There are few conditions that are as common and distressing as headaches.
Headaches are ranked number 3 out of every type of medical / musculoskeletal condition in terms of years lived with disability (Global Burden of Disease 2019). They afflict over 50% of adults worldwide and around 90% at some point in their lives (Onan 2023). Whilst this might seem surprising, perhaps more alarming is that studies have shown over 50% of adolescents also suffer from headaches (Leonardi et al 2021; Onofri et al 2023).
Other than popping a few paracetamol, if you have a headache what can you do about it?
Recurrent headaches require investigation and diagnosis to plan a treatment strategy. There are some serious causes of headache, but these are quite rare in comparison to the common headaches below. In this article I want to highlight the more common “primary” and “secondary” headaches that I see frequently in clinical practice.
Primary headaches include:
1. Migraines (which at last count has 29 sub-types!);
2. Tension headaches (which musculoskeletal experts would recognise as being caused by either a muscular (myofascial) trigger point or a cranial bone dysfunction) and is the most common headache type;
3. Trigeminal autonomic cephalgia (a fancy way of saying that the trigeminal nerve, which supplies large sensory regions of the cranium, is causing the headache).
Secondary headaches:
This type of headache arises from other conditions which activate / irritate the nerves in the head causing head pain (ie headache):
1. Cervicogenic headache (pain in the upper neck joints / muscles causing referred head pain);
2. Headache caused by TMJ disorders (head pain arising from the jaw muscles / joints);
3. Headache following concussion or head trauma;
4. Headache attributable to a disorder of the cranial bones (see tension headache above);
5. Unclassifiable headaches (a surprisingly large percentage of patients that I see implying that their headache doesn't quite fit into one of the other categories).
Headaches frequently co-exist with other symptoms (such as spinal pain) and have a high association with other medical conditions such as depression (23%), anxiety (25%) and high blood pressure (24%) (Caponnetto et al 2020). Addressing these issues when present is usually helpful for minimising the recurrence of headaches.
In my practice I treat many patients will all the above headache types and treat not only their headaches but associated spinal and jaw pain at the same time. How do I treat headaches? It depends! It varies not only according to the diagnosis, but everyone will have their own unique contributing factors which need addressing to achieve success.
Manual therapy treatment is usually beneficial in reducing pain and headache frequency (Bini et al 2022). Skilled manual therapy treatment may involve treating dysfunction involving the lymphatic-venous drainage of the cranium, arterial supply (fatigue, aura in migraines), muscle trigger points (pressure / tension / aching), cranial bone dysfunction (sensitisation of nerves and muscles), jaw complaints, ligament dysfunction (neck, head and jaw pain), myochains (eye, jaw, neck and upper limb effects), cranial nerves and related dura (nerve related headaches), and mesenteric / visceral fascia (which is a major component of the face, jaw and front of neck). It’s rare that you would receive elementary manual therapy such as mobilisation or manipulation in my hands as these techniques are unable to address most of the factors I just mentioned.
Exercise to restore normal muscle function may benefit those in whom the neck muscles have atrophied due to the chronicity of their condition or those whose headaches relate to trauma such as whiplash or concussion. Knowing when and how gently to start rehab is critical otherwise things don’t go well. For example, failing to remove muscle inhibition means the patient is trying hard for no improvement in strength. Similarly, being too heavy with resistance level / loads may aggravate symptoms.
Following through the rehab for long enough to restore normal muscle function (instead of stopping rehab as soon as the headache subsides) is one of the keys to preventing recurrence in those who do have muscle wasting as a contributing factor. Addressing all of the weak muscles, not just "a favourite" one, is also crucial.
Headaches can be effectively treated.
Sometimes they are complex and require a multi-disciplinary approach (such as migraine preventative or short-term medication, or psychology care for related anxiety issues) but in most cases a positive result is obtainable.
References:
Bini P et al (2022): The effectiveness of manual and exercise therapy on headache intensity and frequency among patients with cervicogenic headache: a systematic review and meta-analysis. Chiropractic & Manual Therapies 30:49
Caponnetto V et al (2020): Comorbidities of primary headache disorders: a literature review with metaanalysis. The Journal of Headache and Pain 22:71.
GBD 2019 Diseases and Injuries Collaborators (2020): Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 396: 1204–1222
Leonardi M et al (2021): Global Burden of Headache Disorders in Children and Adolescents 2007–2017. Int. J. Environ. Res. Public Health 18: 250
Onan D et al (2023): Debate: differences and similarities between tension-type headache and migraine. The Journal of Headache and Pain 24:92
Onofri A et al (2023): Primary headache epidemiology in children and adolescents: a systematic review and meta-analysis. The Journal of Headache and Pain 24:8