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Tension Headaches

Physical Therapy/ Neuro-musculo-skeletal Perspective:

This is a very common problem seen by me and Francis in New York City. Tension headaches commonly relate to the sub-occipital region where the vertebrae of the neck, the cranium, and the surrounding tissues come together. In anatomical terms this is known as the craniovertebral junction, which is a collective term referring to the atlas, axis, occiput, and surrounding ligaments and soft tissue.

The headaches arising from this region are also known as “Occipital Headaches” which according to many clinician’s, originate in the cervical region, especially if cervical traction decreases the headache pain. This type of headache typically has it’s origin from a structural source. In other words the structures of the neck and craviovertebral junction are strained from poor posture, overuse activities, or movements. The strain of the cervical structures can be associated with headaches.

According to the Mayo Clinic “tension headaches are the most common type of headache and yet the causes are not well understood.” With tension headaches, the muscles that supported the head, including the posterior and anterior sub-occipital muscles, deep neck flexor and extensor muscles are frequently found to be involved. Tense or constricted muscles of the neck often relate to headaches, which can be very intense and unrelenting, and often difficult to resolve. It is often throbbing, pulsating, and radiating in nature.

The sensation of pain can also relate to areas of the neck, jaw, shoulders, upper back, back of head, and refer to the frontal region of the head.

A brief overview of the anatomy involved in this area involves the following:

· Joints – Occipito-atlanto joint (O-A), Atlanto-axial joint (A-A), Mid Cervical Joints

· Ligaments – OA and AA ligaments, including Alar and Cruciform ligaments

· Muscles – Anterior Suboccipital Muscles (Rectus Capitus Anterio, Rectus Capitus Lateralis), Posteiror Suboccipitals (Rectus Capitus Posterior Major and Minor, Inferior and Superior Oblique), Splenius Capitus, Trapezius, Pectorals, and masseter.

· Nerves – Dorsal Ramus of spinal nerve C1 and C2 (Greater occipital nerve). C2 has a large cutaneous distribution and has a large dorsal root ganglion in a vulnerable location between C1 and C2. Cervical extension motions compress this region and thus Forward head posture can relate to Occipital headaches through this relationship. (ref below)


Abnormal posture has often been related to numerous musculo-skeletal and neuro-vascular impairments. In the area of postural mechanics there is a term that describes a very common position of the head and neck that relates to sub-occipital tension – known as Forward Head Posture. This position puts an abnormal load on the cervical, thoracic, and jaw regions places high amounts of stress on the muscular system. The further forward the head position, the higher the muscular force of the neck muscles must be to counteract gravity.

This posture causes excess mechanical strain on the neck region and results in a cascade of muscular and skeletal problems. As indicated above, it can relate to occipital and tension headaches due to the compression pressure that can aggravate the sensitive C2 nerves.

When working long hours at a desk or computer forward head posture often results- because the body posture will follow the eyes, usually forward, and the posture gets more and more flexed with time due to the force of gravity.

Common history and/or complaints of individual with tension headaches:

· Job that requires prolonged sitting, especially if using computer

· Recent life changes – change of job, living situation, relationship, ANY major change

· Under High amount or long duration of stress

The main clinical objective findings for tension headaches:

· Postural: FHP (Forward Head Posture) with associated increased thoracic flexion and scapular protraction. Occipito-Atlanto Backward Bending.

· Hyper tonicity and shortening of posterior sub-occipital and scapula-cervical muscles

· Tenderness to palpation of external occipital protuberance

· Taut bands and trigger points in mid belly of upper trapezius, sub-occipitals, and often upper cervical joints- especially the transverse processes.

· Restricted Active Range of motion with Chin Tuck, Cervical Forward Bending, and often Cervical Side Bending to contralateral side

· Restricted Passive Range of motion with OA forward bending and often mid cervical up glide restrictions

· Functional Limitations: Varied, often related to increased pain with looking upward, computer work, prolonged sitting, sleep disturbance

Ayurveda Perspective

Ayurveda relates this type of headache to a Vata disturbance, related to the following qualities:

· You cannot have pain without Vata.

· The rough quality of Vata relates to muscle stiffness.

· The dry quality of vata relates to constipation, which sometimes accompanies this pain.

· You may notice these symptoms are worse during Vata times of day 2-6am and pm, and/or Vata seasons (Autumn).

· The mobile qualities of Vata relate to over-activity aggravating the skeletal, muscular, and nervous systems and cause headaches. Pain gets worse with certain movements and less if the body is at rest.

· Fear, anxiety, nervousness, stress can all aggravate Vata and relate to tension headaches.

· Typically Vata headaches are related more to the occipital region, whereas Pitta headaches will be more in the temporal region, and kapha headaches tend to be located more in the nasal/sinus regions of the head.

The treatment for these headaches varies depending on the type of health care practitioner you see. A Physical Therapist or movement specialist would certainly address ergonomics, posture, and physical restrictions with therapeutic exercises and body awareness. A stress management routine and breathing techniques would be indicated. This type of condition responds very well to manual and touch therapies – and in my estimation any treatment plan is incomplete without including it.

I will often use a combination of manual and touch therapies with great results in a short amount of time, including:

·Trigger point Therapy– healing points that can decrease muscles tension, stress, and pain.

The points right underneath the external occipital protuberance are considered the most influential points, called Krikitaka in Ayurveda, and well known in modern medicine for pressure relief because of the location and insertion of the posterior suboccipital muscles into the cranium.

· Manual Therapy – sub-occipital release and myofascial release techniques. These techniques can decompress to posterior joints of the neck and create more extensibility in the soft tissue.