*IMPORTANT - It is always important to investigate the cause of your headache. If your headache is severe, is of sudden onset, is unusual for you, if you have had a recent trauma, if it is associated with other symptoms such as dizziness, loss of balance, speech disturbance or weakness or if you have any concerns you should go to the hospital or see your doctor immediately.

Neck-related Headache (Cervicogenic Headache)

Research has shown that physiotherapy is an effective treatment for neck-related headaches for both short-term relief and long-term recovery. (3,4) It is a very common cause of headache and is often related to posture, prolonged sitting at a computer, stress, head down activities such as reading and head up activities such as painting ceilings. This type of headache can also occur spontaneously with no obvious cause. The headache pain usually refers up into the head, from the neck, due to stiffness and irritation of the top three neck vertebrae or spasm and trigger points in the muscles of the upper neck. The following symptoms may indicate a neck-related headache (5).

• Neck pain radiating up into the head - commonly into the back and top of the head and into the forehead and behind the eyes.
• The pain usually occurs on the same side of the head, but can sometimes move to the other side or be on both sides at once.
• The pain can be dull to shooting or throbbing.
• The pain is often worse in the morning, especially just before getting out of bed and often gets worse if you stay in bed too long. This is sometimes referred to as "weekend headache".
• The headache may be continuous or last from a few hours to a few weeks.
• It can be made worse by neck movements or sustained postures.
• There is usually tenderness at the top of your neck and pushing on the base of your skull may relieve your headache.

Treatment - Treatment begins with your physiotherapist taking a detailed history of your headaches, then carefully assessing your neck, checking for joint tightness, muscle spasm or tightness and muscle weakness. We will also assess your posture. A treatment programme will be developed for you depending on your symptoms. This may include joint mobilisation, muscle releases, massage, stretches and an exercise programme to improve posture, mobility, core strength and control. Research has shown that the recurrent nature of neck pain and related headaches is often related to issues with core muscle control and strength and neck posture (6,7). Your exercise programme is therefore essential to achieve long-term improvement, but it will take only a minute or two, several times a day. Neck-related headaches usually respond very quickly to physiotherapy treatment and you will usually see an improvement after the first treatment.

Jaw-related Headache (Temporomandibular Headache)

Jaw-related headache is a very common condition with around 12% of the population having suffered from a jaw-related headache in the last 6 months. It is often related to stress, grinding or clenching your teeth at night, mouth breathing, prolonged dental procedures, missing teeth or a misaligned bite, trauma such as sporting injuries, car or bike accidents or a blow to the jaw. There is often swelling in your jaw, muscle spasm, muscle soreness and muscle over-activity. This can result in mal-tracking of the jaw. (See our Jaw Problems page for more information) The following symptoms may indicate a jaw-related headache (5).

• The pain can be on one side or both.
• The headache pain is usually felt just in front of the ears and can run up to the temple and/or down along the line of the jaw, into the teeth, and down into the neck.
• It is often a dull, deep ache but can also be throbbing.
• It can occur daily and is usually worse in the mornings.
• The pain can be related to jaw movements, such as yawning, eating, singing and even talking.
• You may feel a fullness in your ears and ringing (tinnitus).
• You may have jaw locking, or clicking and popping noises.

Treatment - A detailed history of your headaches will be taken, and then your physiotherapist will carefully assess your jaw, checking for joint swelling or mal-tracking, muscle spasm, over-activity or tightness and will assess your posture. We may also need to assess your neck if there is an overlap of symptoms. A treatment programme will be developed for you depending on your symptoms. This may include gentle jaw muscle releases, massage, neck mobilisation and an exercise programme to improve jaw alignment, posture, core strength and control. The exercise programme will take only a minute or two, several times a day but is essential to achieve long-term improvement. Jaw-related headaches usually respond well to physiotherapy treatment and you will usually be improving quite well within 2 -3 weeks.

Tension Headache

Tension headache is one of the most common forms of headache and occurs when your neck and scalp muscles become tense. It can be triggered by stress, noise, glare, sustained postures such as sitting at a computer for long periods or close work such as sewing or reading. This type of headache can occur in conjunction with neck and jaw related headache and sometimes with other types of headache such as sinus or migraine headaches. The following symptoms may indicate a tension headache (8).

• The pain can be dull or feel like a pressure band around the head. It is usually not throbbing.
• The pain often feels like it is all over the head not just on one side or one point and can sometimes radiate into neck and across the shoulders.
• The headache can occur daily, constantly or as a one off event. The pain may last for an hour or several days.

Treatment - Your physiotherapists will take a detailed history of your headaches, and carefully assess your neck, checking for joint stiffness, muscle spasm, weakness, over-activity or tightness and will assess your posture. We may also need to assess your jaw if there is an overlap of symptoms. A treatment programme will be developed for you depending on your symptoms. This may include gentle muscle releases, massage, neck mobilisation, heat and an exercise programme to improve posture, core strength and control. Tension headaches usually respond well to physiotherapy treatment and you will usually see an improvement at your first visit.

Migraine Headache

The cause of migraine headaches is not fully understood, but one theory is that migraines are due to sensitisation of a centre in the brain called the trigeminocervical nucleus (TCN). This area receives sensory input from the head, jaw, face and upper neck area. The TCN can become sensitised, so that normal things such as glare, certain foods, lack of sleep and the menstrual cycle in women can trigger a migraine headache. As the neck also has input into the TCN it is thought that postural disorders, neck stiffness and muscle spasm can also trigger migraine. The following symptoms may indicate a migraine. (9)

• There may or may not be an aura (visual disturbance) that precedes the headache.
• The headache is usually one sided.
• The pain is moderate to severe and is usually described as throbbing.
• There may be sensitivity to light or sound.
• The attack usually lasts for 4 to 72 hours.
• There can be nausea, vomiting or dizziness.

Treatment - There is early evidence that indicates that treating neck dysfunction with physiotherapy can significantly reduce the severity and frequency of migraine. (10) Dr Ian Devlin states "In the author's experience the cervical spine has a very significant role in headache causation. Furthermore, some migraine sufferers report dramatic improvement in their migraine frequency and severity with competent management of their cervical spine dysfunction. In clinical practice, patients report that treatment of the cervical spine dysfunction by physiotherapists can reduce the frequency of migraine episodes." (11) At our practice we have found that treating neck stiffness, spasm and pain has reduced not only neck-related headache, but has also been helpful to our patients in reducing the frequency and severity of their migraine headaches.

Self Help

• Posture is very important. If your head stays balanced over your shoulders then the muscles of your upper neck only need to work very gently to hold you upright. However, every 1.5cm your neck is forward of this balanced position doubles the force on your neck. This extra force makes the upper neck muscles work much harder and the head forward position puts pressure on the joints in the top of your neck, these two factors combined can start a headache. So if your head starts to feel heavy or you start to feel a little headache coming on then lift yourself up into a better position. The sooner you adjust your posture the quicker the headache will go.
• Sitting for long periods at a computer can cause a headache. Make sure you sit in a good office chair and make sure you take regular breaks. See our Good Posture and Computer Use page for more information on setting up your office space.
• Take regular breaks. Doing the same task for long periods, whether sitting, standing or working in a head down or head up position puts stress on the neck and can cause a headache. Try to change your position and take a short break away from your activity or change your position every 20 minutes or so.
• Stay well hydrated. Dehydration can cause or aggravate headaches. You should be drinking about 2 litres of water a day, more in hot weather or when you are exercising.Try to limit caffeine intake and drinks with artificial sweeteners as these can increase dehydration.
• Regular exercise is a great way to reduce headache by improving posture, strengthening neck support muscles and getting you out of that same position you spend all day in at work. It also helps to reduce stress and decreases your risk of illness and disease. Try to exercise for at least 30 - 40 minutes exercise 5 times a week. The type of exercise doesn't matter, it's being active that counts. You could try walking, playing sport, running, going to the gym, working in the house or garden or swimming.
• Make sure your pillow is comfortable. If you are waking in the morning with more pain than you had going to bed then chances are your pillow is causing you problems. See Advice for Buying a New Pillow for more information on pillows.
• There are a number of self massage and self mobilisation techniques that can be very helpful. Your physiotherapist can teach you the techniques that would be appropriate for your condition.

Important information if you have a severe or unusual headache

It is important to know that while most headaches are harmless and can be easily treated, a headache can also be a symptom of a more serious disorder.

Go to hospital immediately if :-

• Your headache starts very suddenly.
• You are experiencing a very severe headache.
• You have speech, vision, or movement problems or loss of balance.
• Your headaches get worse when you lie down.

See your doctor if :-

• Your usual headache changes in pain or position.
• Your usual treatments stop working or if you start having side-effects from any medication you are taking for your headache.

At Sutherland Shire Physiotherapy Centre we have a special interest, extra training and many years experience in the treatment of jaw problems, headache, postural problems, and conditions of the neck, back and upper limb. Call today to schedule an appointment with one of our physiotherapists.

Last updated: 1st August, 2020

Please note that the above information is of a general nature and is not intended to substitute for professional advice. You should always seek the advice of your qualified health practitioner to attain a proper diagnosis before starting any treatment regime.

Photo courtesy of stockimages from FreeDigitalPhotos.net

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References

1. Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton RB, Scher A, Steiner TJ, Zwart JA, The global burden of headache: a documentation of headache prevalence and disability worldwide, Cephalalgia, 27: 3: 193-210, 2007.
2. The International Headache Society (IHS) 2004. The International Classification of Headache Disorders, 2nd edition (Cephalalgia 2004; 24 suppl 1: 1-160) Blackwell Publishing.
3. Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine:27:1835–45, 2002.
4. Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJ, Bouter LM. Non-invasive physical treatments for chronic/recurrent headache, The Cochrane Library (ISSN 1464-780X). Cochrane Database of Systematic Reviews, Issue 3. 2004.
5. Zito G, Difficulties with the differential diagnosis of cervicogenic and temperomandibular headache, In Touch: 2: 9-10. 2008.
6. O'Leary S, Falla D, Elliott J and Jull G (2009): Muscle dysfunction in cervical spine pain: Implications for assessment and management. Journal of Orthopaedic & Sports physical Therapy 39 (5): 324-333.
7. O’Leary S, MRI informing exercise prescription for neck pain. In Touch, 3: 10-11, 2011
8. A.D.A.M. Medical Encyclopedia, Tension Headache, US National Library of Medicine, 2010
9. Selvaratnam P, Niere KR, Oddy P, Headache, Orofacial Pain and Bruxism, Diagnosis and multidisciplinary approaches to management, Churchill Livingston Elsevier, 2009.
10. Bronfort G, Nilsson N, Haas M, et al, Non-Invasive physical treatments for chronic/recurrent headache. The Cochrane Database of Systematic Reviews. Issue 4.
11. Devlin, I, Headache in General Practice, Headache, Orofacial Pain and Bruxism, Diagnosis and multidisciplinary approaches to management, Chapt 1, pge 8, Churchill Livingston Elsevier, 2009.