According to the Better Health Channel, headache is one of the most common health-related conditions in Australia:
around 15 per cent of us taking pain relieving medication for a headache at any given time.
There are many different types of headache with many different causes, and most headaches will have multiple contributing factors (we will talk more about these later). Serious underlying disorders, such as brain tumours, are rarely the cause of headache, however persistent headache should always be discussed with and investigated by a doctor.
Headaches are generally classified into 2 categories – primary and secondary. Primary headaches include migraine, cluster or tension headaches. Secondary headaches are usually triggered by an underlying disorder such as infection, injury or tumour (i.e. they are a side effect of another illness).
Headaches can be caused by anything that stimulates the pain receptors in a person’s head or neck. Some common causes of headache include:
- muscle tension
- dental or jaw problems
- diet – fluctuations in blood sugar levels, caffeine withdrawal, food additives such as MSG
- hormonal influences
- eye problems
- injury to the head, neck or spine
- high blood pressure
- poor posture
- hangover from abuse of alcohol or drugs
As physiotherapists, we often have clients presenting with headache or migraine, some of which we can help, and some we can’t. The most common headache presentations that physiotherapists see are migraine, tension-type headache and cervicogenic headache. We will discuss these further before covering treatment options.
Before we can talk about treatment options and how physiotherapy can help, we first need to learn a little about different headache types.
Migraines are one of the most common types of headache in adults. It is not fully understood exactly what causes migraines, however they are thought to be the result of abnormal brain activity temporarily affecting nerve signals, chemicals and blood vessels in the brain.
There are 2 main types of migraine – classic migraine and common migraine. A classic migraine will usually follow a set of warning symptoms known as aura. Common aura symptoms are:
- visual disturbances such as bright zig zag lines, flashing lights or blind spots
- tingling or numbness (usually in the hands, arm or face)
- slurred speech
- poor concentration
- problems with co-ordination
Aura generally lasts from 5 to 60 minutes and is then followed by a headache. Common migraines attack without the warning symptoms of aura.
A migraine headache usually has the following characteristics:
- moderate to severe pulsating or throbbing pain, usually on one side of the head
- usually lasts 4 to 72 hours
- will increase when active, or will stop you from being active
- may be accompanied by nausea or vomiting and increased sensitivity to light and noise
Although the exact cause of migraines is unknown, there are many known triggers. These include:
- hormonal changes
- emotional triggers (stress, anxiety, tension, shock, depression, excitement)
- physical triggers (changes in sleeping patterns, poor posture, neck or shoulder tension, certain foods (most commonly chocolate, cheese, alcohol and caffeine), low blood sugar, strenuous exercise (if you’re not used to it)
- environmental triggers (bright lights, flickering screens like TV or computer screens), smoking (or smoky rooms), loud noises, changes in climate, strong smells
- medications (especially hormone medications such as the contraceptive pill or hormone replacement therapy)
Physiotherapy treatment doesn’t specifically help to reduce the severity and intensity of migraines; however, it can help to address physical triggers of migraine such as poor posture and neck or shoulder tension.
Tension-type headache (TTH) is the most common type of headache.
TTH usually has the following characteristics and symptoms:
- feels like a tight band of pressure around the head
- pain is usually described as dull and persistent of mild to moderate intensity
- often associated with muscle tightness in the head, neck or jaw
- neck movements restricted by muscular stiffness and discomfort
- pain is recurrent and episodic and can last from minutes, hours or days
- may be associated with trouble concentrating and difficulty sleeping
- also commonly associated with depression and anxiety
Despite the name, TTH are not necessarily caused by tension or stress. Triggers for TTH can include:
- excessive muscle contraction such as frowning or jaw clenching
- misalignments of the spine and neck
- poor posture
- muscle tension
- loud noise
- bright lights
- prolonged reading
- emotional upsets
- depression or anxiety
Common contributing factors to TTH are musculoskeletal problems such as misalignment of the spine and neck, poor posture and muscle tension, all of which can refer pain into the head. Physiotherapy can be extremely effective in treating TTH by addressing these contributing factors. More on what physiotherapy treatment will look like later!
Cervicogenic headaches (“cervico” meaning neck and “genic” meaning origin) are headaches that are caused by spinal problems in the neck, such as disc degeneration or prolapse, facet joint arthritis or a whiplash injury. Cervicogenic headaches are one of the most common types of headache.
Typical symptoms of cervicogenic headache include:
- pain at the back of the head which may spread to the top of the skull, forehead or temple
- may also be associated with pain or discomfort behind the eye
- pain described as a constant, dull ache
- pain usually felt on one side
- often, but not always, associated neck pain, stiffness or discomfort
- may be associated with nausea, poor concentration, irritability, light-headedness, dizziness or tinnitus
How can the neck cause a headache?
First, we should understand the anatomy. The spine is made up of many bones known as vertebrae. The top 7 vertebrae make up the neck. Each vertebra is connected to the one above and below it via the intervertebral disc centrally and the facet joints on either side. During neck movements, stretching or compression forces are placed on the muscles, ligaments and nerves of the neck. Abnormal movement patterns or sustained postures can cause damage to these structures and can result in pain, either in the neck or the head via referred pain, causing a headache.
Image courtesy Bounce Rehab (http://www.bouncerehab.com.au/neckpain/)
Cervicogenic headaches usually result from damage to the joints, muscles, ligaments or nerves of the 3 uppermost vertebrae of the neck (C1, C2 and C3). The nerves that supply this area also supply the skin overlying the head, forehead, jaw line, back of the eyes and ears. Pain originating in these structures may refer pain to any of those regions, resulting in a cervicogenic headache.
So, what causes damage to these structures in the neck?
Cervicogenic headaches usually occur as a result of activities that place excessive stress on the uppermost joints of the neck. There are many factors that can contribute to patients developing cervicogenic headache. These include:
- poor posture
- repetitive or prolonged activities such as slouching, lifting or carrying, excessive bending or twisting of the neck, working at a computer or activities using the arms in front of the body
- neck and upper back stiffness
- previous neck trauma such as whiplash
- muscle weakness
- muscle tightness
- inappropriate desk set up
- poor sleeping postures or inappropriate pillows
Physiotherapy treatment can be very effective in the treatment of cervicogenic headache. More on this follows!
Physiotherapy Treatment for Headache
In treating headaches, it is important to first determine exactly what is causing the headaches. Your physiotherapist will conduct a thorough assessment to categorise the type of headache you are suffering and to determine whether physiotherapy is likely to be effective. If the answer is “yes”, treatment may include:
- joint mobilisation or manipulation
- soft tissue massage
- dry needling
- postural correction
- education or advice on activity modification, pillows or ergonomic advice
- exercises to improve flexibility, strength and posture
- Clinical Pilates
Most patients who suffer from headaches referred from structures in the head or neck can achieve full recovery with appropriate physiotherapy treatment, however time to recovery will vary and in more severe cases, may take weeks or months. For more information, speak with your physiotherapist or doctor today!