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”This migraine is a pain in the neck!”
The Role of the Neck in Headache Generation

Ninety percent of us will suffer a headache at some time in our lives, ranging from very mild to completely disabling.  They may persist for hours, or even up to months on end.  Some are in the back of the head, some around the temples, across the forehead or in the back of the eyes.  Sometimes they respond to simple paracetamol or ibuprofen, and sometimes, despite strong drugs, the pounding in your head makes you retire to a quiet, dark room and deposit your lunch in a bucket.

The International Headache Society (HIS) lists over 300 different headache classifications, with specific diagnostic criteria for each.  Of these, almost none have a known cause, and clearly there are not 300 different causes of headache.   Let’s look at the two most common headaches.

Migraine:   The IHS classifies Migraine as one-sided head pain that lasts 4-72hours, has a pulsatile, throbbing nature, is moderate to severe in intensity, aggravated by physical activity, and is associated with at least one of the following; sensitivity to light (photophobia) and noise (phonophobia), or nausea and/or vomiting.   There may or may not be a preceding “aura” – a short-term neurological disturbance such as seeing flashing or shimmering lights, or having pins and needles in half the body.  

Tension-Type Headache (TTH):   In contrast a TTH is a non-pulsatile, tight pressing pain of mild to moderate intensity affecting both sides of the head, often across the forehead, that is not aggravated by physical activity.  It does not cause nausea and vomiting, nor photo- and phono-phobia.  TTH can last between 30 minutes and 7 days, and is the most common type of primary headache.

You may have experienced some of these symptoms, and it is very common to have a mixed headaches with different headache types, durations and intensities at different times.  Indeed the latest thinking suggests that Migraine and TTH may be part of a continuum with one common mechanism, rather than being distinct entities with different causes.

Every headache is felt when signals travel up from a group of nerve cells at the base of the brain and upper spinal cord (the Trigemino-Cervical Nucleus, or TCN) to the outer part of the brain, or cortex.  Any painful input from a disorder within the head, plus any pain arising from the upper three segments of the neck, both travel to the cortex via the TCN.   It is believed that due to the convergence of these inputs, upper neck problems can be misinterpreted as head pain as well as magnifying existing headaches.  Similarly, in a 2012 study on 34 migraine and TTH sufferers by Adelaide Physiotherapist Dean Watson, the person’s same headache was reproduced in 97% of cases by sustained thumb pressure over the upper neck joints.   Other research has also demonstrated the same magnitude of pain relief in migraine and TTH comparing medication and manual therapy to the neck, as well as from anaesthetic blocks of the neck nerves, and also from specific exercises to improve the endurance of the deep neck flexor (postural) muscles.  

So even if you have suffered “stress” headaches or classic migraines for years, an assessment from a physiotherapist can quickly determine whether you have a neck component, and show you how to correct this in order to regain control over your headache.  You do not need a referral to see a physiotherapist.  However please consult your doctor first if you have your very first headache over the age of 40, a sudden onset headache, any neurological deficits, concurrent fever or general illness, headache following head trauma, a change to your typical headache pattern, or progressive worsening of your symptoms. 

Peter Biskup  
APA Titled Musculoskeletal Physiotherapist 
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