Chronic tension headaches: why they keep coming back and what a physiotherapist can do

Tension type, migraine, or coming from your neck

Tension type headache is usually felt on both sides, pressing rather than pulsing, and it does not get worse when you walk up the stairs. There is normally nothing else going on with it, though the muscles across the neck, jaw and shoulders are often tender when you press them. It tends to build through a long day and ease off overnight.

Migraine behaves differently. It is more often one sided, throbbing, moderate to severe, and physical activity makes it worse, which is why people want to lie still in a dark room. Nausea, light sensitivity and sound sensitivity are common, and some people get visual changes beforehand. Migraine is a neurological condition and it is managed medically, so physiotherapy is not the answer to it, although we can help with the neck and shoulder pain that often travels alongside it.

The third one is where physiotherapy genuinely earns its place. Cervicogenic headache is referred pain from the structures of the upper neck, and it behaves like a neck problem wearing a headache costume: usually one side and the same side every time, starting at the base of the skull and spreading forwards over the head or behind the eye, brought on by neck movement or by holding one position, and often with stiff, tender upper neck joints that reproduce the familiar headache when a physiotherapist presses them. That last feature is the useful one, because it is testable.

Why they keep coming back

Pain is produced by a nervous system, and a system that has been dealing with headaches for years gets better at producing them. In long standing tension type headache the muscles around the skull are frequently tender to touch and pressure that would be unremarkable elsewhere registers as painful, which points to sensitisation of the pathways that process signals from the head and neck rather than to damage in the head itself. It explains why a headache can turn up on a quiet day with no trigger you can name, and why hunting for one single cause so often goes nowhere.

The driver almost nobody suspects

Then there is the driver almost nobody suspects: the medication. Taking acute headache medication too often can, over months, start generating the very headaches it is being used to treat. The usual thresholds are simple analgesics such as paracetamol, aspirin or anti inflammatories on 15 or more days a month, or triptans, opioids and combination tablets on 10 or more days a month, for longer than three months. It is a real and commonly missed explanation for a headache that has quietly become daily, no amount of physiotherapy will shift it, and unwinding it needs a plan from your GP because it usually feels worse before it feels better.

Sleep and stress sit at both ends of the loop. Poor sleep lowers your tolerance for pain the next day, headaches wreck sleep, and each one feeds the other. Sustained stress adds muscle guarding through the neck, jaw and shoulders and keeps the nervous system on a higher setting. Neither of these is a character flaw or something to be talked out of, and both are worth treating as part of the headache, not as a separate topic.

Load and posture

Load and posture are contributors, and it is worth being precise about that. The link between a measured posture and headache is weak, plenty of people with textbook posture get headaches, and plenty of people who slouch never do. What does matter is sustained load: hours in one position, a screen at the wrong height, heavy commuting, a job that keeps your arms out in front of you, and neck muscles that no longer have the capacity for the day being asked of them. So we treat the load and the capacity to tolerate it, not an ideal shape.

What a physiotherapy assessment looks like

The first job is the history, and it is most of the diagnosis. How often, how long each one lasts, where it sits, what it feels like, what sets it off, what eases it, how you sleep, and how many days a month you take something for your head. A headache diary over two weeks is worth more than any single appointment, and it is the thing most people have never been asked to keep.

Then the examination. We screen for the features that belong with a doctor rather than a physiotherapist, look at how your neck moves, and test the upper cervical joints by hand, including a rotation test performed with the neck held in flexion, which isolates rotation at the very top of the neck. Our headache physiotherapy page walks through the assessment in full. What you should leave with is a straight answer about which headache pattern you have, whether the neck is genuinely involved, what we are treating, and a measure that will tell us honestly in six weeks whether it is working. If the assessment says this is not a physiotherapy problem, that is a useful result and we will say so and write to your GP.

What the evidence supports, and what it does not

For headache that is genuinely coming from the neck, the evidence for physiotherapy is reasonable. Manual therapy to the upper cervical joints and specific low load exercise for the deep neck and shoulder blade muscles have both been studied in cervicogenic headache, with reductions in how often headaches come and how bad they are, and the combination tends to hold up better than either part alone. It is not quick. The exercise side is measured in weeks to months, not in sessions, and that is the part people abandon first.

Pure tension type headache

For pure tension type headache the picture is more mixed and the research is weaker. Trials have looked at manual therapy, exercise, and relaxation and stress management approaches, and while some report benefit, the studies are often small, hard to blind, and inconsistent with one another. The honest position is that physiotherapy may help, particularly where a stiff upper neck or tender neck and shoulder muscles are clearly part of your presentation, and that we should measure whether it is helping rather than assume it. Good treatment for chronic tension type headache is usually broader than hands on the neck: sleep, activity, stress load and a medication review all sit inside it.

Two things worth saying plainly. Trigger point dry needling, which we use here, can reduce tenderness in the muscles around the neck and skull for some people as part of a broader plan for a musculoskeletal presentation, and it is not a headache treatment on its own. And a long course of passive treatment with nothing changing, or repeat imaging for an otherwise typical headache, does not earn its place. If six weeks of honest treatment has not moved your headache diary, the answer is a different plan, not more of the same.

Red flags that mean a doctor, not a physiotherapist

Most headaches are not dangerous, and the pattern of a tension type headache is reassuringly ordinary. A small number are not, and those features are worth knowing by heart. Get medical review the same day for a headache that comes on suddenly and severely, peaking within seconds to minutes, for headache with fever, a stiff neck or a rash, for any headache after a knock to the head, for headache with new neurological symptoms such as weakness, slurred speech, double vision, unsteadiness or confusion, for a new headache after the age of 50 with scalp tenderness or jaw ache while chewing, for any headache with loss of vision or a red painful eye, for a new or severe headache during pregnancy or in the weeks after giving birth, and for a sudden headache or neck pain that feels unlike any you have had before, particularly after a neck injury or after neck manipulation.

See your GP promptly, rather than a physiotherapist, for a headache that has clearly changed its pattern or its character, one that is worse lying down or brought on by coughing, straining or bending, one that wakes you from sleep, a first new headache after the age of 50, and any headache with unexplained weight loss, a history of cancer or a lowered immune system. None of these mean something serious is happening. They mean the question belongs with a doctor before it belongs with us.

Where to start

If your headaches are running most weeks, start with two things. Keep a headache diary for two weeks with a column for every day you take something for your head, because that single column answers the medication question faster than anything else. Then get the neck examined properly rather than assumed, because that is the part of the picture physiotherapy can actually change and it is testable in one appointment.

At our Miranda clinic that means an unhurried assessment, a plain English explanation of which headache pattern you are dealing with, and treatment aimed at the neck and the load behind it where the examination supports it, with hands on treatment, graded exercise and trigger point dry needling where guarded, restricted muscle is part of the presentation. We see a lot of office work, long commutes and manual work across the Sutherland Shire, and a headache that has been running for years is worth one honest look rather than another year of pushing through.