The Complete Guide to Chronic Tension Headaches

The cervicogenic headache question boils down to a pretty simple answer: some kinds of neck pain probably do contribute to chronic “tension headache.” Most ongoing debate is about exactly how it works and how strong that 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 they also clearly overlap (though mostly in one direction). Many neck pain patients don’t need to know anything about headaches. 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 PainScience.com since 2007, and I’ve been actively upgrading it ever since. Originally it was focused on the weird 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 and all kinds 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 one! 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” 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 most likely to cause headaches.
• The irritation of a neck crick, when it is persistent, inevitably leads to more generalized tension and pain, casting a wider and wider net of discomfort 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…46

• 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 be caused by the upper trapezius muscle on the top of the shoulder (we’ll get into this in the next chapter).
• 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.

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If headaches can come from trouble with the cervical joints… what kind of trouble, exactly?

The gradual degeneration of joints with age — arthritis — is not as simple a process as we think. It’s often surprisingly painless, because several factors other than the condition of the joint determine discomfort. And arthritis is not so much a consequence of wear-and-tear as it is systemic inflammation.474849 But the progression of arthritis certainly does loosely correlate with pain, and eventually it accounts for the lion’s share of neck problems in older people.

But many younger people without any significant amount of joint trouble nevertheless have neck pain, often quite fierce. So clearly arthritis isn’t the only fate that neck joints can suffer. What else is there?

The popular imagination is completely dominated by one major idea, the elephant in this room: a joint that is “out” or a “spine out of line” (an old chiropractic marketing phrase). And could you have a joint that is “out” and not even know it? Not neck pain? Literally all it’s doing is causing a headache?

Subluxation means literally whatever you want it to mean (so it’s meaningless)

Unfortunately, “subluxation” and spinal joints being “out” are not defined clearly enough to be much more useful than just saying “spinal joint trouble!” They are also often defined in a misleading way.

“Subluxation” is mainly a chiropractic idea of some kind of spinal joint dysfunction, with many shades of meaning — too many — depending on who is talking about it. However, it is inextricably entangled with the idea of a spinal joint being “out” of place, and it is this sense of the word that most richly deserves debunking.

Some chiropractors attribute great medical importance to subluxation. Most believe that subluxations cause neck and back pain, at the least, but many also believe that they cause a wide variety of other health problems, and so they “use spinal manipulation to treat visceral disease.”50 Subluxation theory is one of the major controversies about chiropractic,51 and it has never achieved medical respectability. Many experts, including quite a few chiropractors, deny that spinal subluxations exist in any meaningful sense.

It’s problematic that “spinal manipulative therapy” — the umbrella term for all kinds of spinal joint “adjustment” — is routinely motivated by such a murky concept. Subluxation has too much baggage to be a useful term. Let’s use more modern and specific terminology, and get away from the idea of spinal joints being “out.”

The controversies about subluxation theory are described much more thoroughly in a separate article, or you can just read some highlights here and in another section below, treating neck pain with spinal adjustment.

So if not arthritic or “out,” what else is there?

A “minor intervertebral derangement” (MID).5253 I think this is a more useful explanation for most people, most of the time — better than the vague and easily abused “subluxation.” A MID is basically a minor mechanical malfunction in a spinal joint, causing pain directly through mild trauma. A MID is probably not even as painful as a minor toe stub in most cases, but painful enough to provoke a reaction. Aging, arthritic joints are undoubtedly more vulnerable to MIDs, but they can definitely also happen to perfectly healthy joints. Here are some possible examples of MIDs:

• Compression sprain.There are a pair of small, dime-sized joints on either side of every intervertebral joint, the facet joints.54 Their cartilaginous surfaces can be “bruised” when compressed, somewhat like a thumb jam.55 This might happen if you “zigged” when you should have “zagged” — a poorly coordinated movement of the neck.56 Minor compressions of this sort are probably extremely common, and mostly painless. Joint surfaces are not particularly sensitive to pressure.57
• Synovial membrane pinch. Joint capsules — connective tissue wrappings — around the facet joints can probably be pinched between the joint surfaces, basically at random, and probably for the same reason that compression sprains occur (the “zigged when you should have zagged” theory). This has never been demonstrated scientifically to the best of my knowledge, but it is plausible. Unlike cartilaginous joint surfaces, synovial membranes (the lining of the capsule) are extremely sensitive.
• Violent joint popping. The facet joints also “pop,” like knuckles. Although many people are used to the sensation of joint cracking in their necks, for others it is surprising, uncomfortable, and even alarming. A violent “crack” could constitute a minor MID.58
• A nerve pinch. Although less of a problem than most people suppose (more about that in a while), irritation of nerves exiting the cervical spine is possible. A poorly coordinated movement can result in a momentary yank or pinch on nerve tissue. The sensation may be more alarming than actually damaging (but “alarm” probably has as much to do with what hurts us as actual damage).

Note that none of these examples necessarily involve any on-going mechanical problem. It’s just a painful, temporary disturbance. In most cases, persistent symptoms following a MID are probably not a product of an MID directly, but of its sensory consequences. That is, the minor trauma caused by the MID itself quickly settles down, like a minor bruise clearing up, and is overtaken by a variety of perceptual and muscular reactions.

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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.59 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.60 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.6162

Another significant clue is the clear association between headaches, trigger points, and things like eye strain, jaw issues, and even tight ponytails.63 All 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,64 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 headaches. 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 treatment65 is justified. I thoroughly explore the treatment options below. Spoiler alert: it’s mostly about rubbing them.

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Aching temples almost define tension headache — so much so that stock photography depicting “headache” is dominated by people massaging and holding their temples. Pinching the bridge of the nose is not far behind, but most tension headaches have their epicentre in the temples.66

The temples might seem like a “head” thing, as though the pain is beaming directly from your frontal cortex through those depressions in your skull bracketing your forehead. But what is actually in the hollow of the temple? What are those shallow cranial craters filled with?

A jaw muscle. The temporalis muscle, specifically. A overworked, cranky jaw muscle. Most people don’t realize that they have a jaw muscle that high, way up on the side of the forehead. But it is a large muscle that reaches down from well above the ears to pull up on the mandible (diagram coming up in a few paragraphs). If you touch your temples and clench your teeth repeatedly, it’s easy to feel it contracting.

If there is one obvious candidate culprit for the phenomenon of tension headache, this must be it, the elephant in the room, the mother of all obvious causes of common problems. And it’s just a muscle that moves the jaw. Nothing else. No joint pain. No weird nerve things, no funky biology or pathology — just one humble muscle.

How does a jaw muscle make a head ache?

If temporalis pain is practically synonymous with headache, why does the temporalis hurt? Probably because it’s a chronically overused muscle, exhausted and irritated by habitual clenching of the jaw, which is an instinctive human response to stress and anxiety — which is as far down the path of causality as we’ll try to go. I have no idea why homo sapiens is so prone to jaw clenching, but we certainly are.

The simplest explanation — which is always preferred67 — is that it is just tired and sore, a kind of low-grade repetitive strain injury. No “phenomenon,” no puzzling biology, no mysterious neurology or pathology — just muscles groaning from overuse, like your hands cramping up after carrying something heavy — but less acute, more chronic, and pinching your temples “like a vice” (the descriptive cliché for a tension headache). The weirdest thing about it would be that, once the muscle is hurting, the pain spreads around the head a bit, via the mechanism of referral, just as it can spread from neck joints.68

But it probably does get a bit weirder still, and it’s not an accident that this chapter immediately follows the introduction to the idea of trigger points. Temporalis pain is probably not just a case of weary muscle tissue, but perhaps one that has developed little patches of more painful and stubborn dysfunction.

Either way, the state of the temporalis muscle is the main justification for massage, self-massage, and other trigger point therapies for headache. It’s also why mitigating stress/anxiety may be a critical treatment option.

The two big jaw muscles, temporalis & masseter.

The (modest) role of the other big jaw muscle: the masseter

The masseter is a thick, tough, rectangle of muscle spanning from the cheekbone to the jawline. It probably has less to do with tension headaches than temporalis, but it surely contributes, and also harbours a classic trigger point — the seventh of my “perfect spots” for massage, in fact, just under the cheekbone.

Practically everyone with a headache massages their temples, and practically no one rubs their cheeks, where the masseter lives… but perhaps we should. Masseter trouble can cause discomfort throughout the side of the face, ear, and the teeth — all of which could certainly contribute to a headache. Even without being specifically painful, it contributes to jaw tension just as much as the temporalis.

The (huge) role of the temporamandibular joint (and its dysfunctional habits)

Temporomandibular joint syndrome (TMJS) is a slow-motion failure of jaw joint function, strongly linked to habitual clenching and grinding (bruxism), leading to progressive pain and limited and awkward movement. The severity can range from trivial to debilitating, and is one of the classic chronic pain syndromes that can persist without few physical signs and no obvious cause. The worst cases interfere with eating and sleeping, and often involve ear aches and ringing as well.

And headaches most of all.

Chronic headaches and TMJD are not the same thing, but they go together as often as peanut butter and jam. People with serious TMJD almost always have chronic headaches — which really cinches up the link between jaw tightness and headache.69 Headache is more like a classic symptom of TMJD than a separate condition (comorbidity).

If we point the causal arrow the other way, it’s less clear that headache is linked to jaw trouble, because there are so many kinds of headache that have nothing to do with the jaw. Nevertheless, many people with chronic headache do have some degree of TMJD.

It’s unlikely that the jaw joint pain itself is to blame for headaches — not the way pain in upper neck joints can be experienced directly as a headache — but it probably contributes indirectly and even substantially. Thus TMJD treatment is a high priority for all headache sufferers — so high that I will be tackling that later in this guide (even though it’s a separate topic so large that there are entire books about it).

Just like cervicogenic headache

Headaches driven by the jaw are identical in spirit to cervicogenic headaches: both musculoskeletal sources of “head” pain that are close to the head. Only the specific mechanisms are different. Together they probably account for a huge pecentage of tension headaches, but the jaw is much more clearly responsible for the “tension” quality of so many tension headaches.

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This is about more exotic headaches that can still feel like an ordinary “tension” headache.

The discussion of cervicogenic headaches so far has been limited to bog standard neck problems: osteoarthritis and trigger points, mainly. Cruddy joints, cranky muscles. But if headaches can come from the neck, then virtually any neck problem has some potential to cause a headache. Indeed, painful joints and muscles may themselves be the result of more fundamental neck problems.

It would be impossible to review every neck problem that could conceivably cause a headache, but there are some interesting highlights to discuss. In the list of secondary headaches, I mentioned torn blood vessels in the neck, for instance — a serious medical issue, well known for its ability to cause a nasty, weird headache. But there are other neck problems that are primarily known as neck issues which nevertheless may drive headaches.

These conditions are the most obvious examples of neck conditions that are both non-rare and tricky to diagnose — and therefore the most useful to be aware of.

Trigger points, schmigger points: there are several other kinds of muscle injury and dysfunction

I focused on trigger points above because that idea is so common and it’s a half decent guess about how muscle pain might work. But it’s also the tip of an iceberg of other kinds of muscle distress. Many other seemingly muscular problems don’t fit the clinical definition of a trigger point — a sore spot associated with aching and stiffness — but aren’t an obvious physical injury either. There is a big “other muscle hijinks” category, which even exists as a semi-formal classification.70 There are also about a dozen major known types of unwanted muscle contractions (cramps, dystonia, myokemia, etc) that muddy the waters even more.

Here’s an example that is probably relevant to headaches: spasmodic torticollis (wry neck) is a disease of asymmetric slow neck spasm that can cause neck twisting and even deformity.71 It’s an obvious dysfunction of neck muscles that might well cause headaches, although we don’t have good data on that, just hints so far.72 People with milder cases “could have predominantly neck pain and headache.” We don’t know what causes this bizarre twisting, but it’s probably not trigger points.73

The clinical importance of unwanted contractions is not clear: are they actually painful? Without being the result of an obvious contraction? A calf cramp is painful, but that’s because it’s practically tearing itself off the bone. Maybe some less dramatic abnormal contractions can feel merely stiff and sore, but no one actually knows if there’s such a thing as a cramp that is both physically subtle and yet still painful.74

Or maybe I just described a trigger point!

Muscle dysfunction is both complex and relatively unstudied, and if it’s present in the neck it is definitely a candidate cause of headaches. Indeed, it might even be the mechanism by which some of the other problems discussed below actually cause headaches.

Cervical myodural bridges (CMB)

CMBs are an obscure anatomical feature of the neck: connective tissue links 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 a lot,75 like all anatomy.76

The clinical implications are unclear, but they surely exist.77 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,78 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 points79 — hard to tell the difference, unfortunately.

Tethered cord syndrome (TCS)

You know when your spinal cord sticks to the wall of your spinal canal? Just kinda snags? That is the worst. This condition is similar to CMB but more serious: the abnormal tugging is all the way inside the spinal canal, and the spinal cord is directly affected.

TCS is often described as a “rare” condition, and the more severe and obvious congenital versions certainly are. The prevalence of milder acquired TCS —cases caused by trauma, infection, etc — is just unknown, but is probably not so rare. Also, virtually all information about TCS concerns the lower spinal cord, not the neck, but upper cervical tethering may also be more clinically significant than is widely appreciated.

Just a hypothesis. This is the most “exotic” and speculative of the headache-causers discussed in this chapter. But it’s not all that far out in left field.

Chiari malformation

I take it back: your spinal cord snagging is not “the worst.” Surely the worst is when your brain bulges through the hole in the bottom of your skull! Despite how awful that sounds, the bulging can be fairly minor and the symptoms surprisingly subtle. Nevertheless, it’s not good, and in addition to a lot of bizarre systemic symptoms, most patients with this condition have irritable necks and plenty of headaches. Indeed, headache is the main symptom — primarily after coughing, sneezing, or straining. To be a sneaky headache cause, all you need is a mild enough case that headache is the only obvious symptom.

Is this really a “neck” problem? More than it’s a “head” problem. It’s as much about the brain stem as the brain. The action takes place right at the joint between neck and head, and the entire brain stem and upper spinal cord can be affected.

Positional cervical cord compression (PC3)

“Myelopathy” (an odd bit of jargon) is the result of spinal cord insult, which can be surprisingly subtle. It is hardest to diagnose when the irritation is intermittent and minor, as with PC3, which is the pinching of the spinal cord in specific positions only. This erratic and often slight irritation of the spinal cord can probably cause an astonishing variety of symptoms, of which headache could be the most obvious.

Atlantoaxial instability (AAI)

These are the first & second cervical vertebrae — the “atlas” & “axis” — with the peculiar finger-like projection of the axis (the “dens”). It sticks upwards into the ring of the atlas above it … & it shares that small space with the brain stem (red). It is normally strapped to the side of the ring by a tough ligament. But if that ligament loosens or breaks … 😬

A loose upper spine, AKA upper cervical instability, is a loss of the integrity of the joint between the top vertebrae of the cervical spine — called the “atlas” — and the one beneath it, the “axis.” The atlas spins around a weird finger-like post of bone that sticks upwards from the axis. That post, called the dens, is normally held in place by a strap of ligament, which is sometimes broken in accidents, or eroded and loosened by some kinds of arthritis, or by cancer. When someone with AAI moves his or her neck in just the wrong way (flexion), the dens can poke the brain stem, with consequences ranging from unpleasant to lethal.

I have had some interesting experiences with this condition in my career, and I tell some stories about it in a article dedicated to the topic: What Happened To My Barber? Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers.

As dramatic as all that sounds, many people with AAI lead normal lives, oblivious to their problem. They might have occasional unexplained episodes of malaise and disorientation, but they might not. The nervous system is probably well aware of the problem and is working hard to stabilize the upper neck with muscle tension and inhibition. That tension could explain serious chronic headaches, which might be the only obvious symptom. If your chronic headache problem is accompanied by occasional episodes of feeling suddenly very gross, then you should look into this.

Hung on a coat hanger: coat hanger pain and dysautonomia

“Coat hanger” pain is a triangular pattern of headache, neck, and upper shoulder pain. While this pattern of pain can occur for relatively trivial reasons, if it’s very strong and associated with standing up, then more serious causes should be suspected — nothing that’s an emergency, but more exotic, with general medical implications.

The coat hanger pattern is linked to an inability to sustain blood pressure when standing up (orthostatic or postural hypotension ❐), which in turn has many possible causes. Blood pressure is regulated by the autonomic nervous system, and many things can throw the ANS off kilter to varying degrees (dysautonomia), but it’s a common complication of spinal injuries,80 plus some of the other things discussed in this chapter.

If your headaches are caused by this phenomenon, you’ll have surges of symptoms when you stand up after lying down, especially lightheadedness. If you can get some relief by lying down, that’s even more diagnostically certain. And, lucky you, general malaise and fragility are also often part of this clinical picture.

Since the mechanism of pain is probably “just” a lack of blood flow to the muscles, anything that increases blood volume (and therefore pressure) is likely to be helpful: salt, fluids, compression stockings, exercise, and drugs. DysautonomiaInternational.org ❐ is a good source of more information about orthostatic hypertension.

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The neck is a serious place, and all of these conditions can involve some sinister, systemic effects (yet also surprisingly subtle). PC3, for instance, is found in many people with so-called “fibromyalgia.”81 That word is just a label for “unexplained chronic widespread pain,” so the actual diagnosis for these people might be “irritated spinal cord.”82

Another good example is the dramatic and troubling story of unlikely recovery from severe chronic fatigue syndrome by treating craniocervical instability and tethered cord syndrome.83 Like PC3, these neck problems that irritate spinal cords may well wreck a whole body. But for every case that goes way beyond chronic headaches, there are probably a dozen minor cases where headaches might be the only obvious symptom.

Of course, just having serious chronic headaches could well make a person exhausted, miserable, and quite under the weather. But a halo of malaise and some other odd symptoms might have greater significance. The headaches could be the tip of an iceberg of upper cervical distress.

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Nora has had headaches for about half her life now.

They started in her 20s: patches of headaches, nothing dire at first but annoyingly frequent, almost daily at times. Then, at age 26, she had her first migraine while living abroad. And then they kept coming too: once, twice, maybe three times per year ever since.

It might not have been a coincidence that, not long before, she’d hit her head a few times while trying to learn to snowboard on an icy slope. Or maybe it was a coincidence.

It wasn’t an ambiguous migraine diagnosis: intense nausea, and as intolerant of light as a vampire. In time she learned that she could stop them — if she takes gravol and ibuprofen soon enough, but if she can’t get to them in time she gets so nauseous that she can’t swallow them — and they might not work by then anyway.

Classic, awful migraine stuff.

But Nora kept right on having normal headaches too, roughly weekly, hundreds of headaches over the years, along with neck soreness that has gradually gotten worse and worse and often feels like it precedes a headache just as the headaches sometimes precede migraines. Most of her migraines do start out as tension headaches, and this is the most interesting thing about her story: this messy blend of tension headaches and migraines is a good example of the complex, overlapping nature of these two types of headaches. At times, both types of headaches seem to have features of the other, and it seems clear that her tension headaches can trigger her migraines.

That gravol/ibuprofen trick of Nora’s supports that theory. Those drugs do not typically work for migraines, but they might attenuate a bad tension headache enough to keep it from triggering a migraine.

Not much else is clear about her case, though. Over the years, not many meaningful patterns emerged. There have been only a few other obvious headache triggers: getting chilled, wind in the ears, and glaring sunshine. Looming menstruation often seems to trigger one.

The headaches run in her family a little, maybe. Nora’s mother has a similar story — and mostly recovered from them after menopause, a classic pattern, and punctuating the hormonal connection. And her younger sister has begun to suffer as well, only just recently.

Maybe depression and stress? During her stressful years as a school teacher, there certainly seemed to be more headaches. But briefer episodes of stress do not inevitably lead to her headaches.

Nothing else obviously helps either. She was warned about a “forward head posture” many years ago, but plenty of trying to stand up straight has not solved anything — which isn’t surprising (see the posture chapter). Many different kinds of pillows over the years have had no obvious benefit (and again, that’s not surprising). A new career has helped a little: these days she is living a mellower life as a massage therapist, and she gets fewer headaches than in her teaching days… but she still gets them.

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This isn’t a success story, just an interesting one. Success stories are hard to find! But if you have one — if you have wriggled free of a major chronic headache problem, and you think it might help other headache sufferers, please contact me. Interesting case studies without happy endings are always welcome too, of course.

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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.84

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 *#%!@^% 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.

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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.85 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.86 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 boot. 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.87

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:88

• “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 triggers 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.89 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.90

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.91 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 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 chapters zoom in on two other 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.

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Alcohol will come up again — like using it as a pseudo-muscle-relaxant, and of course its potential harms — and then there’s a whole small chapter about juggling all these perspectives.

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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,92 and the discussion is dominated by loud opinions.

Only one thing is certain: monosodium glutamate has been demonized for essentially racist reasons,93 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 of 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.

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We are drowning in myths about water and hydration, especially the fear that mild chronic dehydration insidiously undermines our health. It does not.94

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.95

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 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.97 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,98 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 — dehydration 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.

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Let’s get this out of the way first, because it’s super simple: some medications are just jerks, and directly cause headaches as a side-effect. The major examples are:

• medications that tinker with hormones, like birth control pills and hormone replacement therapy for menopause
• medicines for erectile dysfunction
• some heart and blood pressure medicines (mainly nitrates)
• some vitamins, most notably B-3 (AKA niacin), but also large doses of A and C

Several of these can be casually eliminated to see if your headaches improve. Others are a bigger deal, but still well worth bearing in mind. If you are taking birth control pills, and you’ve tried everything else you can imagine to get rid of stubborn headaches... it might be time for the bigger decision to take some time off from hormonal birth control.

And of course poisoning yourself with too much of anything can give you a headache. Although you will usually have bigger problems than a headache in that scenario, in a few cases headache might be the first and main symptom.

Medication-overuse headaches: pandemic or not?

Many medicines used to treat headaches, even ordinary over-the-counter pain killers, can paradoxically cause them when used too often.99 In other words, pain-killers can revive and prolong pain as well as kill it.

Medication-overuse headache (MOH) is not necessarily the back-stabbing villain everyone thinks it is. It’s widely believed to be a huge problem, causing trouble with as many as 70% of people with chronic headaches.100 This has resulted in some sensational headlines over the years, like “one million Britons have headaches from overusing pain-killers.” The truth is probably less dramatic. In a 2018 paper, Drs. Scher, Rizzoli, and Loder call MOH “an entrenched idea in need of scrutiny” and flag two major concerns:101

• “Evidence of cause and effect is weak. High-quality evidence supporting the existence of MOH is inherently difficult to obtain. A gold standard clinical trial would randomly assign individuals with episodic headaches to overuse or not overuse medication and compare rates of headache progression in the 2 groups. Such a study has not been done nor will it ever be done.”
• “Medication withdrawal does not help most patients with frequent headaches. Another line of evidence supporting the existence of MOH relates to treatment by withdrawing medications (sometimes referred to as detoxification). If MOH is reversible, then withdrawal of overused medications (alone) should improve headache frequency, yet the evidence it does so is weak.”

I will add another:

• We don’t exactly know how MOH works… which tends to be the case with phenomena that we’re not sure we’ve even described correctly. It’s hard to explain what you can’t even define. Although mostly presumed to be a withdrawal phenomenon, there are much more complex and obscure factors that are probably at play as well, such as sensitization and tinkering with brain chemistry.

MOH is a real phenomenon that every chronic headache patient should know about, but it might not be much of a pandemic. There’s a good chance it’s an unusual and minor factor in patients with chronic “tension” headaches. Or maybe it is a pandemic. I’ll explain the conventional wisdom, just in case, for the sake of at least a few people, or maybe a lot.

Medication-overuse headache: the basics

An MOH diagnosis officially requires:102

• A pre-existing primary headache disorder more than 14 days per month for more than 3 months.
• Caused by overuse of a medicine intended to treat the headache. (Not that anyone can actually know this!)

MOH used to be called rebound headaches, because they are presumably mostly caused by withdrawal physiology: after being medicated, they come right back and a bit worse. Whenever your body gets chemical help of any kind in feeling better, you will start to suffer a bit when the help runs out. This is physical dependence, not “addiction.”103 Overuse a pain-killer, and your body starts to rely on it — and not just the hard stuff. And then you can start to suffer without it, even just between doses.

You can end up in a bizarre vicious cycle, taking pain-killers to treat headache caused by withdrawal from pain-killers caused by taking pain-killers to treat headache caused by withdrawal from pain-killers caused by… and so on ad nauseam until your head explodes. 🤯

It sounds about as subtle as a tornado, but I actually suspect that this can go on for years without being all that obvious. The process only makes things a little worse with each turn of the cycle. A boiling-frog problem.

But MOHs don’t behave exactly as we’d expect if simple withdrawal physiology was the only explanation, which is why the name “rebound” was retired. It could still be about withdrawal in spirit, just with a complex dependency chain.104 And then there are other posssible explanations for why medication overuse could actually make headaches worse, but they are all quite speculative.

All of this applies to any kind of pain-killer, but also sleeping pills, and migraine drugs called triptans. Three scenarios that are probably worse, and all relatively unusual in people with non-migraines:

• combinations of multiple types of pain-killers
• opioids, of course, because they are strong drivers of physical dependency, (AKA super duper habit forming)
• triptans, a migraine medication

The next chapter is a personal “case study” that perfectly illustrates a caffeine withdrawal headache — which is a great model for how MOH works, as well as another good example of a cause of headaches from “medication” overuse.

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One day I developed an extraordinary headache. It was one of those can’t-wake-up days when even 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 — but it was certainly the worst 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.

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If you open your mouth wide, can you touch your upper teeth with your tongue?

If not, you might get diagnosed as “tongue-tied,” and warned that is causing your headaches (and/or TMJ pain, and/or neck pain). And so of course you also need tongue stretching exercises, if not surgery. To treat a tongue disability you didn’t even know you had!

What a load of bollocks.

This is an absurd new way to blame painful problems on subtle structural oddities in your body. Will they never end? No, they will not! Not as long as they are profitable. For a detailed discussion of this kind of diagnosis, see my article about structuralism. This is merely one more vivid example of “structuralism” running amok.

This is a healthy lingual frenulum, reaching all the way from the floor of a wide open jaw up to the upper teeth. No problemo. Of course, it would still be no problemo even if it couldn’t quite reach.

Tongue tied: legit versus exaggerated

Some people are indeed born with an abnormally short lingual frenulum, the tight strap of connective tissue under your tongue. This occasionally manifests as difficulty with breast feeding. If you say “tongue-tied” to a doctor (or “ankyloglossia,” if you can pronounce it), this what they will assume you’re talking about.

Frenulopathy is real, but if you got to adulthood without being aware of a problem with your tongue, it certainly isn’t going to be a problem elsewhere in your head. If you need to be told you have any problem with your frenulum, I promise you don’t have one. If you are being told that you are tongue-tied by a dentist or a chiropractor or a physical therapist, you aren’t.

I can easily imagine headaches and TMJ pain as a possible complication of legitimate untreated ankyloglossia, maybe, possibly… but patients who are actually tongue-tied are much more concerned about swallowing. The story here is that this diagnosis is being ridiculously applied to people who have little or no frenulum issue at all. “Pathologizing” healthy people. “Explaining” their headaches (which, as you now know, have literally dozens of other possible causes).

Skeptical dentist Grant Ritchey for Science-Based Medicine:

There has been a tremendous uptick of frenum related diagnoses, especially in the dental and ENT communities. Weekend training courses in surgical correction of these disorders are everywhere, often sponsored by laser companies who claim that these “profit centers” will increase the practitioners income and will help the fancy expensive laser “pay for itself”. It can seem that in these cases, the indication for surgical correction of a frenum is the presence of a frenum. While the risks of these procedures are very low, they aren’t zero and they aren’t cheap.

Is there any possibility that a subtle restriction in tongue movement could cause pain to spread through the head?

Later in the tutorial, I devote an entire chapter to how surprisingly subtle sources of physical stress can cause headaches, citing examples like hats, ponytails, and masks. If those can drive headaches, surely a tied tongue might also constitute a chronic stress?

I can’t rule it out entirely, but there are some major reasons why I’m a lot more concerned about ponytails than tongue ties:

1. I can easily imagine how obvious tongue stress and strain could be a headache trigger, but "obvious tongue stress" is extremely rare, and is almost certainly the primary concern in people who have it. Physical stressors that trigger headaches are usually obvious, even if you didn’t connect them with the headache, or underestimate the connection. But a tongue that you thought was fine? Extremely unlikely to be a problem.
2. The physical stresses that do trigger headaches tend to be more obviously and direct connected to the head. A connection between tongue and headache is not inconceivable, but it is (almost literally) more of a reach.
3. There’s are relatively easy solutions to the other physical stresses I discuss. A tied tongue is not. See next section.

And that’s all if I’m being rather open-minded about the concept of a subtly tight frenulum to begin with. Truthfully, I think it’s extremely implausible that the frenulum can be a problem in this way. Tissues and the nervous system are just too robustly adaptive over long time spans.

“Myofunctional” therapy and surgery for tied tongues

As always with these kinds of diagnoses, they are just a way to sell a “treatment.” The idea of subtle frenulopathy is mostly just a weird, actionable scapegoat. There are two main treatments recommended to these patients:

1. “Myofunctional therapy,” a hilariously pretentious name for … tongue workouts. Mostly stretching and reaching. “Drop and give me ten ice cream licks!” Trying to lengthen that frenulum. This is mostly harmless, but I seriously doubt it’s possible to lengthen the frenulum without strenuous effort, if at all. This is a ligament-like structure we are talking about here; it is tough). And a strenous effort might actually cause a headache. And there’s the time, money, and the mental detour.

2. Because the frenulum is super tough, another “action” often recommended is astonishingly reckless: cut the frenulum. Surgery. What could possibly go wrong? Lots!

What could go wrong

Cara Santa Maria did a great job covering this story for The Skeptics’ Guide to the Universe, episode #845. She tells the hair-raising tale of a woman who got nerve damage and scarring from her first frenulum cutting (frenectomy). That disaster actually restricted her tongue movement, making swallowing difficult.

She was then told by another professional that a second attempt was necessary to fix the consequences of the first… and the second attempt caused even more nerve damage, resulting in permanent loss of feeling in part of her tongue. From frying pan to fire, and from fire to gasoline on the fire.

Such nasty complications are undoubtedly rare, but having this happen to even a single person is unacceptable when both the “disease” and its “cure” are so dubious.

The moral of the story: do not trust stories about surprisingly subtle causes of your aches and pains. Especially when the solution is expensive or invasive.

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Before I dive into reviewing the treatment options, I’d like to respond to a common reader concern that I do too much “debunking,” and not enough telling you what works and exactly how to do it. Where is the road map to cure? The step-by-step action plan? The savvy exercise regimen that will make the pain stop?

But those things just don’t exist. Even if they did, prescribing a treatment “plan” in an article is out of the question, because every case really is different — that’s not just a platitude.

And for headache? I cannot think of any condition less likely to benefit from a one-size-fits-all treatment plan. Not even low back pain, as notoriously multifactorial as it is, comes anywhere close to the bewildering variety of possible causes. Headache is surely the king of idiosyncratic chronic pain conditions, as individual as a fingerprint.

No plan survives contact with the enemy.

Helmuth von Moltke the Elder

Historical perspective and the Age of Hype

The disappointing truth is that there is only a motley assortment of rather underwhelming options with complex pros and cons, but usually more “cons.” Hope sells, and there have always been people willing to sell it, and most of it is false hope — and they have much greater reach than ever before here in the Information Age.

Musculoskeletal medicine is surprisingly primitive. Medicine has always had bigger, scarier fish to fry than treating mere aches and pains and injuries, which were barely studied at all until the 1980s. Musculoskeletal medicine is a cocky teenager, just starting to come of age and figure out that it doesn’t know everything. Even sports medicine, with so much potential funding and relevance to occupational injuries, has been bizarrely slow to build its evidence base.

The trouble with pseudo-quackery: treatments that seem way more legit than they are

The most prominent problem in musculoskeletal medicine today is the prevalence of what I call “pseudo-quackery”: treatments that are about as sketchy as any old-timey snake oil, but seem modern and scientific and mainstream. A few classic examples: laser therapy, ultrasound, platelet-rich plasma, prolotherapy, nerve and muscle stimulation. But there are many more.

These disguised quackeries are actually based mainly on surprisingly stale tradition, speculation, and authority. They generate more false hopes and wasted time, energy, money, and harm than more traditional quackery because they are vastly more popular and very much part of mainstream medicine, or very friendly with it — even many hardened skeptics aren’t expecting snake oil when they go to see a physical therapist or an orthopaedic surgeon.

So musculoskeletal medicine is a minefield, and a lot of debunking just goes with the territory. But it doesn’t mean there’s no good news at all.

The good news

Despite all the debunking and disappointing evidence, I do indeed have positive things to say about several of the options. And you may save some time and money avoiding several others (or at least re-prioritizing them). You may even avoid the heartbreak of those that can do some harm. Knowing what not to do is half the battle, if not more! Understanding the topic well enough to prioritize the imperfect options is actually a huge win, the best you can realistically hope for.

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The “negativity” of ratiocination is a surprisingly big topic, often funny, and sometimes profound. I answer the accusation in more detail in a compilation of tales of outrageous hate mail, the ethics and tactics of debunking, what it’s like to (supposedly) be the #1 Public Enemy of Massage (a therapy everyone loves to love), and more:

And now, on with the treatment reviews and recommendations!

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What all of these suggestions have in common is that they are low-hanging fruit, the easiest factors to address that might make a difference (overlapping with some of the more detailed chapters 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, helmets, goggles, breathing masks, face shields, eye blinds, ponytails, headphones and so on — anything that puts pressure on the head has the potential to cause or aggravate headaches.106

It’s particularly noteworthy in 2020 that “personal protective equipment” — breathing masks and face shields, mainly — is almost certainly a concern for headache sufferers. And wearing PPE is less or not optional at all for millions of people for the foreseeable future. Although the only evidence of this factor is a small survey of nurses,107 it makes sense and is consistent with other evidence.

Ponytails? Oh, yes! They are indeed an extremely common cause of headaches, confirmed by a simple study in 2004,108 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.”109 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 built 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 evidence110 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.

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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.111 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 Matter? for much more information. I want you to beware of the real possibility of wasting time with this concern.

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?

There’s also the very special case of jaw “posture.” Arguably the habital clenching and grinding of the jaw is a kind of postural issue, and probably far more relevant to headache than any other postural concern. I’ll turn to that important topic now.

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As discussed thoroughly above, the jaw has a major role to play in headaches. Recap:

• Jaw clenching and grinding is a standard human reaction to stress and anxiety.
• The temporalis muscle specifically is the main muscle of interest; it’s bigger and higher on the head than most people realize.
• Temporomandibular joint syndrome (TMJS) is a common chronic pain condition and people who have it are much, much more likely to have headaches and migraines. No one knows exactly why.

TMJS is a huge topic — so huge and interesting that I’ve considered writing a book about it. It’s beyond the scope of this guide to do any more than summarize TMJS treatment options, but its link to headache is so strong that I have to do at least that. I believe it’s smart for most headache patients to treat their temporomandibular joints even if they don’t seem to have any jaw trouble, for two reasons:

1. Jaw trouble may be contributing to headache more than is obvious.
2. It’s a good idea to make sure it doesn’t become a problem. The only thing worse than a headache problem is a headache problem plus a jaw problem, and many people with headaches probably develop TMJD. Headaches may be a warning sign!

And so I will summarize the most important options — and maybe someday I will have an entire separate guide to recommend.

How to be good to your jaw (roughly in order of bang-for-buck)

• Avoid obvious sources of jaw stress and strain — mainly eating tough food. But another sneaky source of jaw strain is extreme or awkward neck and jaw positions, like leaning your jaw on your hand too much, or sleeping on your stomach and basically resting the weight of your head on your jaw.
• Light jaw exercise. Spend some time each day practicing painless, gentle jaw movements. This is just gentle, rhythmical stimulation as an antidote to chronic strain. These are “mobilizations” for your jaw. Very frequent, short mobilization sessions — 20 seconds at a time, three times an hour — may be particularly helpful for disrupting jaw tension, because it can be such a powerful habit.
• Massage your temporalis muscle mainly, but also the masseter, and anything else around the face and head that feels relaxing (like the scalp). But mainly the temporalis. Almost any style goes, as long as you’re not too aggressive: just do whatever feels nice. If you crave more intensity, work up to it over a week or two. And you can upgrade by focusing on the techniques of trigger point therapy.

• A simple jaw stretch based on a facial expression of surprise.

  Deliberate jaw relaxation. The most basic version of this is to just remind yourself (with a timer or countless other software options) to unclench your teeth. Behavioural training like this is tough to succeed at, but easy enough to chip away at. In another article about jaw tension, I describe some more advanced tips like “the long surprise” and “the fake drunk.”

• Generally relaxing rituals, where you have an opportunity to practice jaw relaxation while also chilling out in general. I don’t mean meditation, but it is an option. I’m talking about hot baths, 10 minutes of just lying quietly on the sofa listening to some music you love, or just 3 minutes of deep breathing… or whatever else sounds nice to you, just as long as it facilitates a few minutes of loosening your grip on your teeth in a context of general relaxation.
• Maybe a mouth guard, but not necessarily. This is a complicated topic: probably overprescribed, a little pricey, and not necessary harmless. But they are easy and probably worth a try for some patients. I’ll dig into this option more below.
• Anxiety and stress reduction. Treating the roots of jaw tension is all about one of the hardest things imaginable: reducing stress and anxiety in your life, which is an enormous topic and challenge. But the low-hanging fruits of anxiety treatment are: exercise, caffeine moderation, exercise, vigorous breathing exercises, and did I mention exercise? Notably, it’s not meditation. There’s more about stress/anxiety reduction for headache patients below, and a separate article about it.
• De-sensitize. For patients with significant TMJD, it’s hard but vital to try to mitigate the phenomenon of sensitization. Indeed, this may be a major common denominator in both TMJD and headache. All the ideas here can contribute to reducing sensitization, but for the jaw joint that has been hurting badly for a long time, more will probably be required. The fundamentals of sensitization treatment are basically a combination of avoidance and exposure: that is, you both avoid irritating your jaw and give it easy, healthy challenges. These concepts must be creatively applied to each individual patient. I discuss them more below and also in detail in a separate article about sensitization.

Mouth guards for clenching and grinding (bruxism)

Does anyone go to the dentist anymore and not get a prescription for one of these things? 😃 Judging by the inevitable prescriptions, apparently everyone has some kind of jaw-clenching problem… and a night guard is the solution.

I feel suspicious that mouth guards are over-prescribed, because they are probably too profitable for dentists to resist. (They also get sold to athletes with some kooky claims, like improving “strength, endurance and reaction time” and making you “faster, better, stronger.”112)

Does almost everyone really have a clenching/grinding problem? Quite a few of us do. The actual prevalance of bruxism is unknown but it’s probably at least 20% of the population, and probably not more than 40%.113 That’s based on generally lousy quality evidence, and much more dramatic claims have been made by some researchers. Regardless of the prevalance, many clenchers and grinders are probably unaware they are doing it.

Do mouth guards reduce clenching and grinding? This is the big “then a miracle occurs” step in this equation. People certainly grind, and jaw tension certainly causes headaches, but why do we think a mouth guard will help? The assumption most people make — unstated and untested, patients and pros alike — is that putting a piece of plastic between your teeth is soothing. There are two plausible reasons why that might be true:

1. It’s reassuringly secure. If the anatomy feels vulnerable enough, splinting may feel reassuring — like any kind of splint — and feeling safer is always good for tension and pain.
2. It’s protective. Splinting may limit movement and protect teeth enough to reduce discomfort, and less pain is always more relaxing.

But it’s hardly guaranteed, and there’s basically no research on any of this. If mouth guards reduce clenching and grinding, no one has ever demonstrated it in a controlled scientific test. And then there’s another possibility…

Could mouth guards backfire? Unfortunately, yes. The mouth is an intricate machine, and it’s easy to imagine that sticking a big chunk of plastic in it could be like throwing a wrench into the gears. People can and do clamp down just as hard on a mouth guard as they do on their own teeth. As with orthotics for your feet, it seems obvious that introducing a constraint on movement could temporarily or permanently make things worse. And there is evidence of this: “adverse occlusal effects … may be found to be more common than anticipated from existing literature.”114 Lovely. So there’s a reason for caution.

And there is at least one case study of a patient who developed migraines because of mouth guard use115 — oops!

Even if a guard fails to stop the clenching, it likely does at least protect the teeth — and strain on the teeth probably can contribute to jaw tension and headache both directly and indirectly. So you could argue that it’s worth doing for this reason alone.

I think the ideal candidate for a mouth guard is probably someone with teeth that are already in rough shape, where failure to protect the teeth from further damage is almost certainly a major risk.

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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, especially the temples (where the temporalis muscle is, a higher and bigger jaw muscle than most people realize). For lots of ideas about hydrotherapy, see Hydrotherapy, Water-Powered Rehab. For more about choosing between hot and cold, see Ice versus Heat for Pain and Injury.

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Exercise is good medicine for many musculoskeletal conditions, but attempts to prove a benefit for headaches specifically have been unimpressive.116 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.117 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).118 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),119 and begin with lots of pain-free range of motion and mobilizations. Mobilize your jaw as well as your neck — it may be just as beneficial, if not more so.

Progress to endurance exercises, and then finally strength training. Although you will probably need to be disciplined and patient, strength training is remarkably efficient.120

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 for Neck Pain: “Core” strengthening for the neck is even less evidence-based than core-strengthening for back pain.

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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 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.121

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

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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.122 But it certainly does seem to, and often surprisingly easily.123 All advice about trigger points on PainScience.com is based on “seeming” and scientific plausibility, which is weak sauce.124

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,125 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).

“Perfect spot” #1

A likely source of tension headaches.

• The temples are filled with the temporalis muscle, a jaw muscle, which is both larger and higher than most people realize, and probably the “elephant in the room” of direct causes of headache. (See the jaw chapter for more about that.)
• Although it’s probably never a 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 from other kinds of healthcare professionals. 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 Do Your Find Good Quality Massage Therapy?.
• 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.126 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 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 acupuncture127). 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,128 the science is has been discouraging for years,129 and then in 2020 a bit of a nail-in-coffin study for neck pain specifically (and headache by extension): good quality, relevant evidence that dry needling just does not have any clear benefit.130 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 Japanese 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.”131

Addressing other medical factors

There is one more major approach to trigger point therapy that is much more important: attempting 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 of a 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.

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by Gary Lyons

We established above that some headaches probably come from the neck, especially from some kind of trouble with the upper cervical joints. If that’s the case, would 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. In the best-case scenario, it might get a joint “un-stuck” and cure a stubborn headache problem. But those best cases are probably rare, if they exist at all. The scientific evidence is discouraging, and cervical SMT is also associated with substantial controversies and risks.

Redundancy warning: the discussions of subluxation and spinal manipulative therapy are extremely similar in three of my major guides: neck pain, low back pain, and headache. One key difference is the discussion of risks — SMT for the neck may involve rare but serious risks (paralysis, death), while the risks for back pain are much more common but also less severe (mainly pain exacerbation and scaring patients).

I debated whether or not to include this chapter, but it would be hard to justify leaving it out after so much focus on the idea that many headaches come from the neck. And not just from the neck, but from the facet joints in particular — the joints that “pop” during spinal manipulation. Very understandably, many readers want to know more about it.

What is spinal manipulative therapy?

The idea of “adjusting” the spine refers to many different manual therapies that wiggle, pop, and otherwise manipulate spinal joints. The term for all these kinds of treatments is “spinal manipulative therapy” or SMT. This is one of the most famous of all hands-on therapies and the foundation of the chiropractic profession, and it is strongly linked to the (previously mentioned) controversies associated with that profession. But they don’t have a monopoly on it, and physical therapists and osteopathic physicians are also SMT practitioners.

Expert opinions on the value of SMT range widely and many express strong concern and skepticism. SMT relies heavily on the dubious notion that spinal joints can be “out” (in some sense) in the first place, its benefits are probably minor at best, and it can occasionally backfire. Although the risks are unknown and serious harm is rare, the stakes are high: paralysis and death are actually possible (more below).

Despite all the controversy, there has been little high quality study of SMT. Major reviews of the scientific literature published have all ended with a “more study needed” whimper.

One of the best trials done so far was described in a 2012 paper in the Annals of Internal Medicine: a well-designed, large, 12-week trial.132 Athough SMT technically won, and so chiropractors like to cite this study, it also concludes with this thunder-stealing disclaimer:

… a few instructional sessions of home exercise with advice resulted in similar outcomes at most time points.

So … it costs vastly more and performs barely better than sending someone home to do a few simple exercises? Now that hurts! SMT is damned, damned, damned with extremely faint praise — as it always is, every time it does get studied well. Another good example of this comes from an unusually good quality 2016 test of SMT for migraine, which might theoretically help by treating irritation “triggers” in the cervical spine: it did help a tiny bit, by one way of reckoning, but it mostly had no benefit at all.133

SMT once again fails the “impress me” test: it might work a little, or better for rare patients, but it can’t possibly be good medicine for the average patient.

The science of SMT for tension headache specifically

It’s basically the same as the science for SMT in general. But my job is to be thorough. Just skip this chapter if you’re happy to accept that the evidence ranges from inconclusive to discouraging.

The absence of conclusive evidence itself is damning, because there really should be better science on this by now. Three recent-ish reviews (2004, 2006, 2011) are all sad clones of each other:134135136 small reviews of mostly poor quality trials, none of which clearly showed anything, which is fishy in itself.137

There is a single more recent trial of seemingly respectable quality and reasonably positive results — but less so if you check the fine print.138 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.139 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.”140

An encouraging word

Based on all of the above, it seems hard to recommend SMT… but I cannot bring myself to be completely negative about it.

Certainly spinal joint popping is a sensation that people seem to truly crave (whether there’s a good reason for the craving or not). And many clinicians — including myself, and more credible skeptics like chiropractor Sam Homola, DC — believe that judiciously applied SMT can probably be helpful to some patients, some of the time, because there is probably the odd person who benefits in a big way. If these people exist, it’s undoubtedly hard to identify them, and hard for their positive experience to be replicated in controlled tests.

In technical terms, I am conceding the distinct possibility that SMT for headache could be saved by “sub-grouping” — that is, there are specific groups of people that it may work very well for, and if you tested those people, you’d get a clear good-news result. This is a standard rebuttal to skepticism about many kinds of treatments; it can ring very hollow, and it’s unlikely that it’s valid in every case, let alone most.141

But it is probably true for some treatments. And if I had to bet on which ones, I’d bet on this one. It’s dangerously close to a hunch-based conclusion, but it’s what I sincerely think: it probably really does help some people. But not most.

If only it were safer!

Danger! Neck wrenching disasters are rare but they do happen

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.

Sam Homola, chiropractor, “Cervicogenic Headache and Cervical Spine Manipulation”142

Neck manipulation is very “What could possibly go wrong?” The potential for trouble is obvious: a clear hazard with an unknown risk (probably low, definitely not nil).143 The main hazards of SMT are:

• it can cause a stroke by tearing delicate blood vessels in the neck
• it can cause brain or spinal cord injury in people with upper cervical instability
• it can scare patients (which sounds like a minor hazard, but it shouldn’t be underestimated: fear is a major factor in chronic pain)

The danger is greater in patients with severe and unexplained neck pain and headaches — some of which have serious causes that make the neck more vulnerable!144 Many of these patients are also the most likely to desperately try a wide variety of treatment options, including more aggressive and frequent neck adjustments.

Minor but extremely unpleasant consequences are also possible,145 especially for patients with upper cervical instability (as described earlier in the cautionary tale about my barber).

An ominous example: Jason Davidson’s spine was severely injured by a physiotherapist who used “considerable” force “manipulating” his neck even after being asked to stop. This obviously incompetent treatment caused “severe acute injury … which had caused blood flow to the spinal cord to cease.” As previously mentioned,147 no manual therapy is totally safe, but the risks go up when “adjusting” the neck.

Unfortunately, even competent and cautious SMT could be a risk for vulnerable patients. Vulnerability that is rarely obvious!

The dangers are controversial. Is there enough of a risk to be concerned about? Even if it’s low, is any risk acceptable, considering the high stakes? Life is full of risky things that we do for the sake of the benefits, like driving a car to work every day. But the benefits of SMT are unclear and probably minor at best!

I don’t think anyone should get their neck “adjusted” without some understanding of these issues. While the risk of harm is formally unknown — there’s not enough data — that’s not because it’s implausible or unlikely, but simply because it’s hard to study and bad outcomes are almost certainly under-reported.148

Upper cervical chiropractic

A major sub-category of chiropractic focusses on exaggerating the medical importance of the uppermost joints of the spine, and manipulating mainly those joints only. While those joints may be relevant to headache, this therapeutic approach as a school of thought is too sketchy to take seriously. Consumers should steer clear of this “sect” of chiropractors. I discuss it again at the end of the tutorial in the hall of treatment shame.

•

The topic of spinal manipulative therapy, including the different safety concerns for both low back and neck pain, is explored in a separate article (a particularly detailed one):

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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.

Over-the-counter (OTC) pain killers are somewhat effective in moderation, and they are all about equally useful for acute injury pain,150 but benefits vary between people and issues, and they have their own substantial risks, particularly the anti-inflammatories. Beware of taking any of them for long — risks go up over time, and they can even backfire and cause pain, specifically rebound headaches.

Obviously that complication is of special concern to headache patients, so more on this below.

Acetaminophen/paracetamol (Tylenol) is good for fever and pain, and is one of the safest of all drugs at recommended dosages, but overdose can badly hurt livers151 and it doesn’t work especially well for a lot of common musculoskeletal pains.152

The non-steroidal anti-inflammatory drugs (NSAIDs, Aspirin, ibuprofen, Advil, etc) may be a better bet …153 They reduce inflammation as well as pain and fever. Unfortunately, at any dose they can cause heart attacks and strokes154 and they are “gut burners”155 — they can badly irritate the GI tract, even taken with food, and especially with booze. Aspirin is usually best for joint and muscle pain, but it’s the most gut-burninating of them all.

Voltaren is an ointment NSAID, generally much safer because it involves a smaller dose only where you need it. It’s by far the best option for any minor, superficial musculoskeletal pain.156

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.157158159 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, not 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.

The best thing you can do with OTC pain-killers might be to stop taking them

“Rebound headaches” are caused by withdrawal from headache medications, basically. See the medication-overuse headache (MOH) chapter for more information. This is a topic recap in the form of a treatment recommendation.

This phenomenon is a major concern for everyone who uses these medications, but you might be willing to tolerate some headaches for the sake of, say, reduction of a nasty chronic knee pain. But if headaches are your problem in the first place? Deal-breaker! Ain’t nobody got time for that.

For headache patients, it’s critical to be aware of this ironic risk. Either you shouldn’t use any pain killer long-term at all, or you should at least be aware of the danger. Even if you’re vigilant, the problem could sneak up on you. The original cause of your headaches can fade away while medication overuse takes over and becomes the new main cause.

MOH is more likely to happen and to be worse with combinations of drugs, with more potent drugs like opioids, and with triptans (migraine drugs)… but it’s still possible even with humble over-the-counter pain killers. If you are already taking any of these drugs regularly, and you have been for a while, one of your first self-treatment experiments should be to stop taking them.

And just a reminder that some common drugs, especially birth control pills, can cause headaches as a side effect. See the MOH chapter for more information.

Another solid option: switch to an ointment

An anti-inflammatory medication in an ointment (Voltaren) is a particularly good use of OTC pain-killers for unexplained headaches. As discussed extensively above, many headaches are probably caused by trouble in cervical spinal joints and muscles (which may or may not be “inflammatory” in nature). And that trouble may be more effectively and safely treated by absorbing medication only right where it counts.

Trying a little Voltaren on your upper neck and under the back of your skull is a high-potential, inexpensive, safe treatment option.

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Photo by Jose Luis Sanchez Pereyra on Unsplash

Perhaps the most interesting & controversial plant in the world.

Cannabis is a plant, most notably marijuana (bred for its narcotic effects) and the major strain of hemp (bred for other purposes). It’s one of the most interesting plants in the world because it produces chemicals with interesting effects, the cannabinoids. The most interesting and famous of those are THC (tetrahydrocannabinol) and CBD (cannabidiol). All cannabis contains THC, CBD, and hundreds of other related compounds, but there’s a lot more THC in marijuana plants, and a lot more CBD in hemp.

THC gets you high (psychoactive effects), and CBD does not. Both are alleged to be pain killers: it’s their most popular medicinal use (either that or as a sleep aid), but CBD is much less studied.

The evidence for pain-killing

So, are cannabinoids effective pain killers? “It’s complicated”!

As a science journalist, I am honour bound to emphasize that cannabinoids are not proven pain-killers. “Proof” is a high bar that has not yet been cleared. A huge 2017 review of the scientific literature on cannabis concluded that there is “substantial evidence that cannabis is an effective treatment for chronic pain in adults.”160 But the review also explains that the evidence shows only modest benefits so far, there is uncertainty about every detail, and significant practical problems abound for both researchers and consumers.

And that was hardly the last or only word. Other reviews of largely the same evidence have been much less optimistic. In 2017, Nugent et al looked at 27 scientific trials of cannabis for chronic pain trials, and it was disappointing: weakly positive for neuropathic pain, and just inconclusive otherwise.161 In 2019, Häuser et al wrote “Cannabis medicines can be regarded to be third-line therapy for chronic neuropathic pain. There are signals of a lack of efficacy for all other chronic pain syndromes.”162

So that’s not great.

Can getting high help? The role of psychotropic effects in treating headache

THC might have some bonus effects for some patients because it can cause euphoria, reduce anxiety, improve sleep, and therefore (at the least) indirectly function as a muscle relaxant, all of which is potentially relevant to a problem that is probably often partly or entirely caused by tension. It’s probably not a potent muscle relaxant, but nothing else is either (nothing you want to take regularly anyway). More about that in the muscle relaxant chapter.

At the most? These effects may have some potential to help you cope with pain… and maybe there’s even something about pleasantly tinkering with consciousness that can be directly relevant. I don’t really want to suggest that headaches are a manifestation of mental state, and therefore might be treated by improving mental state… but… maybe. I apologize for playing the hunch card (I try to avoid that), but I do have a hunch there is something to this: a lifetime of headaches, many years of getting high, a lot of personal and professional experience with chronic pain… I cannot dismiss the possibility that a seriously altered mental state can be relevant to a headache.

And it could also backfire. Please do be aware that THC can cause anxiety just as easily as it can reduce it. Your mileage will vary. And there’s nothing relaxing about anxiety!

Usage guidelines for beginners

If you’re new to marijuana, there’s a bit of a learning curve. Here are some tips:

• Pure topical CBD creams and oils are overall the safest and most convenient, so they should probably be your first priority to try. THC may be where it’s at, but it’s harder to use…
• Use caution with THC edibles! Dosing and duration of effect are huge wildcards. You can get way, way too high for comfort — not very dangerous, but scary.
• Avoid vaporizers that use oil infused with cannabinoids, due to scandalous, tragic safety issues because asshole manufacturers have added other dangerous, un-tested substances163. Dozens of people died in 2019. Died!
• Infused oils aside, vaping raw cannabis in moderation is quite safe.164 Just take it easy for at least your first three times — just one or two modest inhalations of vapour is just fine to start.

For more detailed information, see Marijuana for Pain.

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“Muscle relaxant” is an odd category of drug. There are several drugs that are relaxing, but are not exactly “muscle relaxants” because they are not specifically interfering with the biology of muscle contraction. A true muscle relaxant is essentially a poison that messes directly with muscle physiology.

You really don’t want too much of a true muscle relaxant. It can cross into paralysis. Amazonians used a muscle relaxant … on their poison arrows. Curare poison relaxes you to death. European explorers encountered the stuff early in their visits to North America, and it led to some of the earliest scientific studies in pharmacology.

And yet, on the other hand, it’s not clear that the muscle relaxant drugs are actually interfering with muscle contraction! So it’s a tricky topic.

Muscle relaxants and headache

As with many other treatment options discussed in this book, this one is mostly only relevant to headache that might be basically muscle pain around the head and neck. If that’s a valid hypothesis, and if muscle relaxants work, then they should be a useful treatment for that kind of headache. But those are substantial “ifs.”

If your headache has some other cause, then even an extremely potent muscle relaxant is not going to make any difference. You could paralyze those muscles, and your headache would march on.

For headache caused by tightness, however, a muscle relaxant is an intriguing idea with some potential. In principle, it could even be used to actually diagnose muscle tension as the cause of the headache: to the extent that a muscle relaxant helps your headache, it isolates uncomfortable muscular contraction (of some kind) as a cause or complication.

Muscle relaxant primer

Muscle relaxants come in many related varieties,165 but only one that is widely available without a prescription: methocarbamol, as found in Robaxin, Robaxacet, and similar brand names.

There are also several prescription muscle relaxants, obscure to most patients, but most notably carisoprodol (Soma), cyclobenzaprine (Flexeril), metaxalone (Skelaxin).

All muscle relaxants are tame cousins of the truly potent sedatives (also discussed below), and can cause significant drowsiness, dizziness, and a laundry list of other common side effects, but there’s also a surprisingly wide range of safe dosage (hard to overdose).

Methocarbamol and friends are not widely used because they are not super effective. It’s probably because they’ve been around forever, because the drowsiness they cause makes them feel more potent than they actually are, and because relaxing muscles just seems like such a good idea to literally everyone, both patients and pros. I think perhaps muscle relaxants have been grandfathered into modern, scientific medicine. Tradition-based medicine, rather than evidence-based medicine.

Muscle relaxants are surprisingly unstudied, like many other popular drugs.166 In particular, good luck finding any study of the effect of these drugs on muscle function. It’s not clear if muscle relaxants actually relax muscles, or if they just make us feel more relaxed.

What evidence we do have is not exactly high quality.167168169

An expert of my acquaintance thinks they are useless specifically at low dosages.170

Acute back pain is the only condition for which there is adequate data. Some muscle relaxants (including methocarbamol) do appear to be roughly as effective for acute back pain as common over-the-counter pain killers171172 — so they can help, but not all that much, and with great potential for side effects. It’s also damning that there doesn’t seem to be much difference between muscle relaxants: “Comparison studies have not shown one skeletal muscle relaxant to be superior to another.”173 So we have a class of drugs that shows little sign of effect, no matter which flavour you use. Whoop-de-do!

Even a prescription muscle relaxant like carisoprodol (Soma) is so impotent that patients will (this is bizarre) actually tense up if they are lied to and told that the drug is a stimulant.174 (The study was quite interesting — if you only read one footnote about a study in this book, this would be a good one to choose.) Clearly the brain is the boss of your muscle tone, and the drugs only nudge us towards relaxation. Bear this fun fact in mind for the discussion of alcohol and other psychoactive drugs coming up — it’s a ray of hope.

And here’s another fun fact: even anasthesia doesn’t truly “relax” muscle.175 It stops voluntary contraction, but it doesn’t eliminate muscle tone. Only death does that, and even in that extreme case the tenacity of the contractile proteins is demonstrated in the phenomenon of rigor mortis.176

Muscle relaxants clearly work at least a little for some people, some of the time, probably usually at higher doses. And they are relatively safe to experiment with, even at higher dosages. In fact, it’s so hard to overdose on them that I even feel comfortable endorsing cautious testing of a larger dosage than what’s recommended on the box. Just don’t go driving, don’t combine with alcohol, and be alert for significant side effects — they aren’t effective enough to bother with if they harass you with side effects.

Narcotic “muscle relaxants” (sedatives like Valium)

If our goal is to loosen up tense muscles that might be causing headache, is there any drug at all that will definitely do the job? Any drug that’s reasonably accessible?

Narcotic sedatives, mainly the benzodiazepenes, relax everything. Like the opioids, the benzos are another “nuclear option” — they do interfere with muscle contraction, while also interfering with everything else: like consciousness! Many drugs have highly unpredictable effects, but the benzos are as potent and predictable as cobra venom.

The most famous of all the sedatives is diazepam, AKA Valium, a benzodiazepene. But it is only the most infamous member of a family of rogues, like Klonopin, Ativan, and Xanax.

Just because they are potent — and they certainly are that — does not mean they actually work, or that they work by relaxing muscles. A 2017 study showed that “Diazepam Is No Better Than Placebo When Added to Naproxen for Acute Low Back Pain” (they put the result right into the title).177 However, I suspect that the your-mileage-may-vary factor is huge with these drugs.

As with the milder muscle relaxants, it’s surprisingly unclear whether or not these drugs actually reduce muscle tone, or whether they achieve relaxation indirectly via their potent sedative and psychoactive effects. Those psychoactive effects are a huge wildcard that could account for a wide range of responses. They are primarily used to relieve anxiety and improve sleep, both of which could easily relieve pain on their own.

I don’t think there’s any question that benzos might be a useful tool for treating headache. It seems worth at least considering this treatment option, despite the hazards… which are a big deal.

Benzos really do involve dire risks of physical dependence and addiction, and withdrawal can be nightmarish, dangerous, and even lethal at the extremes. Although it is possible to take and stop taking benzos safely, many people do not get the information and help they need for that. Sadly, I have extensive personal experience with benzo withdrawal, and I’ve written about that in detail.178

However, benzos can be safe if used in moderation for short periods only. They are a dangerous tool, like a gun, which must be respected and used with great caution. If you’re interested in dancing with this devil, don’t just ask your doctor for a prescription: make a point of showing your prudence by asking for only a 2-week supply of a small dosage only (the exact amount varies with the specific drug).179

The curious case of alcohol as a pseudo-muscle-relaxant

Alcohol might be a headache trigger — but perhaps not as much as people think (previously discussed). And it could be a headache treatment.

Alcohol is hard on your system in many ways, and yet there’s also plenty to be said for a glass of wine or beer as a kind of medicine. Anecdotally, moderate usage seems useful for taking the edge off nearly any kind of pain. This may be because it’s functioning as a kind of muscle relaxant, or at least as a general sedative.

Let me be clear: alcohol is not a muscle relaxant per se,180 not in a biochemical sense (and warning: it also combines dangerously with actual muscle relaxants and sedatives). In a world full of alcoholism and drug addiction, obviously a “prescription” of alcohol has to be offered and taken rather cautiously. But it is highly accessible, cheap, relatively harmless in moderation, and it’s a psychoactive drug — and anything that bends your mind has the potential to be a mild, obliquely effective muscle relaxant.

All psychoactive drugs — anti-depressants, alcohol, marijuana, amphetamines, opioids, benzodiazepines — often seem to help almost any problem, but the emphasis is on seem, because they mainly affect mood: “It is my impression that ‘pain-killing’ drugs improve the patient’s mood rather than take away the pain.” (Sarno)

Mood isn’t nothing. If you are genuinely happy and relaxed… if that’s something alcohol can do for you…

THC as a pseudo-muscle-relaxant

Tetrahydrocannabinol (THC) is the most famous cannabinoid produced by cannabis (marijuana). It is another relatively safe and accessible psychoactive drug, probably the only other one that seems tame enough to take seriously for this purpose. (Sure, you could blow your mind with acid or ecstasy and hope for a muscle relaxant effect, but that seems like overkill.) Obviously its accessibility varies widely from place to place as the entire world grapples slowly and awkwardly with legalization.

Like alcohol, THC doesn’t zap muscle tone directly, but it probably can do it indirectly and erratically.

If you are happy and relaxed while stoned, it’s certainly possible that tension headaches will get … less tense! Whether it can meaningfully affect the kind of tension that might be causing headaches is anybody’s guess, but it seems worth trying.

For this purpose, virtually any strain of marijuana will do, but ideally a THC-rich one (not CBD) because you want the psychoactive effects. Whee!

With pot, there is also the added potential for direct pain relief (discussed above, along with usage guidelines).

And so I do tentatively recommend THC as another “muscle relaxant” worth experimenting with.

Botox?

Botox is the infamous face-paralyzing drug of the stars! Although it has been called a potent muscle relaxant, it’s a special case, quite different from the other muscle relaxants. Like curare on poison arrows, Botox is outrageously toxic and doesn’t so much “relax” muscles but just outright paralyzes them, even in small doses. It’s obviously related to muscle relaxants, but it’s a separate topic with its own chapter.

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