What a Headache!

Get a Handle On a Moving Target

By Ruth Werner
[Pathology Perspectives]

Who hasn’t had a headache? Headaches (or cephalalgia, if one wants to sound erudite) are one of the most common pathological human experiences. They are rarely related to a serious underlying disorder, and most of the time they are essentially benign—a signal that it is time to get some rest, or to be more careful about what we consume, or that we are dealing with an infection of some kind. But, whether serious or benign, headaches can be more than a minor annoyance; they can be chronic and debilitating, causing people to miss work, skip school, and radically curtail their daily activities.


Trigeminal Pathways

The trigeminal nerve provides sensation for most of the head (including the corneas, meninges, sinuses, skin, and teeth), so it makes sense that this nerve is a key operator in most headache etiology.  

When pain sensors within the trigeminal nerve are active, they can trigger a motor response of vasoconstriction, usually on the surface of the brain’s cortex. Vasoconstriction may then be followed by extreme and prolonged vasodilation that spreads across the cortex. In typical vicious-circle fashion, changes in blood flow to the brain can cause the release of pain-sensitizing neurotransmitters that irritate the trigeminal nerve and reinforce the sensation of pain. The link between trigeminal activation and motor response in cranial blood vessels is called the trigeminovascular pathway. Other parts of the trigeminal nerve reach deep into the brain stem, connecting this key sensory nerve to many processes in pain sensation and management.


The International Classification of Headache Disorders-II (ICHD-II), produced by the International Headache Society, is a comprehensive guide to headache identification and terminology. The goal of the project is to prepare care providers to recommend treatment options with the best outcomes and to provide a common frame of reference for headache researchers. (See the sidebar International Headache Society Classification ICHD-II for a brief overview of ICHD-II classifications.)

The headache types that have been found to be most responsive to manual therapies such as chiropractic, massage therapy, and osteopathy include migraines, tension-type headaches (TTHs), and cervicogenic headaches (CGHs). For that reason, the rest of this article will focus on those categories.

Migraine Headaches

Migraines (from the Greek hemicrania, which denotes the unilateral quality of this type of headache pain) are a common and occasionally incapacitating condition. The World Health Organization now lists migraines among the 20 most debilitating diseases worldwide.1 Migraines have several subtypes, but the two most common versions are migraine without aura and migraine with aura. Most migraines (about 80 percent) do not involve an aura, but when they do, the aura may include auditory, olfactory, or visual stimuli. Auras often precede the headache pain, but may sometimes be present all the way through the process. 

Migraines used to be considered primarily vascular headaches, involving a demonstrable expanding vasoconstriction followed by extreme vasodilation and inflammation, which exacerbates pain. However, they are now understood to be neurogenic—that is, they are reliant on signals from the trigeminal nerve. The trigeminovascular pathway is recruited as well, but this is a secondary aspect of migraine etiology. 

People who live with migraines, sometimes called migraineurs, appear to have trigeminal pathways that are more sensitive than those without migraines, even when they have no symptoms. Hyperactivity of the trigeminal pathways puts migraineurs at risk for headache chronicity: episodes can increase in frequency and severity as central sensitization develops. (For more on central sensitization and chronic pain syndromes, see “Pervasive Pain,” Massage & Bodywork, March/April 2013, page 42.)

Migraineurs also have a higher than usual risk of vascular problems, especially heart attack and stroke. In fact, one type of stroke, called cryptogenic stroke, occurs in younger-than-expected populations and is associated with migraines; it is often linked to a birth defect of the heart called patent foramen ovale (“Patent Foramen Ovale,” Massage & Bodywork, October/November 2007, page 126). 

Migraine triggers include hormonal shifts (especially with the menstrual cycle), lack of sleep, irritating odors and tobacco smoke, fluorescent lighting, weather changes, and several ingested substances, including aged cheeses, red wine, artificial sweeteners, monosodium glutamate, and meat with nitrates.

Migraine symptoms usually involve throbbing or pulsing pain on one side of the head, along with nausea, vomiting, and sensitivity to light and sound. Headaches may last 4–72 hours. Some people develop weakness of the facial muscles on the affected side. Pain is made worse by any physical activity or movement, so people in the midst of an episode tend to simply try to sleep.

Migraine treatment can be challenging. Interventions are typically used to prevent headaches (prophylaxis), or to stop them midstream, and include analgesics (including opioids), serotonin agonists, antidepressants, and antiepileptic drugs.

Tension-Type Headaches

TTHs are the most common variety of headache, accounting for about 80 percent of all headache diagnoses. The International Headache Society identifies two main varieties of TTHs: episodic (headaches occur fewer than 15 times per month) and chronic (headaches occur more than 15 times per month).

Both peripheral and central nervous system factors appear to be at play with TTHs. Scientists find that peripheral neuron sensitivity is abnormally high, which means that pain perception is abnormally active, but do not find that muscles of the face, head, or neck are unusually tight or guarded. It has also been observed that prolonged input from nociceptors embedded in muscles and fascia around the head can lead to increased headache frequency. In other words, a central-sensitization pain loop becomes established, and, like migraines, episodic TTHs can become a chronic situation. 

All TTHs have some symptoms in common: they tend to last from 30 minutes to 7 days, they do not involve nausea or vomiting, light and sound sensitivity is minor, they are not exacerbated by low-grade physical activity, the pain they cause is bilaterally mild to moderate, and the pain is often described as “pressing” or “tightening” (as opposed to “pulsing,” as in a migraine).

Cervicogenic Headaches 

As the name suggests, CGHs arise from problems with the neck that then refer, by way of the cervical nerves, up over the head. In addition, fibers from the trigeminocervical nucleus, a region of the upper spinal cord, interact with sensory fibers from the upper cervical nerves, which creates more referred pain pathways.

Three major features of CGHs include restricted neck movement, painful palpation of the cervical joints, and weak neck flexors. Involved muscles include the upper trapezius, the sternocleidomastoid, scalenes, levator scapulae, and the suboccipital extensors.2

The symptoms of CGHs include neck and shoulder pain, sometimes with pain going down one arm. The pain may start with a sudden movement of the head, like a cough or a sneeze. It is usually unilateral, and is often focused in the forehead or behind one eye. Blurred vision, dizziness, nausea, and sensitivity to light are common.  

Does Massage Help?

The research on manual therapies for headaches suggests that massage may have a positive impact in many situations. Massage appears to be especially helpful for chronic headaches (both migraine and TTHs), and the myofascial component of CGHs also suggests that massage would be a useful intervention. Some evidence suggests that peripheral issues like muscle tightness or irritation can trigger migraines.3 Further, multiple headache types can occur concurrently—that is, a person could have the musculoskeletal components of CGHs, along with the trigeminal neurogenic features of TTHs; these patients are good candidates for massage, and with skilled work they are likely to have an excellent response. 

Many headache patients pursue massage along with other interventions.4 Patients with a pattern of severe and chronic headaches tend to report more positive responses to manual therapies compared to patients with milder forms.5 This is exciting, because headache chronicity suggests the establishment of central-sensitization patterns. If massage can be helpful in reducing severity and frequency of headaches, this could be generalizable to other central-sensitization syndromes, many of which are difficult to treat.  

The effectiveness of massage for headache pain is relevant for the many people who would like to minimize or avoid pharmaceutical intervention. Drug sensitivities, cumulative toxicity, pregnancy, fear of addiction, a desire to avoid developing medication-overuse headaches, and other reasons may prompt people with headaches to seek nonpharmacologic options. These patients may look for a variety of acupuncture, behavioral therapies, biofeedback, and manual therapies as alternatives to medication. Fortunately, research suggests that manual therapies may be about as effective as drugs to manage headache pain for some populations.6

Strategies for massage therapists working with clients who have headaches must be determined by what type of headache is present, whether it is acute or not, and the client’s goals. TTHs may call for trigger point work or myofascial release in the neck and facial muscles, while CGHs will respond better to work with the muscles that support the head and determine how the cranium balances on the spine (although care must be taken not to irritate the vulnerable occipital nerves at the back of the head). Clients with migraines may appreciate attention to the myofascial and postural contributors to their condition, when they are not in pain. If a client with an active migraine does seek massage, research shows that neck massage, along with spinal manipulation, can be effective.7

It is quite possible for a skilled massage therapist to build a practice based on expertise with headache management. A network that includes neurologists and chronic-pain specialists is helpful, but the best testament to the effectiveness of massage therapy is most likely to come from satisfied and grateful clients.

Ruth Werner is a writer and educator approved by the National Certification Board for Therapeutic Massage & Bodywork as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2012), now in its fifth edition, which is used in massage schools worldwide. Contact her at www.ruthwerner.com or wernerworkshops@ruthwerner.com.

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