The Hassle of Headaches


I have to admit, when I first started treating patients with headaches, I didn’t do a very good job! I used some basic cervical and soft tissue techniques I had learned, but at times I felt as though I made matters worse. Over the years, through further education and a better understanding of this condition, I have actually come to love treating this population. The big difference? Learning to diagnose the type of headache that was being presented, performing a proper assessment and learning how trigger points can play a key role in treatment.

Trigger Points

Some studies show trigger points located in the neck and suboccipital areas can refer to much larger areas of the head/face than actual head and face muscles. Through a thorough assessment of trigger points in the shoulder, neck and head region, familiar pain patterns can be induced and can help identify what areas need to be treated to reduce headache symptoms. Cervical mechanics are also assessed and treated along with teaching awareness of postures and stressors that contribute to the condition. Specific craniofacial mobilization and cranial nerve contributions should also be considered.


Headaches are one of the most common medical complaints. Recent data suggest the prevalence of this condition is rising. There is a multitude of different types and classifications of headaches, many people suffer from a combination of different types; this will determine the specific treatment approach.

Headaches can be debilitating; affect your ability to work or study and can have a profound effect on the quality of your life. As one headache sufferer states “the way it tends to disrupt intimate relationships, empty all financial reserves, and sabotage the best-laid career plans. It’s not even the endless barrage of (albeit well-meaning) suggestions for “cures” from everyone you meet. No, it’s the emotional suffering – from all the guilt and the shame, of patients like me thinking it’s our entire fault, and maybe all in our heads.”

Here are a few examples of more common types of headaches as noted by the International Headache Society:

  1. Tension-type headaches: (myofascially driven)
    • Last 30 min to 7 days
    • Typically bilateral
    • Pressing/tightening quality
    • Mild to moderate intensity
    • Do not worsen with physical activity
  2. Migraine headaches: (Neurovascular disorder)
    • Attacks lasting 4-72 hours
    • Usually unilateral
    • Pulsating quality
    • Moderate to severe pain
    • Aggravated with routine physical activity
    • During the headache experiencing at least one of the following: o* Nausea or vomiting o* Light or sound sensitivity and/or disturbances
  3. Cervicogenic headaches: (neck-related)
    • Clinical evidence of a disorder of the cervical spine (neck)
    • Headache has developed in relation to the onset of a cervical issue
    • Headache improves with resolution or improvement of a cervical condition
    • Headache triggered by head/neck movements or postures

Physical Therapy

The musculoskeletal factors that contribute to headaches can be treated effectively by physical therapy, along with patient education and behavioral modification. Even migraine headaches, which are a neurovascular disorder, can be treated effectively with dry needling of trigger points whose referred patterns coincide with migraine patterns. Care in assessing a true migraine headache patient is necessary as one study of migraineurs showed that 30% of the subjects had provocation of their migraine attack during the examination. It is always advisable to have migraine patients bring their headache medications with them to treatment sessions.

We cannot always cure migraine headaches, but studies show that physical therapy can reduce the intensity and frequency of migraine attacks. Determining and addressing trigger lifestyle factors such as alcohol, foods, menstruation, poor posture, stress, lack of sleep, can also be helpful in management.

Muscles to be assessed for myofascial trigger points in headache patients include the SCM, upper trapezius, splenius capitus, semispinalis cervicis, OCI/suboccipitals, and cranial facial muscles. Treatment of these trigger points can be extremely effective in managing and actually resolving headaches. I’ve been successful in treating many cases in my 30+ years as a physical therapist including a case of a 19-year old female college student with a 10-year history of constant headaches with failed interventions. By using a combination of trigger point dry needling, cervical mobilization, postural and behavioral modification, teaching home corrective exercise, and strict management and communication, this case was a resounding success.

This is a population that desperately needs our help, trigger point dry needling can be an extremely effective tool when combined with other interventions to manage these patients!

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