Headaches are experienced by most of the population at some point in their lives. For most they are minor and fleeting, and for others they pose an ongoing problem, having complex underlying causes. Types of headaches vary greatly and determining their root cause can be difficult. Having a greater understanding of how these types of head pain are categorised, can at least provide a starting point for minimising the impact headaches have on daily life.
One thing that is certain for all headaches, is that the pain is not felt from the brain. The brain receives pain signals from the nervous system, yet it is one organ of the body that does not have pain receptors. Rather it is the interactions between blood vessels and surrounding nerves in the structures in the head, neck or elsewhere, that send pain signals to the brain, which make a headache felt.
These pain sensations come in a variety of styles, so classifying types of headache is important in determining the appropriate treatment. There are two main categories of headaches, those being primary and secondary. The most common headaches are primary where the headache is the cause of the pain, as opposed to a secondary headache where there is an underlying medical condition.
Infection such as meningitis or a brain bleed due to trauma are examples life threatening secondary headaches. They can also derive from less severe conditions, for example medication overuse and issues relating to the structures of the head, such as the sinus region. Conditions of the head, neck, and even the the stomach or intestines, that are inflammation, trauma, illness or disease related, may also cause headaches.
As one of the most common ailments we experience, the symptoms and pain experienced will vary greatly. Although types of headaches are classified into groups, this is only a rough guide. There is much crossover regarding symptoms between one category and another, which makes headaches difficult to diagnose. This is where some deductive reasoning comes into play in differentiating one type of headache from another, especially considering there are over two hundred documented types of headaches.
Main types of headache
Tension, migraine or cluster are the main types of primary headaches. Migranes can be very debilitating, and often are accompanied by other symptoms such as nausea, vomiting and are often only felt on one side of the head. They can also be accompanied by an aura, which is a visual disturbance such as seeing sparkles or dots. There may also be feelings of anxiety, sensitivity to light or sensations that effect the limbs or stomach.
Unlike a migraine where these sensations can forewarn the onset of a headache, the cluster comes on suddenly, yet departs as quickly as it arrived. As they are one of the most painful headaches, it is fortunate that they are not as common. The name for this type of headache derives from them appearing as a cluster of short but intense pain, that occur in cycles over a period of a few weeks or months.
These characteristics help differentiate between a migraine, cluster and the most common of all headaches, which relates to tension. A tension headache is less severe and often caused by muscle contraction in the head and neck region. It presents as a tightness or pressure across the forehead, like a tight strap, with pain described as a dull ache. A sensitivity to loud noises, muscles aches on the side or back of the head, or even tenderness when touching the scalp, neck or shoulders, can be other indicators of this type of headache.
Developing tension headaches can be due to stress, anxiety or strain on the muscles over a long period of time, such as staring at a computer screen, especially one that has not been ergonomically positioned. Sitting for extended periods, lack of sleep, poor eating habits or chronic stress can all contribute to tension headaches.
So neck strain is one of many sources of a primary type tension headache. Yet the neck can also be the source of referred pain from a type of secondary headache, known as cervicogenic headaches, with ‘cervicogenic’ meaning originating from the neck. This upper most section of the spinal cord, known medically as the cervical spine, also involves the connected muscle, tendon and nerve structures that surround the neck and head region.
As cervicogenic headaches can refer pain to the head rather than being felt in the neck, it can sometimes times be hard to differentiate them from other types of secondary headaches. The names of these secondary headaches are prolific, but often have descriptors preceding the word ‘headache’ that indicate the root cause, for example ‘caffeine’, ‘pregnancy’ or ‘medication overuse’. For other types of secondary headaches, determining less obvious causes is something that can be assisted with the help of both the patient, and the health professionals involved.
Head pain and deductive reasoning
Sometimes the headaches we experience can be explained by a simple cause and effect. Overindulging in wine, staring at a screen for too long or lacking hydration are all self apparent causes for a basic headache. Then in hindsight, avoiding these triggers can then be the best prevention.
Some causes though will require a little more detective work, and a diary can be very helpful for when the headache is evaluated in a consultation. This record should contain a history of the headaches, with a date, a start and finish time, along with any other symptoms that accompany the pain, such as a fever, an upset stomach or the location of muscular aches. A description of the type of pain, such as ‘throbbing’ or ‘sharp’ can be added, as well as the pain severity on a scale of one to ten, ten being to the point of being incapacitated.
Further detail can be added to the diary such as foods or liquids consumed, including medication or supplements being taken. Quality of sleep, physical or emotional stressors at home or work, daily activities and conversely time spent at a desk inactive, are also important in pinpointing any potential triggers.
Even with these records, primary headaches are more difficult to tackle compared to secondary headaches, as determining the root cause of migraines and cluster headaches is often unclear. However when a headache is due to tension or referred pain from bone or soft tissue of the neck, physiotherapy treatment can offer some assistance.
Headaches relating to physiotherapy
Determining whether a headache is originating from the neck region, may or may not be obvious as symptoms for each type of headache overlap. For example a tension headache and a cervicogenic headache can both be accompanied by pain in the scalp, neck and shoulders.
How a headache differs may help in its diagnosis as to which type of headache is being experienced. For example a cervicogenic headache may be felt at the back of the head, the top of the skull, forehead, temple or behind the eye, as opposed to a tension headache where a band like pressure is felt across the forehead, back or sides of the head.
Unlike a tension headache a direct connection with the neck may not be experienced with a cervicogenic headache, instead there may be feelings of dizziness, nausea or poor concentration. Either of these headaches could start or be increased in severity by head movement or a prolonged posture, and a reduced range of motion of the neck may also be an indicator.
The underlying cause of a cervicogenic headache can either be a problem with the vertebrae immediately below the skull or the soft tissues of the neck. It could also be due to a strain or injury, and even long term conditions such as degenerative disc disease of the neck’s vertebrae.
To make matters more complex, what appears to be a cervicogenic headache, may in fact be occipital neuralgia. This is when the nerves that run from the top of the spinal cord and up through the scalp, become inflamed or damaged. Regardless of the type of headache, a physical examination provides a starting point from which further investigation may involve X-rays, scans and imaging to provide a clearer view of the neck’s structures. If nerve pain is experienced as part of the headache, a nerve block injection may be organised where appropriate, to help diagnose the cause and treat the condition.
Treatment of neck related headaches
Any neck treatment is a delicate matter because of the complexity of its structure. The vertebrae of spine at this point are smaller than those lower down the back, and so support of the head relies on a complex layering of muscles. Muscles closest to the spine are shorter, typically connecting one bone of the spine to another, while further away from the spine, muscles are generally broader and longer, spanning more joints and connecting more parts of the body. As such any of these can be injured as can the connective tissues, such as ligaments and tendons. Further to this the cartilage that assists in the smooth action of the neck can degenerate, as can the joints through arthritis which can lead to headaches and neck pain.
The complex interaction of nerves and bone joints at the junction of the upper spine and skull provides multiple points of potential injury as well. Nerve compression can cause inflammation and pain, whilst the upper spinal vertebrae are susceptible to compression and movement injuries such as bone spurs or a bulged disc, that can in turn impinge nerves. Thankfully nerve pain from the spine can be mapped, as general areas of the skin are mostly supplied by a specific nerve, that can be traced back to its root in a spinal segment. For example the second and third vertebrae of the cervical spine cover the areas or ‘dermatomes’ on the back half of the head. So head pain felt in these areas may provide an indicator to damage within the second or third vertebrae.
With physiotherapy, an assessment can help differentiate which type of headache is being experienced, and where appropriate, treatment can be very effective in managing headaches of a neck related origin. A physiotherapist can assess the joints of your neck, associated muscle and nerve structures, to identify any abnormalities. Along with the diary, any previous trauma to the neck region, such as whiplash, can also be taken into consideration.
Depending on the specific presentation and symptoms of neck related headaches, physiotherapy management may include joint or soft tissue mobilisation and exercise. Joint mobilisation can be used to help unlock or loosen stiff vertebrae, whilst dry needling, massage and the prescription of strengthening exercises can address tight or weak muscles, and restore stability to the neck area. A physiotherapist can also look at posture and general ergonomic improvements, as these can have a significant impact on headache development and its recurrence.
Ongoing management can involve postural advice and correction, which could include an ergonomic assessment or general advice regarding the setup of your work place. To compliment the hands on therapy and exercise prescription provided by a physiotherapist, stress and tension management may also include assistance in seeking out relaxation techniques or taking up classes such as yoga, that incorporate meditation.
For short term flare ups a hot or cold pack can be used until your next appointment. The use of over the counter pain medication should be in moderation, for example less than three days a week, and preferably after advice from your physiotherapist or doctor. Too much medication can cause what is known as a ‘rebound headache’. This is where medication is taken to cope with the head pain, that reappears after an analgesic or painkiller used for a headache, wears off. So paradoxically the headache is the result of withdrawal from the very drug, that is supposed to stop the head pain.
Ultimately treatment for a headache should lead to self management through understanding of the stressors that initiate a headache. Broader lifestyle changes such as a balanced diet, regular sleep and exercise can also have a positive influence of the recurrence, duration and intensity of a headache, be that neck related or otherwise.
It is important to note that if neck stiffness is experienced with fever, a severe headache and other irregular symptoms such as muscle pain, drowsiness, confusion, a rash or trouble seeing, speaking or walking, then it is essential to seek medical help immediately, as these are some of the indicators associated with the more serious secondary conditions, such as meningitis and septicaemia.