Why does my head hurt? | The Science of a Headache

By Leslie Davis Rudzinski, PT OCS CFMT
Contributing Author

Headaches are a very common problem in today’s society. There are many different types of headaches which can be caused by a variety of problems. Here we will concentrate on the three most common headaches: tension headaches, cervicogenic headaches, and migraine headaches. Tension headaches are probably the most common type of headache and tend to run in families. Patients with these headaches complain of a pressure or tight band around the head and are brought on by stress or tension.

Tension headaches usually occur on both sides (bilateral) of the head and may be episodic in nature or chronic, that is semi-continuous or frequent, respectively. In general, symptoms are absent in the morning and may increase as the day progresses. Often tension headaches are preceded by neck pain and tightness, however, they are  not related to neck trauma or strain. Pain of this nature is of muscular origin. That is, as we get stressed, we respond with habit patterns that may include raising the  shoulders to the ears, clenching the teeth, or jutting the chin forward. These habit patterns result in excessive contractions of various muscle groups that when overused can develop hypersensitive tight bands within the muscle called trigger points. These “knots” become irritated during times of stress and begin to refer pain to the head. Ultimately the cranial muscle (occipito-frontalis) becomes contracted and painful. A common muscle involved in tension headaches is the upper trapezius which extends from the back of the head to the tip of the shoulder. Most people are familiar with this muscle and the presence of “knots” within it. Other muscles that can produce headache pain include the temporalis which is located just above the ear and is one of the chewing muscles, the sub-occipitals located at the base of the head, and the sternocleidomastoid which is the large tubular muscle on either side of the front of the neck. These muscles can produce the common headache pain in the area of the temple (temporal) the front of the head (frontal) or around the eyes (retro-orbital) and contribute to the feeling of tension around the head.

Cervicogenic headaches, that is headaches caused by the cervical spine or neck, are different than tension headaches in several ways. There is no family history associated  with this type of  headache. Cervicogenic headaches tend to begin in the neck and move to the front of the head. They are usually one sided (unilateral) and do not switch  from one side to the other. Cervicogenic headaches cause a dull aching often “boring” pain and may also produce shooting pain into the head. Unlike tension headaches, cervicogenic headaches are often present on waking. This type of headache may be aggravated by stress; however, it is usually brought on by specific activities or positions of the neck- for example, looking up or down for long periods of time, or suddenly turning the head. Although these headaches may have a muscular component,  the primary cause of the pain is thought to be the joints of the upper cervical spine (C1, C2, and C3). The first cervical vertebra (C1) is called the atlas (since it holds up the head) and the second vertebra is called the axis. The joint between the head and the atlas has been shown to cause pain in both the back of the head (occipital), and pain along the side of the head into the frontal and retro-orbital regions. The joint between the atlas and axis produces pain primarily in the occipital and suboccipital regions.  the C2-C3 joint is also associated with cervical headaches. Injury to the upper cervical spine can result in cervical headaches as a result of soft tissue sprain/strain from a  trauma. Cervical headaches can also be a result of chronic postural strain causing shortening of the suboccipital muscles and compression or stiffness in the upper cervical  joints. Over time, degeneration of these joints can occur and contribute to headache pain referred from the cervical spine

Migraine headaches have many characteristics in common with both tension and cervicogenic headaches, but they also have some differences. The location of migraine headaches is typically the same as the other headaches discussedfrontal, retro-orbital, temporal, and occipital. Migraines described as throbbing, bursting, or boring pain and, like tension headaches, tend to run in families. Like cervicogenic headaches, they are unilateral; however, unlike cervical headaches, they can switch from one side to the other. Migraine sufferers are much more likely to wake with headaches than other headache sufferers. The most distinguishing feature of the migraine headache is the “aura” which may precede the headache. Although many migraine sufferers experience auras (“classic migraine”), the “common migraine” occurs without aura. The causes or “triggers” for migraine headaches are extensive. However, the most common ones are hormone changes, food sensitivities, strong odors, intense activity, fatigue, and alterations in sleep patterns. We often associate other symptoms with migraines like photosensitivity, nausea, and vomiting. Although these symptoms are common with migraine headaches, they are also seen in both tension and cervicogenic headaches as well. Migraine headaches are a result of neurovascular disturbances involving vasodilation (increased blood flow) to the brain. Therefore, migraine medications act in part by reducing blood flow to the brain. Properly diagnosing the type of headache is difficult because of the extensive overlap in symptoms. For example, all three types of headaches can result in muscle contraction of the muscles of the scalp and forehead. This is why botox sometimes works for migraine headaches — not because it addresses the cause of the headache, but because it addresses the ultimate effect which is sustained muscle contraction in the scalp and forehead. Although cervical headaches stem from the cervical joints, the joint pain and irritation results in muscle guarding and therefore sustained contractions similar to those found in tension headaches. Unilateral cervical headaches are triggered by “mechanical” causes such as the prolonged shortened position of the upper cervical spine during a bike ride. But a unilateral migraine could also be caused by that same bike ride because of the intensity of the activity or the ultimate fatigue. To add to the confusion, migraine and cervicogenic headaches have been reported to occur together.

Physical therapy is very effective in treating headaches, especially tension and cervicogenic  headaches. Physical therapy addresses headaches in basically four ways.

First, specific soft tissue mobilization to the involved musculature can reduce the irritability of trigger-points and address other soft tissue restrictions that can lead to headache pain.

Second, joint mobilization of the upper cervical joints to improve mobility, decrease pain, and allow proper positioning of the joints is also effective in reducing headache pain.

Third, addressing postural positions and habit patterns that increase stress on the affected joints and muscles is imperative to reducing the frequency of headaches due to either tension or cervical causes. Sometimes just instruction in posture for things like computer use is sufficient to decrease headache pain. However, often headache sufferers are unable to assume proper posture due to joint and soft tissue restrictions lower in the cervical spine, the thoracic spine (rib cage), or in the lumbar spine (lower back). Sometimes treatment of surrounding areas is therefore necessary to provide the body with sufficient movement to assume proper posture.

Fourth, instruction in simple exercises, relaxation techniques, and self mobilization techniques to maintain range of motion and to deactivate persistent trigger points will enable the headache sufferer to manage symptoms independently.

Although physical therapy does not directly treat migraine headaches, patients with migraines have benefited from these same types of treatment. Is that because cervical headaches are sometimes misdiagnosed as migraines, or because both migraines and cervical headaches can present together? Perhaps it is because migraines can be triggered by the same postural and other mechanical triggers that induce cervical headaches? There is no simple answer. If you suffer from any kind of headache, it’s good to know that there are options out there that may lead to a reduction in headache pain.

It is important to see a qualified health care professional to help diagnose your headache and rule out other serious causes of headache before beginning any treatment for your headaches.

About the Author | Leslie Davis Rudzinski, PT OCS CFMT has been practicing physical therapy since 1987 in the area of orthopedic and sports physical therapy. She is an Orthopedic Certied Specialist as well as a Certied Functional Manual Therapist. She is trained in various forms of manual therapy including Australian and osteopathic techniques as well as numerous soft tissue approaches. Leslie is also on the faculty of The Institute of Physical Art and teaches continuing education courses in the area of Functional Orthopedics. Leslie’s primary expertise is in treating disorders of the spine as well as crania-facial pain including TMJ dysfunction.

References
Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams &
Wilkins, 1983.
Maitland G: Vertebral Manipulation, Fifth Edition. Butterworths 1986.
Price SA, Wilson LM: Patholo-physiology: Clinical Concepts in Disease Processes, second edition. McGraw-Hill 1982.
Jull GA: Cervical Headache a Review. In Grieve GP: Modern Manual therapy of the Vertebral Column. Churchill Livingstone, 1994
Sizer PS, Phelps V, Brismee JM: Diagnosis and management of cervicogenic headache and local cervical syndrome with multiple pain generators. The Journal of Manual and Manipulative Therapy, 2002.
Feinstein B et al: Experiments on pain referred from deep somatic tissues. The Journal of Bone and Joint Surgery, 1954
Yi X, Cook AJ, Hamill-Ruth RJ, Rowlingson JC: Cervicogenic headache in patients with presumed migraine: missed diagnosis of misdiagnosis? Jaw Pain, 6(10), 2005