Headaches are disruptive. Aching, throbbing, even sharp, shooting pain in your head limits your ability to concentrate. This leads to small irritations (forgetting your lunch) or big mistakes (adding an extra zero to a price/measurement). Feeling like a bomb exploded or electrical storm going on in your brain? Headaches severely 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 physiotherapy treatment.

Cluster headache, tension type headache, migraines and cervicogenic headaches can all benefit from physiotherapy headache treatment.

What is the head made up of?

Identifying your head is one of the first “anatomy lessons” a toddler has. Where is your head, hair, eyes, ears, mouth and chin? All these sensory organs have a role to play in how we experience our surroundings. Sensory information then travels to your brain via cranial nerves. Nerves are made up of neurons. Impulses travel along the individual neurons, through the nerve to deliver the message to the specific part of the brain. Almost like a stack of dominoes falls when one is pushed over, impulses travel down the length of the nerve.

The brain processes all this information to give us perception of these experience, plan our reactions, stores information as memories, regulates movement of the neck to turn your face towards a load noise or lovely smell. The brain is suspended in fluid within the skull. The skull protects the brain. The brain stem forms the spinal column that travels down the spine within the vertebrae for protection. A lot of muscles in the neck enables this movement towards the noise or smell under direct command from the brain.

When you have a headache you may be sensitive to noise, smells or light and as a protective response your brain can turn your face away from these stimuli.


Why is your head so important?

Your head houses the sensory organs of sight, smell, taste and hearing. Your neck orientates your senses to experience this world, your brain holds your memories, interpret and give meaning to what is going on around you. Headaches muddle all of this.

Different parts of the brain have different job descriptions. Explaining all of these functions is literally neuroscience and beyond the scope of this article. Let’s suffice to say your brain is your body’s HQ, and smooth functioning of head quarters is top priority.

Different types of headache

No need to explain where you will experience a “head ache” (if all anatomy could have been this descriptive), but if you can locate the area and the behaviour (cause, intensity, duration) of your headache, you are closer to establishing it’s origin.

Headaches are classified into groups:

  1. A primary headache is non threatening, recurring headache, that is not caused by underlying disease or structural problems. 90% of all headaches are primary headaches.
  2. A secondary headache is caused by underlying pathology (disease or structural issues).

Each group of headaches have their own symptoms and criteria. 68% of headache sufferers have a lifetime prevalence of headache! Over the years we have seen countless patients seeking treatment for neck pain and are amazed when they realize that once their neck pain has resolved the headaches also subside. This is because there is a direct link between the change that we introduce affects the cause directly. 

Primary headaches

With primary headaches, the headache is the condition. This means that there’s nothing wrong biologically with the structure of the cells, but a fleeting imbalance of chemical or mechanical origin. Primary headaches include:

  • Tension type headaches
  • Migraine
  • Cluster headaches
  • Exercise induced headaches
  • Miscellaneous – headaches caused by drugs, stress or trauma
  • Hormonal – headaches may come and go or intensify with your menstrual cycle in response to hormone levels

Secondary headaches

With secondary headaches an underlying disease or structural problem is causing the headache. This means the headache is a symptom of something else.  Secondary headaches are a side-effect of another problem somewhere else. This may be:

  • Illness e.g. sinusitis or ear infections
  • Vascular headaches e.g. high/low blood pressure 
  • Brain abnormalities e.g. tumors or bleeding 
  • Cervicogenic headaches – referral from the neck (suboccipital muscles, facet joints)

It is important to remember that in most cases these diseases or structural problems will have other tell tale symptoms too. If you are concerned, give us a call.


Does posture influence headaches?

Posture affects your neck structurally. Imagine lowering a piano from a second story window with ropes. Your head is the piano while your neck is the ropes that holds your head in position. A human head weighs about 5 kg. That means 5 kg of weight rests on top of the neck. If your head moves forward (leaning in to your screen) it adds 1 kg for each cm it is from the optimal position. If your chin pokes forward 3 cm, it adds 3 kgs to the weight that the neck muscles have to carry. The neck was designed to hold 5 kgs, not 8 or 10 or 12 kgs. The ropes cannot hold the piano forever.

Just think on how you’re sitting right now and imagine the amount of load your neck needs to hold to keep your head upright. Scary right?

Why does a headache develop?

Primary headaches

Pain sensitive structures in your head and neck cause primary headaches. There is no underlying disease. Chemical changes in your brain, from the blood vessels, nerves or muscles, or a combination of the two causes headaches.

Some people have a gene mutation (of the CACNA1A, ATP1A2, SCN1A, and PRRT2 genes) that makes it more likely for them to get unilateral (one sided) migraines.

What makes a primary headache worse?

  • alcohol, particularly the sulphates in red wine
  • certain foods, such as processed meats that contain nitrates, and sugar
  • changes in sleep or lack of sleep
  • poor posture (working or sleeping)
  • skipped meals
  • stress

Secondary headaches

Secondary headaches are a symptom of a disease or structural problem. This disease can activate the pain sensitive structures in the neck or head. These diseases vary greatly in severity. If you are concerned, please skip to the symptom list. The following can cause a secondary headache:

  • sinusitis
  • arterial tears
  • blood clots (venous thrombosis) within the brain
  • brain aneurysm
  • brain tumor
  • concussion
  • dehydration
  • dental problems
  • middle ear infection
  • glaucoma
  • hangover
  • high blood pressure
  • infections
  • meningitis
  • panic attack
  • stroke
  • trigeminal or occipital neuralgia

Types of primary headaches

  • Cluster headaches
  • Tension type headaches
  • Migraine (with or without aura)

Types of secondary headaches

  • cervigogenic headaches (caused by neck injury)
  • external compression headache, caused by tight fitting headgear or headbands
  • ice cream headaches, what we usually call brain freeze
  • medication overuse headaches
  • sinus headaches, that are caused by inflammation and congestion
  • spinal headaches are caused by decreased pressure of cerebrospinal fluid, because of a leak or spinal tap (epidural/lumbar puncture)

Characteristics of different headaches

Type of HeadacheCluster headacheTension headacheMigraineCervicogenic headache
Area of pain




Who is at risk?

What makes it worse?

one sided, involves eye


15 min – hours

follows a pattern through the day



pressure in entire head


Few days to weeks



stress, poor posture

one sided, pulsating/throbbing


72 hours



caffeine, alcohol, hormone levels

one sided, spreads from neck to head


Comes & goes



history neck injury, poor posture, OA

How bad is it?

Because headaches can be the main pathology (primary headaches) or a symptom of another problem (secondary headaches) it is important to know when you should have it checked by a professional. If you experience the following symptoms with your headache, please seek medical treatment because these are not your ‘usual’ headache:

  • unrelenting headache that doesn’t respond to medication
  • worst headache you have ever experienced
  • fever
  • double vision
  • struggle to swallow
  • numb feeling around mouth and lips
  • struggle to speak, forming words or remembering terms
  • confusion
  • nausea and vomiting
  • loss of consciousness / fainting / blackouts / seizure
  • numbness / sensory loss anywhere on the body
  • loss of sight
  • elevated blood pressure (140/90 mmHg)

Characteristics of the different Primary Headaches

Cluster Headaches

Cluster headaches occurs in patterns, usually the same time of the day (frequently at night) or year. These cluster periods can last weeks to months and stops as abruptly as they start. A cluster headache may last 15 minutes to three hours, occurring every day or frequently throughout the day. Symptoms include:

  • Excruciating pain usually behind or around one eye
  • One-sided pain
  • Restlessness
  • Excessive tearing, swelling and redness of the affected side’s eye
  • Stuffy or runny nose on the affected side
  • Drooping eyelid on the affected side

Cluster headaches are like a Electrical thunderstorm that incapacitates you, but blows over quite quickly. They are thought to be a abnormality of the sensitivity between neurons in the brain that reduces the sensitivity of the neurotransmitters in the synaptic cleft. This means that where the nerves transfer an impulse between other neurons the nerves are more sensitive to the slightest input, so the nerves fire all at once causing a neural storm.

The exact cause of cluster headaches is unknown. Cluster attacks are not associated with triggers, like in migraine. But it may be aggravated with alcohol use. Risk factors for cluster headaches include:

  • Sex (men are more likely to get cluster headaches)
  • Age (cluster headaches mainly develop between ages 20 – 50)
  • Smoking
  • Family history

Fortunately, cluster headaches are rare and not life-threatening. Physiotherapy treatment can make cluster headache attacks shorter and less severe. In addition, medications can reduce the number of cluster headaches you have.

Tension type Headaches

Tension type headaches are generally diffuse, mild to moderate pain in your entire head. It is often described like a tight band around your head, like a helmet. Tension headaches are the most common type of headache. It is linked to a heightened sensitivity to pain. Increased muscle tenderness, that may accompany tension headache, can be the result of a sensitized pain system. Stress is the most common trigger for tension headaches. Symptoms include:

  • Dull, aching pain of the whole head
  • Tightness or pressure across your forehead or on the sides and back of your head
  • Tenderness on your scalp, neck and shoulder muscles

Tension type headaches may last form 30 minutes to hours and recur daily, leading to chronicity. The intensity of the pain influences your ability to function and can affect productivity at work. Prevention is better than cure. You can limit your risk of developing tension headaches by:

  • Enough good quality sleep
  • Don’t smoke
  • Exercise regularly
  • Eat regular, balanced meals
  • Drink plenty of water
  • Limit alcohol, caffeine and sugar

Physiotherapy treatment for tension headaches decrease the intensity of the pain and frequency significantly. Guiding you through a program to identify the triggers that’s causing your headache.


Migraines cause severe throbbing/pulsating pain, usually on one side of the head. It is often accompanied with nausea, vomiting and extreme sensitivity to light and sound. The pain is severe and affects day to day function. Aura can be a warning sign that a migraine can follow. Aura can include:

  • Visual disturbances like seeing shapes, bright spots or flashes of light or loss of vision
  • Pins and needles sensations in an arm or leg
  • Weakness or numbness in the face or one side of the body
  • Difficulty speaking
  • Hearing noises or music
  • Uncontrollable jerking or other movements

Migraine causes are still studied, but genetics and environmental factors play a role. Migraines can be triggered by:

  • Hormonal changes (during the menstrual cycle)
  • Alcohol
  • Caffeine
  • Stress
  • Bright light
  • Loud noise
  • Strong smells (perfume, paint thinner, secondhand smoke)
  • Sleep changes (too much / too little)
  • Exertion (unaccustomed exercise or sexual activity)
  • Change in weather
  • Medication use (contraceptives / vasodilators)
  • Food & additives (MSG)

A migraine can last up to 72 hours if left untreated. Most migraines will keep you bed bound, you can feel washed out and drained the day after. Medications can help prevent some migraines and make them less painful. The right medicines, combined with self-help remedies and lifestyle changes, might help.

Characteristics of Secondary Headaches

Secondary headaches are caused by an underlying structural issue. Physiotherapy can address problems in ligament, joint and muscle tissues. Headaches that are caused by the neck are referred to as cervicogenic headaches.

Cervicogenic headaches

Cervicogenic headaches are caused by an injury to the neck, like whiplash, a fall, a scrum gone bad or bad posture. It can develop during the course of the day, with a definite aggravating position, like sitting behind your screen or studying all day. It is relieved by movement and position change, heat and over the counter medication. Cervicogenic headaches are characterized by:

  • Unilateral (one sided) pain
  • Pain at the base of the skull, spreading over the scalp and around the eye
  • Decrease in pain with pressure to neck muscles
  • Stiffness of the neck
  • Decreased movement of the neck, especially when turning the head

Anybody can develop cervicogenic headaches. Risk factors include:

  • history of neck injury
  • previous surgery to the neck
  • non optimal posture
  • muscle weakness
  • forward bent position at work, typing, baking, sewing, nail technicians, hairdressers, surgeons, dentists

Physiotherapy can decrease the intensity of the headache by addressing the structural problems.

General symptoms of most headache types


Imaging may be necessary to rule out any sinister cause of a secondary headache. If no abnormality is identified for your headache, that means all imaging is clear, you have a primary headache.

X ray

X rays show the vertebrae, joint space and integrity. If your headache is influenced by your neck, X rays will indicate this.


A MRI is a costly study that can only be ordered by a specialist. It would be standard protocol to have a MRI  if you consult a neurologist for your headache symptoms. MRI shows bone and soft tissue (disc, ligaments and muscles) and allows a glimpse into the brain too, but it is a snapshot. A functional MRI gives us access to the image while the brain is working. This will be necessary if you have serious symptoms from the start, or your symptoms gets worse as time goes on.


Computed Tomography (CT) combines different angles of X rays to allow cross sections (vertical/horizontal), which are more detailed than a single X ray. Clear images of the brain can also be seen with CT. This can be ordered by a specialist if you experience any serious symptoms.

What NOT to do

  • Do not ignore your symptoms, it could be the sign of a deeper issue.

  • Leave it untreated, if you are uncertain of the diagnosis, rather call us and be safe.

What you should do

  • Make an appointment to confirm the diagnosis and determine the severity of your problem.

  • Eliminate anything that may aggravate your symptoms.

  • Stay well hydrated.

  • Eat balanced meals.

  • Get good quality sleep.

Making the headache worse

  • alcohol consumption

  • excessive caffeine and sugar consumption

  • smoking

  • rigorous cardiovascular exercise or inversions (headstands / handstands)

  • prolonged computer work

  • poor lighting when working/reading

  • bright light, wear sunglasses outdoors

  • offensive smells (anything strong, like perfume or paint)

How we test it:

Physiotherapists are trained to distinguish between what we are able to treat and what we need to refer. If you are unsure of the cause of your headaches, we are skilled to determine the severity. You can expect a lot of questions in your first consultation to determine the history of your headache and general health. Next we will test the ligaments, joints, muscles (strength and length) and nerves to find the culprit. Because each case is unique each treatment approach will be different.

After a thorough assessment we will be able to give you answers regarding the duration of your treatment. Please take into account that stressing the structures may aggravate your symptoms. This feels bad, but is not a bad sign, it means we found the structures that contribute to your pain, we must continue, adapt and see what works for you. Please let us know what you feel during your consultation.

Some questions you can expect during your first consultation:

  • When did your headache start?
  • Did you sustain an injury prior to your headache starting, like whiplash or a concussion?
  • Have you changed anything in your routine recently, like taking up a new hobby or exercise?
  • What makes your headache worse? And what makes it better?
  • Do you experience any of the following symptoms with your headache?
  • Light sensitivity?
  • Double vision or other visual disturbances?
  • Trouble reading or focussing on signposts or moving targets?
  • Numbness of your mouth, lips or face?
  • Nausea or vomiting?
  • Trouble swallowing or speaking?
  • Ringing of in your ears?
  • Noise sensitivity?
  • Have you lost consciousness when you have a headache?
  • Weakness,  numbness or pins and needles in your face, scalp or arm?
  • What is your general health like? Are you being treated for any other illness or disease?
  • Have you had your thyroid function tested?
  • What position do you sleep in?
  • What pillow do you use?

Why is my headache not going away?

Unfortunately there is no quick fix to a problem that has been lingering in the background for a long time. You need to address the cause of the problem. Sometimes this can only be done by trial and error. Because so many different factors can influence a headache, a lot of different strategies can be experimented with. We treat a lot of people who suffer from headaches and are able to guide you through the process of making positive change.

A big problem we see with headaches

Over use of prescription or over the counter medication. It is not normal to take pain medication daily without a diagnosis. The side effects are alarming and can range from gastro intestinal symptoms to rashes. You can even get a headache from withdrawal. Please do not be satisfied with a prescription to relieve your symptoms. Continue your journey to get to the real cause and you’ll be headache free.

There is no quick fix either. If you have had the symptoms for years it will take time to change the structures, find and eliminate the contributing factors. A manipulation or a machine may ease symptoms, but if your pain comes back you are not addressing the cause of your headaches.

Many people get frustrated, understandably so, with the medical process of identifying the cause and may give up the search all together. Changes is mood is frequently treated with prescribed mood stabilizers, sleeping tablets or sedatives. These medications lead to drowsiness, trouble concentrating and mental fog.
Stress and anticipation of a headache causes you to change your lifestyle, avoiding concerts or shopping centers, you end up missing out on a lot.

Dentists may recommend a bite plate if you grind your teeth at night. This will alleviate jaw pain. Optometrists may change your spectacle prescription, even dietitians can plan a diet to eliminate the most common triggers, and that may not be enough to make a dent in your pain.

Each profession offers different solutions to deal with headaches that are within their scope of practice. You need to address the whole to make a difference to the pain. For some people it works perfectly, but if your headache don’t change, you need to continue your search for the cause.

Headaches and the “S” word

Stress plays an important role in our lives, especially for people who experience headaches. Stress is such a loaded subject, what might be stressful for one person may not be stressful for another. You don’t need a deadline, monster boss or traffic to experience stress. Any circumstance that has a potential threat value can lead to stress. Not all stress is bad for you. It enables you to finish the race or reach the deadline. Long term stress has a negative effect on your physical and mental health. Whether you acknowledge it or not, stress may be contributing to your symptoms. If you do not deal with that aspect of your symptoms, your headaches can keep coming back.

Physiotherapy treatment for migraine, cluster, tension and cervicogenic headaches

Our first aim is to identify the cause of your headaches. Then we aim to lessen the intensity of your pain, the duration of your headache or the frequency of how often they strike. A change in any of these characteristics is a win, however small the change. Headaches have a big impact on your life, so a change in symptoms is a big win. Your response to treatment will guide the process. Physiotherapy treatment includes:

  • Pain relief by means of electrotherapy, eg. TENS, LASER
  • Soft tissue release by means of massage or dry needling
  • Joint mobilisations
  • Nerve mobilisations
  • Strapping to limit/encourage movement
  • Exercises to improve strength, endurance and mobility of supporting muscles

We can discuss common lifestyle factors that influence your symptoms and if necessary refer you to other experts in the field of nutrition or psychology.

A holistic treatment approach is all about preventing recurrence of symptoms or flare ups. Our aim is for you to know what aggravates your symptoms, modify your behaviour (at work or home) to prevent flare ups and get you back to what you love doing, be it baking or head stands.

Very often patients tend to come in for “maintenance treatment” when needed, be this during a challenging or busy time at work or maybe when taking up a new hobby or exercise regime.

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Phases of headache treatment

Acute phase of headache treatment

During this initial phase of your headache treatment the aim is to decrease the intensity and duration of your pain. Headaches are finicky and can easily be flared during a clinical evaluation. So testing will be limited if your pain is severe. We address the structures that contribute to your pain. Expect pain relieving modalities, gentle mobilisations of the neck, soft tissue release, LASER and active self mobilisations. We start to manipulate your home and work environment too, moving your computer, changing your chair ect. Any change, even aggravating symptoms, is a win here. Because then we know that we are addressing the right structures, maybe too aggressively.

All headaches are unique, and every lifestyle that contributes to the headache is unique. The red wine connoisseur will be differently affected from the short-sighted student that only got a seat at the back of class. Usually this first phase of headache treatment lasts between 2 –  4 weeks.

Intermediate phase of headache treatment

Once intensity and duration of your headache has decreased, our aim is to limit frequency of the headaches. During this intermediate phase go your headache treatment we know what contributes and what makes it better we are able to push the limit during a treatment session. You can expect more treatment modalities aimed at contributing factors from “far away”. This may include shoulder stability and endurance training and cervical muscle strengthening exercises for home practice. Myofascial release, dry needling and deeper joint mobilisations can be done hands on during your headache treatment session. We eliminate the last habits, which are under your control, that may be contributing to your pain.

This phase of headache treatment is usually researched from week 6 – 8.

Final phase of headache treatment

Usually the final phase of headache treatment is reached by week 8. You now know what factors contribute, aggravate and relieve your symptoms. What to avoid and what to incorporate into your day. Your exercises are easy and effective and you only need to come for treatment if and when something has changes. New commute route, new deadlines or new hobby or exercise. This is how you know your headache treatment was effective and covered all the aspects. “Maintenance”  sessions for headache treatment are common on a monthly/ six weekly basis.

To take or not to take pain killers before a consultation?…that is the question…

I don’t have the answer either, unfortunately. There is no use in suffering before your session for the sake of the evaluation. If you are so sensitive during your first consultation that an evaluation is not possible, we’ll advise taking something a few hours before your next session. When you take strong painkillers before your session and have no pain, but know that the movements we are doing during the consult would not be possible without the meds, we’ll advise not to take anything prior to your next consult. Don’t take anything, if you can bear the pain. If your pain influences your sleep, then take something. Sleep trumps all.

Medical management

Your GP can prescribe oral medication, analgesics, anti inflammatories or muscle relaxants, to relieve your pain. This will ease your symptoms, but you need to address the cause of your headache to prevent recurrence, be it postural, hormonal or dietary. Medication helps you cope while you sort out the main cause. Think of it as crutches to lighten the load while you heal. Long term use of medication has side effects, therefor you should manage it responsibly.

Injections can be done to decrease the intensity of pain for migraine sufferers.

Chiropractors can address skeletal contributing factors and offer adjustments to optimize alignment.

Optometrists evaluate sight and eye health and can prescribe spectacles if necessary. Less strain on your eyes may relieve your headache.

Dentists can recommend and fit a bite plate to decrease grinding of your teeth at night.

Dietitians and nutritionists can help you eliminate foods that are contributing to your pain. Bloodsugar that is poorly regulated may also influence your pain. They are experts in their field.

Psychologist evaluation and treatment may be beneficial if your mood is greatly influenced by your headache. If necessary for prescription medication they can refer you to a Psychiatrist.

Neurologist consultation may be necessary to eliminate any malignancy from the brain or nerves.

Physician referral may be necessary if the cause if your headache is not found. Blood tests and imaging may reveal other pathology.

Recovery time

Each headache is part of a different person with different causes, that can either make recovery quicker or slower. On average cervicogenic headaches take six weeks to sort out the soft tissue and joints, change bad habits and gain strength from your rehab program. Patience is of the essence.

Surgery for headache

Surgery is the treatment of choice where serious pathology is the cause of your headache. It may be done where a brain bleed, after head trauma (fall, car accident or concussion) was the source of the headache. Poorly managed neck pathology (neck disc bulge or neck spondylosis) may require surgical intervention to the neck (disc replacement or fusion). Cauterizing (burning) the superficial arteries has been shown to decrease the intensity of pain in cluster headaches and migraines.

What else could the pain be?

  • Migraine
  • Hormone induced headaches
  • Increased blood pressure
  • Concussion
  • Dehydration
  • Withdrawal symptoms (sugar, caffeine, etc.)

Headache also known as:

  • Cervicogenic headaches
  • Tension type headaches
  • Cluster headaches
  • Occipital neuralgia
  • Sinusheadaches