Introduction to Headaches
According to the World Health Organization (WHO), headaches affect 3.1 billion individuals every year, imposing substantial personal suffering while negatively impacting quality of life (WHO 2024). Global Health Estimates (GHE) found that headache disorders were the third highest cause of disability worldwide, following stroke and dementia (GHE 2020). In short, headaches are a worldwide problem that impact nearly everyone!
And while headaches may impact everyone, not all headaches impact everyone the same way. In 2018 the International Classification of Headache Disorders (ICHD) identified 14 different types of primary headaches (Olesen et al. 2018). Yes, you read that right - 14 different types! In fact, the most recent classification document put together by the ICHD, called the ICDH-3, is so extensive that it encourages frequent referencing of the document as memorizing it is nearly impossible (or maybe attempting to do so causes a headache!).
However, of the 14 different types of headache and their many sub-types, this article will focus on the type that is the most prevalent in society. Any guesses as to which type that might be?
Did you guess migraine? I wouldn't be surprised if you did. While migraine is perhaps the most well known and researched headache type, tension-type headache (TTH) is the most common form of primary headache experienced by individuals worldwide. In fact, TTH is experienced by up to 78% of individuals at least once in their lifetime (Olesen et al. 2018)! So it is very likely that you or someone you know has experienced TTH.
Tension Headaches vs. Migraines: Understanding the Difference
Most people who hear about someone experiencing a terrible headache think migraines, and rightfully so. Migraines can be seriously debilitating regardless of whether or not they are coupled with something called an aura. An aura is an impending sign or cluster of symptoms prior to an individual experiencing a headache, such as visual changes, tingling, or light flashes. The first time someone experiences an aura it can be very scary as these symptoms can mimic signs or symptoms of a stroke or other serious pathology.
Migraines without aura usually last between 4 to 72 hours and are described as a moderate to severe pulsating symptom that can occur to one or both sides of the head. Also, migraine is aggravated with activity, and can cause nausea, vomiting, and sensitivity to light and/or sound.
Fortunately, most individuals who suffer from TTH have symptoms that are different from those who suffer from migraine headaches. TTH tends to last more than 30 minutes as a mild to moderate continuous pressing or tightening sensation to both sides of the head and is usually aggravated by stress. Increased tenderness to various muscles in the head, neck, and face is the most significant finding in patients with TTH, and can help differentiate migraine without aura from TTH.
Not to get into the head-y details here, but there are 4 different subtypes of TTH:
Infrequent episodic (less than 1 headache per month)
Frequent episodic (less than 15 days of headache per month)
Chronic (15 days or more of headache per month)
Probable TTH
Obviously, the more chronic and frequent the headache, the more debilitating it will be.
Comparing Headache Types
Headache Type | Migraine | Tension Type | Tension Type | Tension Type |
Subtype | No Aura | Infrequent | Frequent | Chronic |
Pain Duration | 4-72 hours | 30 min - continuous | 30 min - continuous | 30 min - continuous |
Pain Frequency | <15 days/month | <1/month | 1-14/month | >14/month |
Pain Quality | Pulsating | Pressing | Pressing | Pressing |
Pain Location | Uni or bilateral | Bilateral | Bilateral | Bilateral |
Pain Aggravation | Physical Activity | Stress, Pericranial tenderness | Stress, Pericranial tenderness | Stress, Pericranial tenderness |
Pain Intensity | Moderate - Severe | Mild - Moderate | Mild - Moderate | Mild - Moderate |
What Causes Tension Headaches?
While TTH used to be considered primarily psychological in nature, a number of studies have suggested TTH has both a neurological (brain and nerves) and a biological (cellular and chemical) basis (Ashina 2004; Ashina et al. 2005). It is believed that peripheral pain mechanisms (i.e., things outside the brain and spinal cord) play a role in both infrequent and frequent episodic TTH, whereas central pain mechanisms (i.e., brain and spinal cord) play a greater role in chronic TTH (Bendtsen 2000).
In addition, TTH is often associated with anxiety and depression, and individuals suffering from chronic TTH tend to be 3-15 times more likely to have anxiety or mood disorders (Schiller et al 2023). Perhaps, because of the central pain mechanisms, chronic TTH changes aspects in the brain that lead to worsening disability and function over time.
Common triggers for tension headaches include:
Stress and anxiety
Poor posture, especially when working at computers
Skipping meals
Eye strain
Effective Treatment Options for Tension Headaches
Unfortunately, chronic TTH is not very responsive to current pharmacology treatments (Bhoi et al. 2021), and yes you can suffer from medication overuse headache (i.e., medication used to treat headaches causes headache)!
The National Institute for Care and Excellence (NICE) recommends a course of up to 10 sessions of acupuncture over 5 to 8 weeks for the prophylactic treatment of chronic tension-type headache (NICE 2021). For differences between acupuncture and electric dry needling, see my article here. A research article by Schiller et al. in 2023 recommended PT and acupuncture as "important alternatives" for headache management.
Because chronic TTH involves central mediated pain, it is critical that cervical spine manipulation be considered as an additional treatment option. Usually, central mediated pain involves changes to the brain that alters interpretation of and heightened sensitivity to pain and other non-painful stimuli.
Manipulation, near infrared light therapy, electric dry needling, and Physical Therapy may help with improving those central mediated changes brought about over time by decreasing an individual's frequency, intensity, and duration of headache symptoms.
Lastly, because TTH has a causative stress-related element, it is important for individuals with TTH to find optimal ways to manage their stress levels throughout the day, which can include prayer, meditation, controlled deep breathing, regular exercise and obtaining adequate amounts of sleep.
Try This Simple Breathing Exercise for Headache Relief
One of the things I instruct my clients on involves a simple breathing drill. Breathing is an often under-rated and underutilized aspect of treatment for anyone suffering from headaches or chronic pain.
Follow these steps for immediate tension relief:
Lie on your back in a comfortable position
Place one hand on your chest and another on your belly
Close both eyes while taking slow deep breaths both in and out through your nose
Make sure both inhalation and exhalation are easy and unrestricted
During inhalation, the hand on your belly should rise first followed by the hand on your chest
Repeat this sequence for a minimum of 60 seconds
Practice this technique daily, especially during times of stress
This simple technique activates your parasympathetic nervous system (your body's "rest and digest" mode), helping to reduce tension throughout your body, including the muscles of your head and neck.
Summary: Finding Lasting Relief from Tension Headaches
If you or someone you know suffers from tension-type headache, there is hope! While some medications may help, there are always unwanted side effects, including medication overuse headache!
Conservative holistic options such as:
Stress management techniques
These approaches can significantly reduce frequency, duration, and intensity of tension-type headaches, thereby giving headache sufferers their life back!
For those suffering from headaches, keep your head up! Relief may only be a few treatment sessions away.
SCHEDULE YOUR SESSION TODAY!
Here's to your health!
Dr. David Didlake, DPT
PT, Cert. SMT/DN, CSCS, Cert. TPI Medical Level 3, Dip. Osteopractic, FAAOMPT
Owner, Integrative Therapeutics "Home of the Saint Louis Golf Doc"
Follow me @theintegrativeclinic @thestlgolfdoc
Related Articles
Electric Dry Needling: A Modern Approach to Pain Relief. by Dr. David Didlake, DPT
Manipulation Therapy Explained: Benefits, Safety, and When It's Right For You. by Dr. David Didlake, DPT
Vitamin Z: How Quality Sleep Enhances Recovery, Mood, and Pain Management. by Dr. David Didlake, DPT
Near Infrared Light Therapy: The Red Light Revolution in Healthcare. by Dr. David Didlake, DPT
Understanding Pain: A Journey Through Your Body's Warning System. by Dr. David Didlake, DPT
What is Physical Therapy? Understanding Treatment, Benefits & Expert Care. by Dr. David Didlake, DPT
The Vital Connection Between Breathing and Pain-Free Movement. by Dr. David Didlake, DPT
References
For those interested in the scientific evidence behind headaches, we've included some key research citations:
(2024 March 6). Migraine and other headache disorders. Retrieved March 14, 2024 from https://www.who.int/news-room/fact-sheets/detail/headache-disorders#:~:text=Globally%2C%20headache%20disorders%20affect%20approximately,until%20the%20age%20of%2080.
Global Health Estimates 2020: Disease burden by Cause, Age, Sex, by Country and by Region, 2000-2019. Geneva, World Health Organization; 2020.
Olesen J, et al. The International Classification of Headache Disorders. 3rd ed. Cephalalgia. 2018 38(1):1-211.
Ashina M. Neurobiology of chronic tension-type headache. Cephalalgia 2004; 24: 161–172.
Ashina S, Babenko L, Jensen R, et al. Increased muscular and cutaneous pain sensitivity in cephalic region in patients with chronic tension-type headache. Eur J Neurol 2005; 12: 543–549.
Bendtsen L. Central sensitization in tension-type headache – Possible pathophysiological mechanisms. Cephalalgia 2000; 20: 486–508.
Schiller J, et al. Effects of acupuncture and medical training therapy on depression, anxiety, and quality of life in patients with frequent tension-type headache: A randomized controlled study. Cephalalgia. 2023 Jan;43(1):3331024221132800. doi: 10.1177/03331024221132800. PMID: 36622877.
Bhoi SK, Jha M, Chowdhury D. Advances in the Understanding of Pathophysiology of TTH and its Management. Neurol India. 2021 Mar-Apr;69(Supplement):S116-S123. doi: 10.4103/0028-3886.315986. PMID: 34003157.
Headaches in over 12s: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2021 Dec 17. PMID: 32017486.
This article is for informational purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider before beginning any new treatment.
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