Have you ever felt the aching, throbbing pain of a headache? The term headache describes it so well. A literal ache in and around your head. It feels like a bomb exploded in your brain and gives a sharp jab of pain that makes you want to clutch your head often. Headache disorders affect approximately 40% of the world’s population. That is almost half of all people in the world. It’s a disruptive type of pain that limits your ability to concentrate. This leads to small irritations, like forgetting your lunch, or big mistakes, like adding an extra zero to a price or measurement. There are many different types of headaches, but all affect your mood and patience. So, stop snapping at your colleagues and family and discover if you are suffering from a headache that can be relieved with treatment. Tension-type headaches, migraines, and cervicogenic headaches can all benefit from physiotherapy headache treatment.

Headaches are complex painful experiences and have many causes. Understanding the anatomy of different structures in your head and neck will explain it better.

The brain is the centre of pain

It seems logical to think that all headaches must be pain coming from your brain. All the nerves in your body come together in your brain and your brain has to process all the incoming and outgoing messages to and from your body. But, even though your brain is mostly made up of nerve tissue, it does not have any nerves sensitive to pain. So, that means that your brain itself cannot actually feel pain. Everything around your brain is very sensitive to pain and headaches typically start there.

Meninges

Your brain is covered with three layers of membranes called meninges. There is fluid between these membranes to help protect the brain and give nutrients to it. So, in essence, your brain is floating inside your skull. The meninges can feel pain and are very sensitive to changes in the fluid pressure around your brain.

Blood supply and blood pressure

A few big and important arteries carry blood from your heart to your brain. Your brain is one of the organs in your body that needs the most oxygen. Blood vessels form a layer around your brain and a specific blood pressure level needs to be maintained for your brain to function. Increased blood pressure can put increased pressure on the brain, which leads to pain.

Nerves

Even though your brain is one big bundle of nerves, it connects to the cranial nerves (important nerves found around your brain) and spinal cord. Cranial nerves supply things like your eyes, ears, tongue, skin, and throat. Giving your senses the ability to observe the world around you. Your spinal cord runs down your neck and the rest of your spine and from here nerves run to your arms and legs. These nerves can feel pain and are sensitive to pressure.

Neck joints

Your neck connects to your head and consists of 7 vertebrae (neck bones). These bones form joints between them, allowing your neck to move and turn. The neck bones also carry your head, keeping it stable, as it is quite heavy. The top two vertebrae carry the most weight and are specially formed to cradle your head.

Muscles

Several layers of muscles connect your head, neck, and shoulders. Some muscles are big and can help to move your head in almost any direction. Others are smaller and found deep in between the neck joints. These help to stabilise the head and neck.

Head

You can almost think of your head as the headquarters of the body. It houses your brain and keeps it safe. This is where the messages are received and decisions made.  Your ability to see, smell, taste, and hear comes from your brain. As well as your ability to think, concentrate and remember. That’s just to name a few.

Neck

Your neck has the important task of moving your head around. This way you can see, hear, and experience the world around you. Your neck also gives your head a stable foundation. Keep in mind that your head is almost 8% of your total body weight. So, something needs to keep that weight in place.

Headaches interfere with everything

A headache disrupts the way that headquarters should operate. Suddenly, your ability to concentrate and make decisions becomes impaired. Your senses become overwhelmed and you want to turn your head away from bright light and loud noise. Even your neck feels weaker and your head feels heavier.

The day starts like any other day. You have lots of work to do and before you know it, you’ve sat behind your computer for too many hours. A pressured feeling starts to build up in your head and you can feel the tension in your jaw. You take a break and try to shake the feeling. But, by the end of the day, you have a full-blown headache and you can not think of anything else.

You hope that a good night’s rest will help, but the next morning you wake up feeling worse. Now, your neck feels incredibly stiff and you can’t look over your shoulders or see the blindspots when you drive. The headache itself feels like an intense band of pressure around your head and your vision feels blurry and you feel nauseous.

It often starts with tension

What most people don’t realise, is sitting in front of a desk or computer is often a big cause of headaches. Looking down and sitting still for many hours every day requires your neck to work extremely hard to keep your head up. Add stress (which most people experience every day) into the picture and you have a perfect recipe for a headache.

Since your brain itself cannot feel pain, something else triggers the headache. It starts with tension of the muscles around your neck, shoulders, and jaw. They become overworked and strained from stabilising your head for too long. This puts pressure on your neck and TMJ (jaw) joints. It leads to extra strain and traction on nerves and the pain-sensitive membranes around your brain. Once these pain sensors have been triggered, it causes a headache.

With time, it causes an inflammation response in and around the nerve, joint, and muscle tissue. This leads to extra stiffness and muscle spasms.

Headaches are classified into two main groups:

1. A primary headache is a non-threatening, recurring headache not caused by an underlying disease. 90% of all headaches are primary headaches. 
2. A secondary headache is caused by underlying pathology (disease or structural issues). This means the headache is a symptom of something else.

Causes of primary headaches

• Tension
• Stress/anxiety
• Strenuous exercise
• Lack of sleep
• Alcohol
• Smoke
• Processed foods
• Poor posture
• Caffeine
• Skipped meals
• Changes in hormones

Causes of secondary headaches

• Cervigogenic (neck) injuries referring pain into your head
• Concussion
• Sinusitis
• Ear infections
• Tooth infections
• Meningitis (infection around the membranes of the brain)
• Influenza
• Medication overdose
• Stroke
• Spinal fluid leak
• Brain tumor
• Brain aneurysms (bleeding)
• Hypertension (high blood pressure)

• Caused by tension and stress
• Most common type of headache
• Tight band of pain around your head
• Feeling of pressure
• Tightness and spasms in neck and shoulder muscles
• Lasts for hours or days
• Can easily re-occur and become a chronic problem
• Other triggers include a lack of sleep, poor head and neck posture, long hours of work

• Pulsating, throbbing pain
• Mostly on one side of your head and face
• Accompanied by nausea and vomiting
• Extremely sensitive to light and sound
• Blurred vision or seeing spots
• Aware of an aura before the migraine starts
• Can be caused by genetic factors
• Other triggers include hormonal changes, alcohol, smoke, caffeine, stress, overtiredness, food and additives

• Headache and pain referred from the neck
• Typically pain at the back of the head
• Can spread into one side of the head
• Caused by degeneration in the neck joints (or arthritis)
• Previous neck injuries (like whiplash) can trigger it
• Neck pain and stiffness
• Movements like turning your head are limited
• Often improves when you rest your neck
• Worsens with neck movements and posture

Intensity

The most obvious way to measure a headache is to ask: “How bad is your pain?” If it isn’t an intense headache it might feel like an irritating niggle. Whereas, a fierce headache could feel like an explosion inside your head. Constant, unrelenting pain that leaves you feeling hopeless. The pain scale is helpful to measure the intensity of someone’s pain. Can you score your pain out of 10? It can be tricky, but no one else can experience your pain, so it is important to measure it in some way.

Frequency

How often do you have a headache? An important question to ask yourself. A headache now and then is very different from a headache every week or every few days. Maybe you are getting headaches more regularly than before. That is a good enough reason to investigate why it is getting worse.

Limitations

A headache can limit you from living life in various ways. Some people can push through and continue with daily life, even though they have a niggling headache. Whereas, others can only manage by lying in a quiet, dark room, wishing sleep would take the headache away. It can limit you from exercising, socialising, working, concentrating, or even worse, from sleeping. Usually, the worse the headache gets and the longer you struggle with it, the more it pulls you down.

Need for pain medication

There’s a big difference between taking one pain tablet to relieve your headache versus taking handfuls of pills. Some headaches go away with a good night’s rest, whereas others need medication to fall asleep and stay asleep. If you realize that you need more and more medication to treat the headaches and the tension, it’s time to make a change. Simply taking stronger medication is not the solution.

As physiotherapists, we are expertly trained to distinguish between different causes of your headaches. It is frustrating if you can’t find long-lasting relief for your recurring headaches. That’s where we come in. We guide you through the process of finding and understanding possible triggers for your headaches.

You can expect a lot of questions in your first consultation. We must get as much information about your history of headaches, your health, and your symptoms. Next, we test the structures in your head and neck that could contribute to a headache. This includes joints, muscles, nerves, ligaments, vascular and vestibular systems. It helps us to determine whether your headaches/migraines are caused by tension or cervicogenic (neck) joints. This will make your treatment much more effective.

Please take into account that stressing the structures may aggravate your headache initially. This feels bad but is not a bad sign. It means we found the structures that trigger your pain and can treat it. Every patient is different and we give our best to find what works for you.

X-rays show the integrity and alignment of the joints in your spine. It enables us to see signs of degeneration, loss of disc space, or postural changes. X-rays are not effective in diagnosing problems with muscles, ligaments, nerves, or other soft tissue.

Your physiotherapist can refer you to get x-rays taken if necessary.

Diagnostic ultrasound (sonar) can be used to show the presence of muscle tears, strains, or spasms. It is also effective to show areas of inflammation and swelling. Sonar is not a typical investigation for headaches, but your physiotherapist will refer you if necessary.

An MRI scan can image all the structures in your head and neck, including your brain, neck joints, discs, nerves, muscles, and bones. As well as areas of swelling, pressure or even bleeding. However, this is a very expensive scan and you need to be referred by a specialist doctor to get one taken. It is not necessary to go for an MRI right from the start. Your physiotherapist can help determine whether you need to be referred to a specialist for further tests.

Putting a small plaster on a big problem

It might start with a couple of headaches and spread out over time. It barely bothers you. But, if it worsens to chronic, recurring headaches, that is no joke. It is no way to live. Hiding in a dark room, unable to work or feel like yourself. But, hope returns once the headache passes. You feel like yourself again and forget about the way these headaches disable you from living life.

If you do nothing and hope the headaches go away, you are taking one step forward and two steps back. You need to dig deep, find the root of the problem, and start there. It takes hard work, but will be worth your while if you can feel relief from the pain.

Long-term pain leads to changes

It’s a slow process, but recurring headaches can lead to physical changes in your body. Your posture becomes more stooped with your head feeling heavy all the time. Muscles decondition and become shorter and tighter. Joints become increasingly stiff. More pain leads to more tension and stress in your body. It leads to chronic increased inflammation levels in your body. Your health starts to take the backseat. Chronic pain also leads to mood changes like depression and anxiety. Soon, the fear that you might get a headache will be enough for you to change your lifestyle, to avoid socialising or exercising, or doing things you used to love.

As you can see, this vicious cycle is something to avoid.

Expecting a quick fix and a magic solution

Recurring headaches make you feel desperate for relief and understandably so. Unfortunately, people grasp at any kind of headache treatment marketed as a ‘quick fix’. The sad news is that there is no magic solution to take away your chronic headaches. What works for one person, might not work for the next. The good news is that you can get help. It takes hard work and effort to understand your headaches and figure out what combination of treatment will be appropriate. You will need more than one treatment session of any type of treatment if you want a permanent change.

Relying on too much medication

Medication can be a handy tool to treat pain, but should always be used with discretion. It is not normal to take pain medication daily without a diagnosis or chronic prescription. Even chronic prescriptions need to be revised and changed over time. So many people rely on handfuls of medication as a treatment for their headaches. The more you take, the more you need. With time, you need stronger medication to make a difference and the side effects of this are alarming. It can range from gastrointestinal problems, like stomach ulcers, to kidney and liver problems. You can even get a headache from the withdrawal of pain medication.

Not addressing root causes of your headaches

Most people can easily identify a few things that trigger their headaches. If you have suffered from many headaches, you start to pick up a few patterns of your pain. Often, it includes things like stress, lack of sleep, screen time, dehydration, or caffeine. The real question is: what did you do to try and change it? 

Take stress as an example. We all experience daily stress. Some days more than others. Stress isn’t always a bad thing. It can motivate us to reach goals and work under pressure. But, it is a well-known fact that high levels of long-term stress have negative effects on your health and mental well-being. If you know that stress and tension often trigger your headaches, you need to take action. Unfortunately, no one can eliminate stress from your life altogether. And no one can change your working hours or need for caffeine to stay awake. Only you can make the change to prioritize sleep, drink more water, and turn your computer off. Any other treatment for your tension headache will feel ineffective if you don’t address ALL the causes.

Getting too many opinions and not following through with it

These days it is so easy to read up online about headache treatment. And since so many people suffer from headaches, you can ask almost anyone for an opinion. One person might say that their headaches cleared up when they got their eyes tested. Another might say they had to change their diet, like cutting out caffeine or sugary treats. However, these online sources and people with well-meant advice have no idea about the extent or severity of your headaches.

Many people get frustrated with the medical process of identifying and treating the causes of their headaches and give up altogether. If you’ve seen a doctor, physiotherapist, optometrist, or any other medical professional about your headaches, you need to commit to the treatment process. 

There are steps to success when we treat your headaches. After helping to identify the causes of your headaches, we aim to gradually lessen the intensity, duration, and frequency of how often they strike. A change in any of these characteristics is a win, however small the change. As physiotherapists, we guide you through the treatment process step by step. Our aim is always to give you the best and long-term relief.

Physiotherapy treatment will focus on muscles, joints, nerves, discs, ligaments, and tendons. Your headache treatment experience will differ from someone else and will take time. But, we are committed to walking the road with you. Your response to treatment will guide the process.

Physiotherapy treatment includes:

• Soft tissue release through massage or dry needling
• Joint mobilisations
• Nerve mobilisations
• Pain relief through electrotherapy, eg. TENS, LASER
• Strapping to limit/encourage movement
• Graded movement to decrease joint stiffness and muscle spasm
• Supervised exercise to improve posture, strength, and mobility

Our treatment will always include discussions and advice about common lifestyle influences on your pain. Sometimes, treatment needs to include other areas, like your shoulder or back, to address compensatory patterns.

Due to the complex nature of a headache, there is no simple answer regarding recovery time. Unfortunately, there is no miracle cure to take a problem like this from 100% to 0%. Recovering from a single headache might take a few hours or a few days. After that, you might feel back to normal. But, the bigger problem is recurring headaches. For that, you need to take a step away and look at treatment through a long-term scope. Headache treatment is not aimed at healing your headaches, but rather at slow improvement. Improvement in the intensity, frequency, how badly it limits you, or how much medication you need.

We suggest an initial 4 – 6 sessions of physiotherapy treatment. This gives your physiotherapist time to address physical sources of pain, like muscles, joints, and nerves. In the meantime, you will need to address problem areas at home, like posture, exercise, and sleep. Treatment like this is a cooperative effort from both you and your physiotherapist. After the initial sessions, your physiotherapist will re-evaluate the scope of your headaches and together with you discuss a long-term treatment plan. This includes monthly physiotherapy sessions to maintain your recurring headaches. With time, you’ll be able to look back and truly feel the difference.

• Medical doctor: Often, people need medication as a treatment to help relieve the pain and tension that comes with a headache. A doctor will be able to prescribe medication and manage long-term prescriptions if you are suffering from recurring headaches. Another important thing that a GP can help you with, is to look at your overall health and determine if there could be systemic triggers for your headache (like blood pressure, sugar levels, or hormones).
• Chiropractor: A neck manipulation can worsen a headache. However, a chiropractor can assist you with the treatment of neck pain and stiffness. Care should be taken to look for the root cause of the headache before a high-velocity manipulation is performed.
• Optometrist: An optometrist performs tests to measure your eyesight. This can help to determine if poor eyesight is contributing to your headaches. Working long hours and focusing on a computer screen strains your eyes more than you think.
• Dentist: Clenching your jaw and grinding your teeth increases tension in your jaw and neck. A dentist can prescribe a bite plate to wear at night. This in turn can relieve headaches.
• Dietitian: A dietitian (or nutritionist) can help you eliminate foods that cause a spike in your blood sugar or blood pressure. This can be a trigger to headaches.
• Psychologist: If tension and stress trigger your headaches, a psychologist can help you. It is of great help to look at your coping mechanisms and ways to manage stress sustainably.

Often, headache treatment is a multidisciplinary effort. If more of these medical professionals (together with physiotherapy) are involved in your treatment, it will be more effective. Headaches have many causes and triggers and it will benefit you in the best way if you address your problem from different angles.

A bad headache can make you feel like you might need surgery to fix it. However, surgery is not the first line of treatment for headaches, certainly not for tension headaches.

If you suffer from unrelenting headaches that do not ease at all from any medication, rest, or physiotherapy, it becomes important to get a specialist opinion. The first step would be to get a referral to a neurologist or neurosurgeon. A doctor like this will be able to help with more in-depth medical tests and scans to help find the root cause of your headaches. Only then will surgery be discussed as an option if your doctor can recommend it as a medical form of treatment.

• Temporomandibular joint (TMJ) disorder: Clicking and pain in one or both of the joints of your jaw. It is often caused by grinding your teeth, especially at night. Speaking, chewing, and yawning are painful to do.
• Locked cervical facet joint: Sharp pain in your neck that can shoot up to the back of your head. Caused by a ‘pinched’ joint in your neck. Looking over your shoulder feels almost impossible.
• Cervical osteoarthritis: Stiffness and constant pain in your neck that feels worse in the morning. Pain can often spread into the back of your head and make your head feel heavy. Caused by degeneration of your neck joints.

• Tension headache
• Migraine
• Sore head
• Cervicogenic headache
• Cluster headaches