Headaches And Migrains Physiotherapy

Experiencing Headaches and Migraines?

Headaches are the result of many conditions – dehydration, fatigue, sleep deprivation, stress, medications, drugs, infections, colds, head injuries. However, one of the main common types of headaches are tension headaches and migraines.

Tension-type headaches are defined as a mild to moderate bilateral headache with a steady non-pulsating pain unaffected by movement and lasting between 30min to 7 days. Not associated with vomiting and can manifest with photophobia or phonophobia.

Tension-type headaches are headaches that can be associated with pericranial tenderness. This can be detected in the frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius and trapezius muscles (Arnold, 2018).

Tension-type headaches are the most common in the general population – studies show that the prevalence ranges between 30-78%(Arnold, 2018). It is subcategorized into three types of tension type headaches according to The International Classification of Headache Disorders 3rd Edition:

Infrequent Episodic Tension Type Headaches – One or less episodes per month which occurs in almost the entire population. Usually has little impact on the individual and in most cases does not require medical management.

Frequent Episodic Tension-Type Headaches – Headache episodes more than once per month. Associated with considerable disability and sometimes warrants further medical attention.

Chronic Tension-Type Headache – Headaches on 15 or more days out of a month for 3 consecutive months. Disease with a significant impact on quality of life and a high level of disability.

Migraines are usually felt as more severe throbbing headaches with neurovascular origin with altered central neuronal processing. Symptoms typically last 4-72 hours. Transient focal neurologic deficits occur in some patients in throughout the migraine cycle. This is a progressive disorder that can transform from episodic to chronic.


Conditions related to Headaches and Migraines

There are over 200 types of headaches identified by the international classification of headache disorders 3rd edition.


Common symptoms / signs

Episodic/Chronic Tension-Type Headaches

  • Symptoms on both sides of the head (Bilateral) in the scalp.
  • Feels like constant pressure around one’s head like a vice.
  • Typically mild to moderate ache but can be quite severe.
  •  Possible areas of pain include Upper back and neck, Base of head, Ears, Above Ears, Jaw, Above eyes.


  • Irritability
  • Depression
  • Numbness and tingling on part of body
  • Throbbing/Drilling/Icepick in the head
  • Burning
  • Nausea
  • Vomiting
  • Giddiness
  •  Insomnia
  • Anxiety
  • Depressed mood
  • Sensitivity to light, smell, sound
  • Neck pain/Stiffness
  •  Fatigue

What Causes Headaches and Migraines?

In general, the pathophysiology of headaches and migraines are unclear however there are some theories attempting to explain some of the symptoms.

The hypothesis for the musculoskeletal contribution to headaches is that the trigeminocervical nucleus processes information from the trigeminal cranial nerve that supplies the face and the afferent nerves that send the sensory signals from the C1-3 nerve roots. They send signals from the C1-3 facet joints and the upper trapezius. This means that when pain signals are sent from these locations, the brain may think it is receiving pain signals from the face.


          Intracranial vasculature are innervated by trigeminal fibers which cover the meningeal perivascular nerves. They release neuropeptides which produce inflammation and causes the blood vessels to dilate and sensitize. This is the classical vascular explanation for migraine.

          Characteristics of vestibular symptoms and balance dysfunction may be attributed to neurovascular issues from the proprioceptive, vestibular, and visual systems. It may also be attributed to peripheral nervous system dysfunctions in the labyrinthic, visual, proprioceptive and exteroceptive afferents and the malfunctioning of the central nervous system in structures like the brain stem, cerebellum, inner ear, basal ganglia, and cortical hemispheres (Carvalho et al., 2020).

Tension-Type Headache

          Pathophysiological mechanism is not yet completely clear and likely multifactorial.(Edvinsson et al., 2020).

          The most likely explanation appears to be central sensitization of the trigeminal nerve, especially in patients with chronic tension-type headaches (Edvinsson et al., 2020).


How is it treated?

The treatment begins with a thorough assessment of the musculoskeletal and vestibular deficits in a patient to guide individualized treatment. A high prevalence of neck pain is found in individuals with migraines and headaches. Reduced mobility in the cervical and thoracic region, dysfunction and weakness of the scapular musculature and the presence of trigger points in the paracervical area are common clinical findings to be addressed in the population (Carvalho et al., 2020). Other treatments should be included such as pharmacological prescriptions from a doctor.

The neck, temporomandibular joint and thoracic region is assessed for trigger points in the sternocleidomastoid, suboccipital and upper trapezius muscles. Some studies in the review did not meet high methodological standards, but others have found that manual treatments can reduce migraine attacks (Carvalho et al., 2020). In addition to the manual therapy, strengthening the neck and scapular musculature, improving posture and nerve tissue mobilizations is recommended to reduce pain and disability (Carvalho et al., 2020).   is recommended to maintain the benefits.

Vestibular symptoms are considered common symptoms in individuals with a migraine. Dizziness, disturbance of spatial orientation, vertigo, sensation of self-motion, unsteadiness or instability while upright is found in between 12-85% of the population(Carvalho et al., 2020). These symptoms are correlated with the presence of aura symptoms, severity pain intensity and migraine frequency (Carvalho et al., 2020). Since the reduction in stability limits decreases anticipatory postural adjustments this should be addressed by the clinician.

Since migraines are chronic and long-lasting, further education and behaviour modifications are recommended – studies show that identification of migraine triggers, self-management strategies, emotional coping, medication safety, relaxation and diet are suggested to improve migraine frequency, decrease disability and improve the quality of life (Carvalho et al., 2020).


Risk factors Headaches and Migraines

  • Stress/Emotional Conflict (Chen, 2009)
  • Sleep Deprivation
  • Poor Posture
  • Poor Diet
  • Hunger and Eyestrain
  •  Medication




Arnold, M. (2018). Headache classification committee of the international headache society (IHS) the international classification of headache disorders. Cephalalgia, 38(1), 1-211.

Carvalho, G. F., Schwarz, A., Szikszay, T. M., Adamczyk, W. M., Bevilaqua-Grossi, D., & Luedtke, K. (2020). Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice. Brazilian journal of physical therapy, 24(4), 306-317. https://doi.org/10.1016/j.bjpt.2019.11.001

Chen, Y. (2009). Advances in the pathophysiology of tension-type headache: from stress to central sensitization. Current pain and headache reports, 13(6), 484.

Edvinsson, J. C. A., Viganò, A., Alekseeva, A., Alieva, E., Arruda, R., De Luca, C., D’Ettore, N., Frattale, I., Kurnukhina, M., Macerola, N., Malenkova, E., Maiorova, M., Novikova, A., Řehulka, P., Rapaccini, V., Roshchina, O., Vanderschueren, G., Zvaune, L., Andreou, A. P., Haanes, K. A., & On behalf of the European Headache Federation School of Advanced, S. (2020). The fifth cranial nerve in headaches. The Journal of Headache and Pain, 21(1), 65. https://doi.org/10.1186/s10194-020-01134-1




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