knots”: myofascial trigger points are a major suspect in the case of cervicogenic headaches

If headaches have origins in the neck, then there are several possible specific causes. The most interesting is the humble muscle knot or “trigger point,” defined most broadly and simply as a sore spot — as common as pimples, and yet their biology remains largely mysterious, though the dominant idea is that it’s basically a stagnant micro-cramp, just one member of a big family of unwanted muscle contractions.33 They are associated with aching and stiffness and the main reason we crave massage.

No one doubts that people get these weird little sore spots, but there are a lot of legitimate concerns about the industry of half-baked science and therapy that has grown up around them.34 Hundreds of studies have failed to clarify their nature or confirm that they can be treated. Skeptics have begun to point out that the trigger point emperor is having a wardrobe malfunction. I share all of these doubts about trigger points, and consider trigger point therapy experimental.

But we really do have the sore spots! Again, no one doubts that.

And it’s also clear that they are linked to headaches. They occur much more often in headache sufferers. There is evidence of this for both tension headache and migraine.3536

Another significant clue is the clear association between headaches, trigger points, and things like eye strain, jaw issues, and tight ponytails.37 These problems probably involve muscle pain and irritation of superficial muscles, skin, and connective tissue. While jaws and eyes and scalps can and do certainly hurt for other reasons, in both cases it’s clear that muscle pain could be a major factor. While some experts caution that eye strain might not be a factor in headache, the evidence suggests it is,38 and muscular discomfort could easily be the underestimated specific mechanism by which eye pain is converted into head pain. The same is generally true of jaw trouble as well.

Which came first, the trigger point or the headache?

We know that trigger points are a thing, even if we don’t know for sure what kind of thing or how to treat them. And we also know that they are a thing that happens with headaches.

What we don’t know is if the headaches happen before or after: headaches might be causing trigger points, or trigger points might be causing headache. There is evidence pointing each direction, and of course all of it is generally low quality.

But the simple correlation is clear: they definitely go together. We know that much at least. Probably.

Another possibility is that trigger points cause headaches and headaches cause trigger points. There’s no reason it couldn’t work both ways, and there are reasons to believe it does.

Although trigger point therapy is experimental, it can also be pretty cheap and safe to experiment with, and so I think that presumptive treatment39 is justified. I thoroughly explore the treatment options below. Spoiler alert: it’s mostly about rubbing them.

“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.40

It’s nice that primary headache has mostly escaped the stink of the “functional” label, but diseases like fibromyalgia and irritable bowel syndrome are hopelessly mired in it (they should also be called “primary pain” problems, I believe). Primary headaches are mostly thought of as legitimately unexplained, with much less judgement.

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.

Red wine and other triggers (not just for migraines)

A “trigger” is an informal term for something that aggravates a condition, but does not actually cause it. There is some trigger/cause overlap, but mostly triggers provoke symptoms that would have been provoked by something else sooner or later.

Headache is one of the only common problems for which the idea of triggers is widely used.41 You don’t hear much talk about “back pain triggers” or “fibromyalgia triggers” even though it’s a useful enough concept for those conditions, which is kind of odd.

Alcohol as a general headache trigger

The most notorious headache triggers are red wine and chocolate as migraine triggers. But get ready to have your mind blown here: alcohol triggers non-migraine headaches just as much.42 A 2017 paper reports that 22% of headache patients believe their headaches are triggered by alcohol, regardless of what kind of headaches they have. So much for that conventional wisdom! Even if red wine does trigger migraines more often than tension headaches, it would still clearly be of concern to anyone with any kind of chronic headache problem.

Wine was three times more likely to be cited as a trigger than beer, in case you were wondering. (I was.)

Another addendum: there’s no evidence that people with headaches turn to drink. (Maybe because it triggers too many headaches?)

Only a hangover headache is actually caused by red wine, and we know how that works. We do not know how red wine (or anything else) triggers headaches. Whatever the mechanism is, it’s not required, so it’s not a cause. It is definitely possible to have headaches without red wine.

The trouble with triggers

There’s more to this topic than meets the eye. 22% of people reporting alcohol as an any-kind-of-headache trigger isn’t exactly a huge number, and probably a bit overstated to boo. How many people in history have confused a hangover headache with an alcohol-triggered “migraine”? Quite a few, I’m betting. I want to carefully respect what people think they know about their own problems, but obviously the patient isn’t always right, and some experts believe that:

there is no reason to tell headache patients in general to abstain from alcohol. Individual dispositions as well as cultural factors may play a role in alcohol‐induced headache.43

That is not an opinion I expected to encounter when I started researching this.

If you could eliminate every trigger, you would cure the condition for all intents and purposes. And since other treatments are few and far between, people with unexplained headaches are often told that the best thing they can do is to avoid the triggers. And so many healthcare professionals recommend abstinence or caution based on the precautionary principle, despite any concerns that it might not actually be a thing.

But it’s not just that it might be a pointless abstinence. More serious concerns are bluntly summarized by Martin and MacLeod:44

  • “the advice is given in a theoretical vacuum”
  • “it is associated with practical problems”
  • “it is not evidence-based”

We sarcastically say “what could possibly go wrong” when it’s obvious that something probably will. But what could possibly go wrong avoiding alcohol? Something we’re supposed to do to be healthier anyway, because alchohol truly is not good for us in general.

The “practical problem” here is a genuine sensory trap, and well-known to me as “pain guy”: the advice to vigilantly avoid triggeres could backfire, because worrying about triggers can make them worse! Hypervigilance is never good for pain. Literally anything that worries people can become a seed for sensitization.45 This is a major consideration in the management of chronic back pain.

This might also explain why wine is considered a trigger for both migraine and any other kind of undiagnosed headache: because it’s more about the sensitization than the chemistry and pathology of wine and headaches.46

To the extent that this concern is legit — quite a bit, I think — then the way to deal with triggers should not be to fearfully avoid them “like the plague” but just minimize them more calmly and also deliberately confront them occasionally (like exposure therapy for phobias). That is, force yourself to get used to the trigger; refuse to let it be the boss of you.

That might sound a bit nuts, but it’s absolutely consistent with modern pain science.47 There’s a good chance that the right advice for patients is “don’t be scared of red wine” rather than “try hard to avoid all triggers.” And here’s a compromise that I have always liked: avoid triggers in the short term, but with a plan to work towards confidently reclaiming them in time. I like to to plant that optimistic seed: maybe, someday, this won’t be a problem anymore. It’s a good idea for any kind of chronic pain patient to reduce stress and anxiety generally, but learning not to worry about triggers is a fine example of a specific form of “stress relief” for headache patients.

Other headache triggers?

The next two short chapters zoom in on two of other most famous, interesting, and controversial headache triggers/causes: MSG and dehydration. The sketchiness of both of them adds substantially to the case that triggers may not be as straightforward as they seem.

Does MSG cause headaches?

No one knows for sure if MSG causes or triggers headaches, but this is probably the answer: not for most people.

“Chinese restaurant syndrome” has been controversial for decades now. Although it has been studied, the evidence that it’s a real phenomenon is still paltry, mixed, and inconclusive,48 and the discussion is dominated by loud opinio

Only one thing is certain: monosodium glutamate has been demonized for essentially racist reasons,49 and so people’s beliefs about it are intense. It’s unclear if that passion for the topic is being driven by cultural factors, by actual pathology, or a bit of both.

The main MSG myth is that it’s a carcinogen, which it almost certainly is not.

MSG’s role as a headache trigger is a separate assumption, with lower stakes, and much more likely to actually be true: headache triggers seem to be common, diverse, and much harder to definitively settle. And, if it is a trigger, it may also be one of the reasons for the much nastier belief that it’s a carcinogen.

But the headache trigger assumption may also just be wrong. Certainly it’s not true just because they are convinced it is. Medical history is full of ridiculous things that lots people fully bought into. The lack of a clear signal in the evidence probably means there’s not much to detect. If there’s any truth, it’s only a seed: a minor trigger for some people, some of the time, perhaps. Maybe a strong trigger for one in a million people. But it seems to be rare and/or minor enough that it’s quite difficult to confirm, and unlikely to be important for most people.

Does dehydration cause headaches?

We are drowning in myths about water and hydration, especially the fear that mild chronic dehydration insidiously undermines our health. It does not.50

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.51

But what about mild dehydration? The kind that sneaks up on you, dehydration without obvious thirst? Can that be a headache “trigger”? Not the root cause of headaches, but it can make them worse?

Maybe. But I suspect it is 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, 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.53 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!

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,54 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 making a point of hydrating does not help headaches.

My watery conclusion: sure, drink a bit extra just in case — it might actually trigger some kinds of headaches — but don’t expect it to make a major difference or be the entire solution to any significant unexplained headache problem.

Part 4

Treatments for headache

Reviews of all the major treatment options for common headaches

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.55

Hats off! Eliminate minor sources of physical stress that cause headache

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 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 and ponytails.

Ponytails are an extremely common cause of headaches, confirmed by a simple study in 2004,56 a small survey that showed more than half of a hundred women with ponytails got headaches, and most of the headaches extended beyond the site of the ponytail. The study also confirmed the efficacy of the obvious cure: loosening the pony tail! Which was helpful immediately for some, while the slowest relief took a few hours.

You might be thinking that this is a pointless bulletin from the Department of the Extremely Obvious, but we haven’t gotten to the real point yet.

Obvious sources of irritation don’t really need to be highlighted, but it’s extremely likely that some sources of irritation are more insidious. If a tight ponytail causes trouble within a few hours or days, how about a looser one? It’s much harder to prove, but minor sources of irritation around the head and neck might constantly contribute to a chronic headache problem. Remember that we know that hypersensitivity (allodynia) can develop due to “prolonged continuous painful input from pericranial myofascial tissues.”57 Once that sets in, you are more vulnerable, and it sets up a bit of a vicious cycle — vicious and yet maybe not so obvious.

So, you definitely should survey your life for possible minor but chronic irritants. Some of the remaining suggestions are more common sources of unsuspected irritation…

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 yet also 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.

Plus “comfort” is inherently valuable anyway. 😉

Display position is the workstation ergonomics factor that’s the most likely to be relevant to headaches. If your computer display is too high or too low, it could constitute a relevant postural stress. “Too high” is more likely to be a problem. Most people think they should be looking up at a computer display. I’ve seen people boost displays up with books. Others actually pay for custom build products that elevate displays. Personal comfort trumps all other considerations, but it seems like a bad idea to me: when you look up at a display, you have to tilt your head back a bit, and that shortens all the muscles in the back of the neck. And those are notorious headache and neck-pain generating muscles.

Low displays are less common, but they also seem like a bad idea to me. Tilting the head down even slightly for hours at a time may become an irritant: muscle hates to be stretched for too long (imagine holding a standard hamstring stretch for an hour). Also, if you tilt your head down at all, you have to roll your eyes up to see the top of the screen — which could be another source of headaches (from strain on the itty bitty little eyeball muscles, which are rather hard to massage).

But what “seems” like a bad idea to me may not actually be correct. Yes, it’s true: common sense is fallible, and educated guessing too. Decent evidence58 has shown that people who believe their computer display is in a poor position are actually not at greater risk for neck pain. Headache may be a different matter, of course, but if neck pain isn’t a risk there’s a good chance headaches aren’t either. The evidence might not be the whole story, but most likely this is just a classic case of failed common sense.

Still, it’s often no big deal to position your display so that you don’t feel like you’re looking much up or down at it. So why not? If it’s possible. As with keyboard height, display height isn’t always adjustable. It’s almost always easy to prop them up higher, but usually hard to bring them lower — and that’s the direction most people need.

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! This happened to me in a big way in my forties. I was astonished to discover how bad my vision had gotten without really noticing. I caught myself squinting hard at the television one night and went to see an optometrist the next day. The loss of visual acuity was so substantial that I had been struggling along obliviously for months at least — and I’d been having headaches! It seems bizarre to me that I wasn’t aware of the cause, but it happened.

A related problem, and becoming increasingly common as aging people adopt computer usage, is with bifocals and trifocals. Even if vision is well corrected, reading a computer screen with bifocals or trifocals can still cause some strain. They may demand sharper viewing angles for both the neck and eyes than we’re used to, causing a little strain of the ocular muscles as well as 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, consider investing in a pair of glasses specifically for computer use. While you’re at it, ask your optometrist for other ideas about how to ease eye strain.

Postural correction for headache

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.59 The full debate is beyond the scope of this article, but correcting posture is a difficult and uncertain business, even if it does matter — please see Does Posture Correction Matter? for much more information. I want you to beware of the real possibility of wasting time with this concern.

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

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

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

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 for headache: 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.60 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.61 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).62 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),63 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.64

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.

The role of general exercise in headache treatment

Just getting the heart rate up any old way — is a no-brainer treatment option for all stubborn painful problems, but it’s probably extra worthwhile for tension headaches because:

  1. It’s 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).
  2. If you have a little migraine mixed in with your tension headaches, as many probably do, then fitness is even more relevant, in theory.65

General exercise is the single most important component of another treatment goal: see reducing systemic vulnerability below.

Massage, self-massage, and other trigger point therapies for headache

Drawing of a thumb pressing downwards on a target, suggesting trigger point therapy.

Quick review: as introduced above, trigger points (TrPs) are common sore spots associated with aching and stiffness, which may be a cause and/or complication of nearly almost anything else that hurts — headache particularly, maybe. The main theory is that they are a “micro cramp,” which fits the idea of a “tension” headache particularly well — which could be a coincidence, or it could be exactly why we all settled on the word “tension” to describe so many headaches.

Rubbing trigger points seems to ease them. No one knows how well it actually works, or even if it works at all.66 But it certainly does seem to, and often surprisingly easily.67 All advice about trigger points on is based on “seeming” and scientific plausibility, which is weak sauce.68

However, given the potential importance in headache, presumptive treatment — treating as if trigger points matter — is worth a try if you focus on the safer and cheaper options: mainly self-massage, possibly supplemented with some professional massage help as long as it isn’t overly aggressive.

Dry needling is popular too, and I will discuss it below mainly to discourage you from using it: it’s more expensive and risky, especially around the neck, but no more likely to help.

How to treat trigger points with self-massage

Grope around your shoulder with fingers and thumbs and find acutely sensitive, aching spots in muscle tissue. You may or may not feel a slight bump or twitch, but those are inconsistent and unreliable signs. Finding trigger points is the exact opposite of an exact science,69 but don’t sweat it: just cast a wide and pleasant net, it doesn’t matter if some effort is “wasted” on some wrong spots.

The soreness of a trigger point should feel “relevant” — that is, the soreness of the spot should feel like it is related to your headache, part of it or the whole thing, rather than some other kind of discomfort that just happens to be in the same area. See below for several more specific places to look for headache-related TrPs.

Massage tools are not very important for head and neck massage — it’s one of the places in the body where we can easily reach most spots — but they can still be useful. What tools? For the neck, mostly “thumb replacers” like the Knobble or cane-type reaching tools for getting to the back of the neck and shoulders.

“The Knobble” is basically a sturdy plastic thumb with a nice grippy handle.

When you find a sore spot, either simply press and hold for a while (10–100 seconds), or apply small kneading strokes, either circular or back and forth. You’re hoping for the sensitivity to ease, which is what we refer to a “release” in trigger point therapy.

Rub very gently at first, just tugging the skin to and fro over the surface of the sore spot — some initial gentleness has a specific purpose, don’t skip it — and then ramp up to rubbing firmly but not viciously. You’re not trying to “kill” it, you’re trying to soothe and “scratch” it. Too much intensity can backfire, and a just-right intensity may actually be a key to success: vivid and clear “good pain” is an ideal level, intense but somehow satisfying. Don’t grimace through it as if a brutal massage therapist was inflicting it on you.

A good first self-massage experiment should take several days, two or three sessions per day, with a few minutes of exploration each time. If you are finding points that feel relevant but they aren’t easing, you could up the ante and try a few basic upgrades: treat right before bedtime, get better tools (just the right tool can be a game-changer), avoid chills or actually have a hot bath/shower with treatment, or follow treatment with light exercise.

If a couple weeks of this yields little or nothing, it’s time to give up, or get some professional help to explore other possibilities.

Where to search for trigger points relevant to headache

Massage of practically any part of the head, face or neck will usually feel soothing to headaches, but by far the best place to look for TrPs is the suboccipital region under the back of the skull. And there are some other high-priority locations. Four of these correspond to members of my “perfect spots for massage” series (the only other common pain problem with so many “perfect spots” is back pain).

Anatomical illustration of the suboccipitals muscle group.

“Perfect spot” #1

A likely source of tension headaches.

  • 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.

Professional trigger point therapy (mostly massage)

Some important things to bear in mind if you seek trigger point therapy for headache:

  • We’re mostly talking about massage therapists — they are the most likely kind of professional to be competent to help — but you can also get help with trigger points. There are other kinds of trigger point therapy, but none are great options.
  • It’s a crapshoot. The quality of trigger point therapy is all over the map and low on average. So you have to be prepared to shop around for someone who seems humble, sensible, and experienced. See How to Find a Good Massage Therapist.
  • When in doubt, it is much better to just have a great massage than bad trigger point therapy. There is plenty of overlap between decent trigger point therapy and an ordinary pleasant massage.
  • Please, never tolerate extremes of massage pressure.

Warning! Massage complications can make headaches worse

“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.70 If you have a chronic headache problem, it’s particularly important not to 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.

Other kinds of trigger point therapy

There are several other major types of trigger point therapy. Not one is promising for the average headache patient, but all are worth considering when you get more desperate. Here are the other approaches, quickly summarized. (Again, every topic here is explored in much greater detail in my book).

Stretching seems like a good idea for “knots” that may be micro-cramps by nature. It might work about the same way that stretching out a calf cramp works: you win the tug-of-war with contracting muscle, just on a tiny scale. As with massage, people believe it helps, including some experts. Unfortunately, there are major problems in both theory and practice. Even if it’s possible in principle to win a tug-of-war with some trigger points, it’s unlikely to work with all of them, and especially not the worst ones. How can we pull apart a powerful contraction knot — a tiny segment of muscle fibres in full spasm — with anything less than pliers, a vice, and a glass of bourbon? That trigger point is like a knot in a bungie cord: all we’re going to to do is stretch the bungie cord on either side of the knot.

Stretch with … spraying? A coolant spray, that is. This is one of the “original” types of trigger point therapy, used by Dr. Janet Travell (famous for her study and promotion of trigger point therapy in the 1970s and 80s). It’s just stretching enhanced by a chill on the skin, which might have some interesting reflex effects. It is obscure, rarely practiced today, and unvalidated scientifically — but probably worth a shot if you can find someone who does it.

Maybe stabbing will help! “Dry needling” is a popular but sketchy method of treating trigger points with acupuncture needles (but it’s not acupuncture71). It is “dry” needling to distinguish it from “wet” injections of medications. It involves some risks, from wasted money to worsened pain to infection and (seriously) lung puncture… which can actually happen with neck needling, because the tippy top of the lungs are surprisingly exposed just lateral to the base of the neck (they are higher than people realize, and lurk just under the skin).

Needling is provided mostly by physical therapists. Every practitioner will claim they know what it’s doing, but none of them can actually explain it in any detail: ideas about it are imprecise and contradictory speculation. It feels potent and patients have a love/hate relationship with it. Other than a handful of positive studies,72 the science is discouraging.73 I do not think it’s a good option for most people: it is plausible and interesting theoretically, but also has risks, costs a lot, and can hurt like hell. Few patients should be willing to accept those downsides without much better evidence that it works.

Shiatsu is another Asian therapy that might include some “accidental” trigger point therapy. It’s needle-less Japanese acupuncture, using lots of pressure to stimulate acupuncture points, so it definitely includes a bunch of vitalistic nonsense (“energy medicine”). Nevertheless, it has far more in common with massage therapy than acupuncture does. Remove the Japenese elements and it’s just “acupressure,” which can be almost indistinguishable from trigger point therapy. Typical shiatsu/acupressure is 30-60% in tune with what I consider to be good trigger point therapy… which is probably better than some bad trigger point therapy.

Injection. Trigger points may be treatable by injecting them with a saline solution (to dilute the tissue fluids), with an anaesthetic or anti-inflammatory medication, or even with Botox to paralyze and “deactivate” them. Evidence of efficacy is incomplete and unimpressive so far. A 2001 review concluded that “Any effect of these therapies is likely because of the needle or placebo rather than the injection of either saline or active drug.”74

Addressing other medical factors

There is one more major approach to trigger point therapy that is much more important: attem,pting to reduce the biological vulnerabilities that may cause trigger points (and/or other kinds of chronic pain). This can be a huge project and a bit wild goose chase, but it’s a near certainty that there are at least some treatable medical factors, such as disturbed sleep, nutrient deficiencies, or hormonal imbalances, that make trigger points worse.

Or they might just cause the headaches directly! See the “Reducing vulnerability” chapter.

Recap of key trigger point points

  • Trigger points may be a major mechanism of headache.
  • Trigger point therapy is experimental but can be very safe, cheap, and easy.
  • Self-treatment is mostly about finding sore spots around the neck and head and rubbing them with fingers or simple tools, at moderate intensity, a couple times a day for a week or two.
  • By far the most important place to look for trigger points relevant to headache is in the suboccipital muscle group under the back of the skull.
  • Good professional help with trigger point therapy is hard to find, but any good quality head, neck, and shoulder massage is probably better than bad trigger point therapy. So mainly just try to find a massage therapist whose style you love.
  • There are several other kinds of trigger point therapy — most notably the needles, both dry and wet — but none of them are promising options for headache patients.

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:757677 small reviews of mostly poor quality trials, none of which clearly showed anything, which is fishy.78

There is a single more recent trial of seemingly respectable quality and reasonably positive results — but less so if you check the fine print.79 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.

Finally, probably best study available is almost 20 years old. It seems positive at first glance: treatment with manual therapy, specific exercises, or manual therapy plus exercises were somewhat more effective than general care by a physician.80 Unfortunately, manual therapy alone did no better than exercising, and that’s a negative result: low-value medical practices are “either ineffective or that cost more than other options but only offer similar effectiveness.”81

How about manipulation for migraine?

Does spinal manipulative therapy 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.82

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 risks83 — risks that are higher in patients with unexplained headaches, which can have serious causes that make the neck more vulnerable.84

Pills, pills, pills: treating headache with over-the-counter pain-killers

Photograph of a bottle of generic pills.

Many people with a headache reach for one of the common non-prescription pain-killers long before they think of trying anything else. There are several confusing options, 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® 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! Worse, it may impair tendon recovery.

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.868788 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

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

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

I massaged and soaked to no avail. It got worse. It progressed so steadily that I was 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.

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,89 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.90 A 2014 review was a little less pessmistic, but still far from conclusive.91

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

When the primary complaint is pain, the treatment of pain should be primary.

~ Barrett Dorko, Physical Therapist, online discussion, 2010

We tend to assume that chronic pains have specific causes — especially strained or damaged tissues — but some of the most important causes of pain are the general conditions in which it flourishes, the soils and fertilizers it likes.

For instance, just for the sake of argument, what if you knew that the exact same thing causing your headaches — a cranky upper cervical spinal joint, say — is happening in a bunch of other people, but they aren’t getting headaches? Same specific issue with a specific tissue, but not painful for everyone? What if you knew the reason it hurts you is because you are an out of-of-shape smoker with way too much sleep deprivation, making that sore joint much more sore, and so slow to heal that it’s practically permanent? Is that really a “spine” problem?

There are several common modifiable risk factors for any kind of chronic pain that are typically neglected:

These are all things you can change, in theory.

As tempting as it is to focus on the head and neck, it may make much more sense to work on these bigger picture issues. It’s difficult, of course. The big factors are often thoroughly entangled, all making each other worse. An impoverished single mom with a nasty ex husband, a nicotine addiction, and diabetes looming is going to have a tough time digging her way out of that mess. And yet it could be her only real hope, too.

Headaches, sleep deprivation, and mood disorders

Many common stubborn painful problems are particularly associated with one of the vulnerabilities above. For instance, frozen shoulder is strongly linked to metabolic syndrome. And headaches…

Headaches are linked to sleep and mood disorders. Insomnia, depression, and anxiety are all particularly strong risk factors for headache.

Sleep deprivation might be the strongest. Practically everyone who just lost a night of sleep has a headache. It very clearly 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 a joint gets a wee bit irritable, and boom… now that’s driving a headache. Once rested again, the joint mechanics normalize, the tissue settles down, and the headache eases.

The which is usually improving your sleep quality, because a great deal of insomnia is an “unforced error.” This is actually good news, because it’s actually fixable. See The Insomnia Guide: Serious insomnia-fighting advice from a veteran of the sleep wars

Or maybe mood disorders are the most strongly linked general vulnerability to headache. I don’t think there’s an objective way to settle it, but c’mon: anxiety is almost synonymous with stress, and what could be more relevant to headaches than stress?

How to reduce general vulnerability to pain

Many of the options follow obviously from the list of vulnerabilities above, but for the sake of thoroughness I sumarize them here. This advice will seem general to the point of being trite and useless, but that’s actually the point: we want specific treatments, but general ones actually do matter a lot.

  • Get more exercise, above all. It’s the closest thing there is to a miracle drug.
  • Get more sleep. Protecting your sleep is probably just as good an investment.
  • Get less smoke. If you smoke, you already know you should quit, of course.
  • Eat an anti-inflammatory diet… which is mostly just a non-stupid, normal, moderate diet with decent variety.
  • De-stress. The ultimate easier-said-than-done challenge!
  • Make more friends. “Loneliness” is an incredibly common and underestimated stressor.

Tackling all of this vulnerability-reducing stuff could turn into a complete personal makeover, a huge project that might never end. Like any difficult, complex problem, you break it up into pieces and start with the easiest bits. It’s a long-term “pick your battles” challenge. Hint: more exercise and sleep deprivation are usually the lowest hanging fruit.

I discuss all of these options and more in much greater detail elsewhere. See Vulnerability to Chronic Pain: Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems.

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

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.

Specific stress relief

Wherever possible, aim to reduce anxieties and stresses that are specifically related to your headaches. The classic example is headache trigger avoidance. Hypervigilantly avoiding triggers like red wine may actually make them much worse, a vicious cycle: the more you are concerned about them, the more they become a problem worthy of your concern. Interrupting that vicious cycle — a long-term project for most people — is a kind of “stress relief.”

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.

Breathe faster!

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.

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About Paul Ingraham

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

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

Part 5


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.

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

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

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

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 section: No notes. Just a new section. [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 section: No notes. Just a new section. [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 adjustment and spinal manipulation.]

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 sections around for clarity.

MayNew section: No notes. Just a new section. [Section: Muscle “knots”: myofascial trigger points are a major suspect in the case of cervicogenic headaches.]

MarchNew section: No notes. Just a new section. [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 section: No notes. Just a new section. [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 section: No notes. Just a new section. [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 adjustment and spinal manipulation.]

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 adjustment and spinal manipulation.]

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 section: No notes. Just a new section. [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 adjustment and spinal manipulation.]

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.]



  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.”

  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.

  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
  18. 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.”

  19. 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
  20. 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
  21. 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
  22. Bogduk N. The neck and headaches. Neurol Clin. 2014 May;32(2):471–87. PubMed #24703540.  BACK TO TEXT
  23. Lebbink J, Spierings EL, Messinger HB. A questionnaire survey of muscular symptoms in chronic headache. An age- and sex-controlled study. Clin J Pain. 1991 Jun;7(2):95–101. PubMed #1839715. 

    This survey asked people with and without headache about the soreness and tightness of their neck, shoulder, and jaw muscles. Tightness was more common and severe in the headache suffers, and soreness was more severe (that is, everyone was sore to some extent, but people with headaches were more sore). All areas were linked to headache to some degree, but the neck much more so. Such data can't tell us anything about causality, but it certainly helps to reinforce what seems obvious to most people who have ever had a headache: there is some kind of link to the neck, jaw, and shoulders.

  24. 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.

  25. Bogduk 2014, op. cit. BACK TO TEXT
  26. This is a key passage from Bogduk’s 2014 paper. I have lightly edited, annotated, and formatted for clarity. Note that this is quite a wise protocol he’s recommending, because it includes sham blocks, like a tiny controlled trial with one subject, the diagnostic equivalent of doing a blind taste test. Smart stuff.

    A diagnosis can be established using controlled diagnostic block protocols. Such blocks include intra-articular blocks of the lateral atlantoaxial joint, blocks of the third occipital nerve to anesthetize the C2-3 zygapophysial joint, and blocks of the medial branches of the C3 and C4 dorsal rami, which innervate the C3-4 zygapophysial joint.

    Suitable controls include using local anesthetic agents with different durations of action, or injections of normal saline, or anesthetizing an adjacent structure that is not the source of pain.

    To be convincing, diagnostic blocks should completely relieve the headache whenever the target structure is anesthetized with an active agent, with relief lasting for the duration of action of the agent used (and no relief if normal saline is used, or if an alternate structure is anesthetized).

    Target structures can be selected from epidemiologic data, [which] implicates the C2-3 zygapophysial joint as the most common source of cervicogenic headache. Next most likely are the lateral atlantoaxial joint and the C3-4 zygapophysial joint. These pretest probabilities may change in the future as diagnostic blocks of the lateral atlantoaxial joints become more widely used. If synovial joints prove not to be the source of pain, the C2-3 intervertebral disk can be tested using diskography.

    Bogduk cites several sources in this passage:

  27. The brain is somewhat inept at precisely locating internal pain and sometimes experiences pain in a broad area around or near the cause. This is exactly the same phenomenon as heart attack pain felt mainly in the arm: the brain literally can’t figure out where the pain is coming from. Patterns of referral from the musculoskeletal system are somewhat predictable, and most referred pain spreads away from the centre and the head (laterally, distally). By contrast, visceral referral is much more erratic. Notably, referred pain from the neck probably goes “up,” causing headaches. In the case of cervicogenic headache, there are some ver BACK TO TEXT
  28. Rather than citing every example, I’ll just quote Bogduk, who did all the homework on this in 2014. Every specific referral pattern is accompanied by a citation in his paper.

    The anatomic basis of cervicogenic headache is convergence, onto second-order neurons in the C1-C3 segments of the spinal cord, between nociceptive afferents of the first division of the trigeminal nerve and nociceptive afferents of the C1, C2, and C3 spinal nerves. Convergence between trigeminal and cervical afferents explains referral of pain from cervical sources to the forehead, orbit, and temporal regions of the head. Convergence between other cervical afferents and those of C2 explains referral of pain to the occiput and parietal regions.

    Physiologic convergence has been shown in laboratory animals, between trigeminal afferents from the dura mater of the skull and cervical afferents in the greater occipital nerve. … Stimulation of trigeminal afferents sensitizes the response to cervical input, and stimulation of cervical afferents sensitizes trigeminal input.

    In human volunteers, pain in the head has been evoked experimentally by electrical stimulation of the dorsal rootlets of C1 and by noxious stimulation of the greater occipital nerve11 or the suboccipital muscles of the neck. Noxious stimulation of the C2-3 intervertebral disk, but not lower disks, produces pain in the occipital region. Distending the C2-3 zygapophysial joint with injections of contrast medium produces pain in the occipital region, as does distending the lateral atlantoaxial joint or the atlanto-occipital joint. All segments from the occiput to C4-5 are capable of producing referred pain to the occiput, but referral to the forehead and orbital regions more commonly occurs from segments C1 and C2.

    C1 and by noxious stimulation of the greater occipital nerve or the suboccipital muscles of the neck. Noxious stimulation of the C2-3 intervertebral disk, but not lower disks, produces pain in the occipital region. Distending the C2-3 zygapophysial joint with injections of contrast medium produces pain in the occipital region, as does distending the lateral atlantoaxial joint or the atlanto-occipital joint. All segments from the occiput to C4-5 are capable of producing referred pain to the occiput, but referral to the forehead and orbital regions more commonly occurs from segments C1 and C2.

  29. Vincent MB. Cervicogenic headache: the neck is a generator: con. Headache. 2010 Apr;50(4):706–9. PubMed #20456157.  BACK TO TEXT
  30. As put very technically by Vincent: “Cervicogenic headache may depend in addition on a central predisposition counterpart, leading to the activation of the trigeminovascular system and pain generation.” BACK TO TEXT
  31. 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
  32. These criteria are a combination of my own opinion and adapted from from Antonaci et al. BACK TO TEXT
  33. The “expanded integrated hypothesis” was presented out by Dommerholt, Gerwin, and Shah in 2004. It’s detailed and technical! When abridged and oversimplified, it closely resembles the integrated hypothesis (“a possible explanation”) put forward by Travell and Simons in the first edition of their famous textbook in 1981. The expanded integrated hypothesis basically says this:

    Under some circumstances, muscular stresses can causes patches of poor circulation, which results in the pooling of noxious metabolic wastes and high acidity in small areas of the muscle. This is both directly uncomfortable, but also causes a section of the muscle to tighten up — a micro cramp — and perpetuate a vicious cycle. This predicament is often called an “energy crisis.” It constitutes a subtle lesion. TrPs research has largely been concerned with looking for evidence of a lesion like this.

  34. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392–9. PubMed #25477053. 

    Quintner, Cohen, and Bove think the most popular theory about the nature of trigger points (muscle tissue lesions) is “flawed both in reasoning and in science,” and that treatment based on that idea gets results “indistinguishable from the placebo effect.” They argue that all biological evidence put forward over the years is critically flawed, while other evidence leads elsewhere, and take the position that the debate is over. (They also point out that the theory is treated like an established fact by a great many people, which is definitely problematic.) However, their opinion is extreme, and most experts do not think we should throw out all the science so far (see Dommerholt et al).

    (See more detailed commentary on this paper.)

  35. Lebbink 1991, op. cit. Previously discussed, basically a survey showing that “tension and soreness” are linked to headache. But what’s the link between “soreness” and trigger points? Well, they are almost synonymous! A trigger point is just a sore spot in muscle. It’s possible have diffuse soreness, but usually only with temporary delayed-onset muscle soreness. Most soreness is patchy and focal (as every massage therapist knows very well). And a focal sore spot in a muscle is a trigger point by definition. BACK TO TEXT
  36. Do TP, Heldarskard GF, Kolding LT, Hvedstrup J, Schytz HW. Myofascial trigger points in migraine and tension-type headache. J Headache Pain. 2018 Sep;19(1):84. PubMed #30203398.  This is a well-written review. Although the authors are likely somewhat biased — “believers” in the clinical significance of trigger points, and interpreting the evidence through that lens — their conclusions are appropriately cautious, clearly acknowledging the limitations of the evidence. BACK TO TEXT
  37. Ponytail headaches are a thing (Blau) and we also know that allodynia (painful response to non-painful stimuli) can develop due to “prolonged continuous painful input from pericranial myofascial tissues” (Filatova et al). If that is possible, then it is also plausible that trigger points can also drive headaches and sensitivity to other physical stresses. More about ponytail headaches later. BACK TO TEXT
  38. Vincent AJ, Spierings EL, Messinger HB. A controlled study of visual symptoms and eye strain factors in chronic headache. Headache. 1989 Sep;29(8):523–7. PubMed #2793458.  BACK TO TEXT
  39. “Presumptive treatment” is treating a problem based on the presumption of the cause. Sometimes the best way to find out if X is the problem is to give a person a treatment for X and just see what happens. If it works, the diagnosis of X is probably correct. This approach to medicine was dramatized every week by House, M.D.. BACK TO TEXT
  40. 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.”

    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.

  41. Other conditions where we speak of triggers: multiple sclerosis (heat, fatigue), and irritable bowel syndrome (fibre, overeating, fried foods). Can you think of another? Contact me.

    Why so much talk of triggers for headaches, and not other conditions? I suspect this is the case because we can never figure out the cause of so many headaches in the first place, so talking about triggers is just the next best thing.

  42. Davis-Martin RE, Polk AN, Smitherman TA. Alcohol Use as a Comorbidity and Precipitant of Primary Headache: Review and Meta-analysis. Curr Pain Headache Rep. 2017 Aug;21(10):42. PubMed #28844083.  BACK TO TEXT
  43. Dueland AN. Headache and Alcohol. Headache. 2015;55(7):1045–9. PubMed #26121267.  BACK TO TEXT
  44. Martin PR, MacLeod C. Behavioral management of headache triggers: Avoidance of triggers is an inadequate strategy. Clin Psychol Rev. 2009 Aug;29(6):483–95. PubMed #19556046.  BACK TO TEXT
  45. This is the formal sense of the term sensitization, a well-described phenomenon in pain science: more pain with less provocation, lowering the threshold of stimulation required for the brain to interpret it as a threat. BACK TO TEXT
  46. That is, the trigger may be a nocebo that can amplify any kind of headache. Sensitization makes different problems behave in similar ways, because they are being driven as much by the sensitization as the original problem. BACK TO TEXT
  47. And for lack of understanding of this, there’s a mistake that is being made systematically throughout the world of rehab and musculoskeletal medicine: too much emphasis placed on triggers as pseudo-causes, which backfires and exacerbates the more fundamental underlying problem of sensitization. For most chronic pain and musculoskeletal conditions, the “triggers” are different, usually biomechanical and structural factors. A classic example would be “lifting poorly” as a cause of back pain, which is occasionally relevant, but it’s a terrible idea to exaggerate its importance: people need to be taught to be less wary of lifting, not more wary of it. Headache triggers may be similar. BACK TO TEXT
  48. Obayashi Y, Nagamura Y. Does monosodium glutamate really cause headache? A systematic review of human studies. J Headache Pain. 2016;17:54. PubMed #27189588.  PainSci #52464.  BACK TO TEXT
  49. [Internet]. Maria Barry-Jester A. How MSG Got A Bad Rap: Flawed Science And Xenophobia; 2016 Jan 8 [cited 19 Apr 26]. BACK TO TEXT
  50. PS Ingraham. Water Fever and the Fear of Chronic Dehydration: Do we really need eight glasses of water per day? 4405 words. BACK TO TEXT
  51. 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
  52. 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.”

  53. 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
  54. 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
  55. No, not really. I’m just being cute. BACK TO TEXT
  56. Blau JN. Ponytail headache: a pure extracranial headache. Headache. 2004 May;44(5):411–3. PubMed #15147248.  BACK TO TEXT
  57. Filatova 2008, op. cit. BACK TO TEXT
  58. Paksaichol 2012, op. cit. BACK TO TEXT
  59. 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. PubMed #27174256.  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.)

  60. 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.

  61. 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
  62. 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
  63. 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
  64. 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
  65. 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
  66. All trigger point therapy is experimental by definition, because the evidence of efficacy is barely there. Massage is overwhelmingly the most popular way to attempt to “release” trigger points, but the limited research available cannot support it. Other methods have even less evidence, or fairly negative evidence. BACK TO TEXT
  67. Trigger points may be a purely sensory phenomenon without much pathological substance, and sensation is relatively easy to “hack.” It's also possible that rubbing actually does help muscle tissue directly in some relatively simple way, like literally pushing and flushing waste metabolites out of a trigger point (see Shah). And, if the problem is slight nerve entrapment (see Quintner), then it makes sense that even slight manipulation might free them. BACK TO TEXT
  68. I do not trust “anecdata,” and I handle it like venomous snakes. I don’t trust any of it, but I don’t ignore it either. I have a lot of clinical experience with trigger point therapy, and deep knowledge of the science of how it supposedly works, and of all the expert opinions. In other words, I am painfully aware that we lack adequate scientific evidence of efficacy, but I tentatively “believe” in trigger point therapy anyway, because it sure seems to work, it is scientifically plausible that it works (much more so than, say, homeopathy), and it’s relatively safe and cheap, and it’s not likely to distract anyone from other valuable therapy. That is, it avoids all the major red flags for quackery. BACK TO TEXT
  69. There are many bumps and sore spots in the body that are not trigger points. We all tend to perceive what we expect/want to perceive, rather than what is. Even massage therapists, with lots of experience with feeling anatomy, often mistake miscellaneous lumps for trigger points. The only defence against this murkiness for the amateur is to be humble, cautious, and thorough. BACK TO TEXT
  70. 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
  71. Although the shared hardware makes dry needling look a lot like acupuncture, these techiques are mostly cousins, not siblings — all they really have in common is the needles. BACK TO TEXT
  72. Couto C, de Souza IC, Torres IL, Fregni F, Caumo W. Paraspinal Stimulation Combined With Trigger Point Needling and Needle Rotation for the Treatment of Myofascial Pain: A Randomized Sham-controlled Clinical Trial. Clin J Pain. 2013 Apr. PubMed #23629597. 

    This study was conducted based on the premise that sticking needles in trigger points is an effective treatment for pain, and they wanted to find out which method works better: dry needling or wet needling (lidocaine injection). That’s a bit of dodgy way to start, but they did compare both types to a proper sham (a deactivated electroacupuncture device that patients were told was “a high-frequency, low-intensity stimulation and that they would most likely feel no sensation from it.”)

    They worked with 70 female patients who had “experienced limitations in their routine activities due to MPS … as confirmed by an independent examiner” and excluding eliminating a variety of other common diagnoses. The primary outcomes measured were pain, sensitivity to pressure, and pain-killer usage over several weeks of treatment (plus some secondary measures, like sleep quality, that seem highly vulnerable to confounding factors).

    It should be noted that the positive results here are at odds with some reviews published since that have concluded that there is no benefit (e.g. see Cagnie, Kietrys).

    All the women improved, including those who received only a sham (as they always do), but the researchers concluded that dry needling produced the greatest improvement.

    After a week, the improvement in pain compared to sham was detectable but trivial. Needling gained a little ground each week, until those patients were enjoying a stastically and clinically significant lead over the other groups: about one point better on a 10-point scale than wet needling, a couple points better than the sham. Results were similar with pressure tolerance and pain-killer usage.

    How clinically significant the difference was is debatable. It’s not enough of a difference to seem like a “powerful” treatment, and that’s the damning-with-faint-praise problem that afflicts so many “positive” studies of pain treatments.

    The other concern I have about is that it was a fairly large, relatively long-term study, which is both a strength and a weakness. Such a complex study presents plenty of opportunities for p-hacking, for statistical jiggery pokery … and the text is overflowing with assumptions that betray a strong bias in favour of needling. These authors clearly were looking for a “win,” and so I just flat out don’t trust the conclusion.

  73. I review all the evidence thoroughly in my trigger points book, but the theme is clear: barely positive studies that damn dry needling with faint praise. See Kietrys, Cagnie 2015 Liu 2015. BACK TO TEXT
  74. Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001 Jul;82(7):986–92. PubMed #11441390.  BACK TO TEXT
  75. Lenssinck ML, Damen L, Verhagen AP, et al. The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review. Pain. 2004 Dec;112(3):381–388. PubMed #15561394.  PainSci #56057.  This review of two higher quality trials and six not-so-high quality ones “concluded” that “there is insufficient evidence to either support or refute the effectiveness of … manipulation in patients with [tension headache.]” BACK TO TEXT
  76. Fernández-de-Las-Peñas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC. Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache. Journal of Orthopaedic & Sports Physical Therapy. 2006;36(3):160–169. “There are few published randomized controlled trials analyzing the effectiveness of spinal manipulation and/or mobilization for TTH, CeH, and M in the last decade. In addition, the methodological quality of these papers is typically low.” BACK TO TEXT
  77. 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.”

  78. 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
  79. 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.

  80. Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine (Phila Pa 1976). 2002 Sep;27(17):1835–43; discussion 1843. PubMed #12221344.  BACK TO TEXT
  81. Herrera-Perez D, Haslam A, Crain T, et al. Meta-Research: A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals. eLIFE. 2019 Jun 11;8(e45183). PainSci #52236.  BACK TO TEXT
  82. 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.)

  83. [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
  84. See Arnold et al, Kerry et al, Maruyama et al BACK TO TEXT
  85. 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
  86. 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
  87. 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
  88. 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
  89. 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
  90. 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
  91. 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.”