Let’s Talk About Tension Headaches

Tension headaches are the most common headache presentation and can be a major distraction when they start creeping in halfway through your day. Thankfully there are simple adjustments that can be made to help reduce tension and prevent these headaches from popping up.

Let’s first understand what tension headaches are. Just under 40% of the population will experience these kinds of headaches. They are most commonly seen in women in their 30s but can show up across all demographics. Prevalence tends to increase with a sedentary lifestyle and increased physical and emotional stressors. Tension headaches are different from cervicogenic headaches or migraines. So how do we reach this diagnosis? Tension headaches can be the primary headache someone is dealing with or secondary to cluster headaches or migraines. In either case, we want to understand where the tension headache is coming from.

First, let’s talk about how we diagnose it. Diagnosing headaches is often based on the symptoms you’re experiencing. This includes the presentation of pain, location, and duration. Tension headaches are often described as feeling like a strap in the front of the head or like pressure in the head. It can feel like a dull achy pain, potentially with noticeable neck and shoulder tension or tenderness. They are called tension headaches because tension is the cause. This can mean a couple of things. It could be the tension you’re feeling in your neck and shoulder muscles, but it can also mean stress. Whatever that stress might be (work, relationships, travel, etc.), people often associate it with a tension headache. Whereas migraines and cervicogenic headaches tend to present on one side, tension headaches are usually felt on both sides of the head. This is based on where the problem lies. If the issue is related to a specific joint and its surrounding muscles, that pain signal may appear in a specific location on the face. Tension headaches tend to be more diffuse because more than one area is impacted. In this case, the brain is getting pain signals from the neck, shoulders, and everything trying to keep your head upright and your shoulders pulled back. These kinds of headaches also tend to hit later in the afternoon, after tension has had time to build in your body.

Here’s what we see clinically. If you come in and have more of a tension headache presentation, we’re often able to attribute it to the postures you’re in throughout the day. For example, this could be sitting with your head pushed forward and shoulders slumped. In the clinic, when we’re working on someone, a lot of the musculature in the shoulders and neck will feel tight and activated. It often feels like a tight band throughout the muscle itself. While some muscles will be working too hard, others may appear more atrophied because they haven’t been in an optimal position to be used. Oftentimes, the joints are restricted but most pain is coming from surrounding structures.

Now let’s contrast that with someone with trigger points. In this case, most of the muscle will be relaxed with a specific spot that’s angry and sensitive. When we apply pressure to this spot, it may create a referral pattern that reproduces headache symptoms. With tension headaches, we’re not always looking to reproduce their headache because there are so many different muscles that are angry and involved. They’ve been asked to do a lot of work throughout the day so by early-mid afternoon, they’re angry and generating symptoms. In this scenario, a hands-on approach is very effective. Self-care is also important and can help control tension headaches very well. The suboccipital region at the base of the neck can be very sensitive. There are little muscles that contribute to side bending and turning the head in the upper part of the neck that can be tender as well. You’ll also find a lot of sensitivity throughout the paraspinals, the big muscles that line your spine. Many of our patients complain of tension or knots around their shoulder blades, which are often just in the paraspinal muscles. When these muscles contract, they allow us to extend our neck and back. Consider your posture when sitting: it may often consist of looking down, rounding your shoulders forward, and having a forward head position. When we’re in this kind of posture, the mid portion of the neck has to extend to keep your head up. When the head is 10-12 pounds, holding it forward for 8 hours in this position is extremely taxing on these muscles. 

We’re not designed to work this hard. When we’re standing or sitting in a neutral position, the weight of the head is just resting on the spinal column. We’re asking our muscles to do extra work when we’re in a more forward posture. Minimal muscle activation should occur to keep your head upright. On top of this, you have multiple shoulder muscles that insert into the neck. As our head is forward, not only are the paraspinals activating to keep our head from flopping forward, but our shoulder muscles are working hard as well. This general tension over time is the key to addressing tension headaches. 

So what do we do? 

  1. Move more – get up and walk around. Taking breaks throughout the day can help counteract the negative impacts of being sedentary for long periods. 
  2. Be mindful of your posture – check in with yourself. Where are your neck and shoulders sitting? What is your work setup like? Taking time to be mindful throughout the day of how you’re positioned can make a big difference. If you’re standing, engage your core and unlock your knees. Be intentional about creating an active posture. 
  3. Start an exercise routine – it doesn’t have to be extremely rigorous, but just starting some sort of routine can help condition your muscles (especially your shoulders) to tolerate what your day entails. This could be a Youtube video, an exercise class, or going to the gym. 
  4. Incorporate specific neck and shoulder stretches throughout the day – lay on your foam roller for 5 minutes to counteract some tension so it doesn’t continue to build. Having a targeted routine to counteract that forward head and shoulder positioning is an important part of self-management.

Everyone’s situation is different, but getting into a regular exercise routine and being mindful of your habits throughout the day is the best way to start self-managing your tension headaches. We hope that you have now gained a better understanding of how tension headaches are diagnosed, where they come from, and how to begin some self-management strategies to counteract neck and shoulder tension. If you need more guidance or a hands-on approach, reach out to our clinic to schedule a free Discovery Visit with one of our clinicians. 


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