Headaches can be caused by many factors. Headache Australia describes 35 different causes to headaches. In 2014, the International Headache Society (IHS) classified some headaches, such as migraine, tension type headache, cluster headache and exertional headaches, as ‘primary headaches’. These headaches were classified by the IHS as presenting without a specific medical cause.

Migraine can be a hereditary disorder associated with nerve activation. Secondary headaches have a medical cause due to involvement of neck muscles, joints or nerves, the jaw (temporomandibular joint (TMJ)), infections, tumours, hormonal changes or circulatory changes, to name a few. One of the most common causes of secondary headaches is referred to as ‘rebound headache’ and is a result of medication usage. Lifestyle stressors can contribute to or make headaches worse. These include anxiety, anger and depression. Foods containing tyramine can also contribute to or worsen headaches.These include some smoked or fermented meats and aged cheeses. 

The most common headache is tension-type headache, followed by rebound headache, migraine, infection, neck or jaw related headaches. Consult your GP or the emergency department (ED) if you experience a headache for the first time or if it is the worst you have experienced to assess whether your headache is serious or life threatening.

You might experience the following symptoms if you have a headache:

• pain in the head
• an aching sensation
• throbbing
• pain or aching behind the eye
• blurred vision, pins and needles or numbness in your face or legs
• the worst pain in your head.

It is recommended that you consult your GP to diagnose your headache before seeing a physiotherapist or other allied health practitioner.

If you have an excruciating pain in the head, or if it is your first or worst headache, you should consult your GP or attend the nearest ED to rule out any serious condition. You should also consult your GP if the headaches are ongoing or associated with dizziness, disorientation, difficulty speaking, swallowing, falls, nausea, numbness or nystagmus (where the eyes move rapidly and uncontrollably).

In rare circumstances, headaches can occur after prolonged painting (ie, looking up), go-carting, shaving, motor vehicle accidents or infections that can slowly progress with or without dizziness. In these circumstances, you should consult your GP or attend the nearest ED.

A dentist who deals with TMJ conditions should be consulted if your headaches are associated with teeth sensitivity or jaw pain. This is to rule out a dental abscess, Quinsy or Ludwig’s angina.

Postural ergonomics

Your physiotherapist can assess your ergonomics at work and home to recommend appropriate changes to assist your recovery when headaches occur while sitting, sleeping or in other postures. Some headaches are heightened while working with a laptop, personal computer, iPhone or an iPad. Your physiotherapist will recommend the most suitable strategy to improve your condition. Consult your GP if the headache is ongoing at night or when you wake up. 

Mobilisation

Gentle mobilisation of the spinal joints as well as the spinal or jaw muscles can assist in headache treatment. Mobilisation has an effect on muscles, joints and the nervous system and can improve recovery.

Dry needling or acupuncture

Dry needling or acupuncture can benefit by having a local effect at the site of injury, pain or centrally on the brain, thereby reducing the intensity of the symptom. Local effects include reduction of inflammatory biochemical milieu or increase in fibroblastic activity for healing of inflammation products. MRI studies show that dry needling or acupuncture has an effect on the pain-modulating regions in the brain and the emotional areas. A study on rabbits has demonstrated release of endorphins that can reduce pain.

Botox injections

Botox has been demonstrated to be effective in reducing pain in patients with migraine, headache and jaw (TMJ) pain.

Low-level laser therapy

A systematic review on laser and neck pain reported that low-level laser therapy reduced pain immediately after treatment and up to 22 weeks after completion of treatment in chronic neck pain sufferers.

Spinal taping

Spinal taping uses the engineering principle that indicates forces travel to the ‘stiffest’ region, hence the force being exerted on the muscles and joints is transferred to the ‘stiff’ tape. Taping also modifies biomechanics and function with daily activities and thereby assists recovery.

Feldenkrais therapy

Feldenkrais therapy is a technique that improves postural awareness with functional activities and assists to improve long-standing postural changes and habit.

Stress management

Negative stress can increase muscle tension and heighten nervous system function. Prolonged stress may increase your headache or jaw pain. It has been reported that anger may be associated with some migraine sufferers. Physiotherapists can recommend relaxation strategies, breathing techniques and simple lifestyle management to enhance your recovery. It is recommended that with prolonged headaches you consult your GP, who can organise an assessment by a psychologist for specific stress management strategies and deal with the challenges you are facing.

Mobilisation or exercises

Research on neck-related headaches demonstrates treatment by a physiotherapist with gentle manipulative therapy and a specific neck exercise is more effective than medication. 

Other clinical research shows better effects with medication for migraine and tension-type headache. Your physiotherapist can help with migraines associated with neck and jaw pain. They can also recommend specific pain treatments and rehabilitation exercises for other headaches and temporomandibular disorders, dizziness, benign postural positional vertigo (BPPV) and Bell’s palsy.

Biofeedback has been recommended in the US guidelines, followed by stress-management strategies. Your physiotherapist can help to reduce the intensity of migraines associated with neck and jaw pain and provide preventative strategies. They can recommend specific pain treatments and rehabilitation exercises for other headaches as well as temporomandibular disorders, dizziness, BPPV and Bell’s palsy.

Postural ergonomics

Research demonstrates that the forward head posture (in slumped positions while sitting) could contribute to unilateral migrane and tension-type headache. Your physiotherapist can assist with ergonomic strategies for sitting and different functional positions for long-term improvement. They may apply a specific spinal taping program to improve your spinal biomechanics and posture.

Dry needling and acupuncture are sought by patients with headache and migraine. Researchers in acupuncture and dry needling find that needling can benefit patients with headache and neck pain. Data from multiple studies suggests that acupuncture and dry needling may be useful adjuncts in the treatment of idiopathic headaches. Physiotherapists find that a multi-modal approach combining dry needling or acupuncture with patient-centred exercises and spinal mobilisation is more beneficial.

A systematic review suggested that patients with neck-related headache may benefit from laser for their neck pain and thereby help with their headache.

The Cefaly transcutaneous electrical nerve stimulator has been demonstrated to help patients with headaches and migraine. The Cefaly may be helpful to reduce the intensity of migraines and other headaches in some patients, and should be trialled at home over a period of three months. Patients whose migraines or headaches are sensitive to touch in the forehead or to the Cefaly stimulation may not find it as helpful.

Before self-treating, it is important to consult your GP to rule out whether your headache needs further evaluation or investigation. If your headaches have a contribution from the neck, jaw (TMJ) or spine or due to your posture, your physiotherapist will be able to assist you with home management strategies.

These home strategies will vary from person to person and therefore need to be performed with caution:

• avoid prolonged bending of the neck and trunk while working, reading or cooking
• avoid prolonged neck extension by looking up (eg, when painting or shaving)
• address activities or positions that cause your headache and modify them
• cold therapy (apply a wet towel around your forehead for 15 minutes and repeat every four hours until the headache is eased)
• application of ice cubes in a plastic bag on the top of your head for 15 minutes and repeated four times per hour while awake (if the pressure of the ice bag heightens your symptoms, apply it on the back of your neck)
• if ice is sensitive, apply a warm wheat pack on the back of your neck for 15 minutes (instead of a heat pack) once every four hours
• application of the Cefaly TENS unit following demonstration by a physiotherapist who uses it
• application of gentle pressure on temples, top of neck and top of shoulders for 30 seconds times three per day, as instructed by your physiotherapist
• walking (if possible) for 15 minutes two times per day or 30 minutes once per day
• self-traction of the neck and head in sitting or lying, once demonstrated by your physiotherapist
• gentle neck exercises without increasing your headache or neck pain. (eg, turning your neck from side to side five times and assess your response)
• consult your physiotherapist for more specific exercises
• if sitting and working on a laptop causes headache:

1. Sit against the back of your chair and avoid slouching.
2. Position the top of the PC or laptop just below eye level to have optimal neck posture. Have your feet on the ground. If they do not touch the ground, use a book, box or preferably a slanted foot stool.
3. Get up every 20 minutes for one minute. After one hour, walk around your office or home to reduce glare from the computer and have a break from the habitual sitting posture.
4. If the sitting posture causes ongoing headache, be assessed for a sit-stand workstation (first, trial by placing the laptop on top of a box supported by a table, then sit and position yourself so that the top of the laptop is just below eye level and assess the response to your headache).

It is difficult to predict how long each person’s headache can take to improve.

• An acute migraine headache usually settles within 24–72 hours.
• A chronic migraine or tension-type headache can be ongoing.
• Cluster headaches can occur for 10 minutes and then settle and come again every 20 minutes to one hour. After a few days they may settle for weeks or months.
• A neck headache can be ongoing until the cause of the headache is improved. This could be a result of your posture or stress levels. A physiotherapist who specialises in headache treatment can help you.

See your GP or nearest ED if it is your first or worst headache, a ‘thunderclap’ or excruciating headache.