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  • Writer's pictureDr. Donald Littlewood

Why does my head hurt?

Tension-type headaches (or TTH) are the most common type of headache in the world. In fact, it is thought that ~80% of the people on Earth will get a TTH at some point in their life. In fact, a recent article published in 2021 calls tension-type headaches ‘the most prevalent disorder in the world’, affecting 1.89 billion people. Yup, they’re that common.


We call TTH a benign primary headache, which means that nothing is actually wrong with you (it just hurts) and that it is coming directly from sources in the head and not from anywhere else (like your neck or last night's tequila).


So, how do you know if you have a TTH? Well luckily, the International Headache Society (yup, there’s one of those) has a nice little definition for us. In order to be a tension-type headache, it must have:

·      Episodes last for several hours or are continuous

·      Pressing or tightening feeling

·      Mild-moderate in pain intensity

·      On both sides of the head, or like a headband all the way around the head

·      Not aggravated by physical activity

·      Can be associated with sensitivity to light or sound

·      No nausea or vomiting


These headaches can also be episodic or chronic, which is differentiated simply by how often you have the headaches.

·      Infrequent episodic: less than one headache a month (or less than 12 per year)

·      Frequent episodic: headaches occur between 1-15 days a month (or 12-180 days per year)

·      Chronic: 15+ headaches per month for at least 3 months duration


Where do TTH come from?

Now that we know what tension-type headaches feel like, let’s talk about how we get them.


This is where things get a little up in the air. To be truthful, there is no research out there that tells us exactly why one might get a TTH. We do have a couple of theories, so let’s chat about those, since it really is the best we have.


Nociceptive System

Before we get to it, I know what you are thinking… what the heck is nociception? Nociception is the detection of a painful stimulus. Your body has special nerves to detect pain, heat, cold, chemical signals, etc., all to protect you from something potentially dangerous.


In terms of a TTH, the activation of myofascial nociceptors in the muscles of the head and neck can become stronger and this can increase the pain you might be feeling. We also see increased levels of inflammatory chemicals in those with TTH than those without them.


Muscle Stiffness

It has been shown multiple times in multiple different studies that an increase in muscle stiffness and tenderness is seen in those with TTH, most notably in the muscles of the head and neck. We have seen that sustained muscle contractions (or trigger points), a lack of oxygen, and a liberation of inflammatory chemicals in the muscle tissue can all increase TTH.



Interestingly enough, there is almost no genetic link in episodic TTH with research stating that environment plays more of a role with them. In chronic TTH however, there are several genetic associations. We need way more research here to give any specifics.


Sleep disorders

Up for a classic conflicting stories moment?!


We have evidence showing us that TTH are prevalent in those with sleep disorders and that dysregulated sleep can actually trigger a TTH. But, we also have evidence (both in research and anecdotally) that sleep and rest are one of the most common (& effective) strategies to relieve your TTH.


Use that information as you will!


Gender & hormones

It has been fairly well documented that hormonal changes (particularly in those assigned female at birth) can trigger TTH. We know this to be especially true in perimenopausal women. These hormonal changes can also lead to the onset of more stress, fatigue, and sleep disturbances, which are all TTH triggers on their own.


Additionally, those assigned female at birth are more likely to have trigger points (and worse ones, at that), regardless of the location in the body.



TTH are commonly diagnosed in childhood. Interestingly enough, there are a few different environmental factors of childhood that can predispose people to TTH:

·      Maternal smoking

·      Stress during pregnancy

·      Percent body fat at age 11

·      Bullying at age 11

·      Low childhood socioeconomic status

·      Parent-reported difficulties between ages 3-5


Treatment of Tension-type Headaches

We’ve gone over what tension-type headaches are and what kind of factors can bring them on or make them worse, so now it is time for some treatment options.


Note: I will only be talking about things that chiropractors can do to manage TTH. I am not at liberty to discuss pharmaceuticals (over the counter or otherwise). Please discuss these options with your physician or pharmacist.


There is really good evidence out there supporting chiropractic care and manual therapy for the treatment of TTH. Yay!


It has been shown that manual therapy can:

·      Decrease headache frequency (average of ~6 days a month). Fun fact: 87.5% of people in the study I’m referencing showed a 50% decrease in their headache frequency.

·      Decrease in duration of each headache episode

·      Decrease in intensity by ~2 points (out of 10)

·      Improvement in neck range of motion and muscle endurance

In this particular study, the participants received 9 treatments of 30 minutes duration over 8 weeks. Those results were found after the 8 weeks and were maintained at a follow up 6 months later.


Now let’s talk about what some of these treatment options might be.



Applying a small heat pack to the temples or the muscles of the neck/upper traps can be really helpful for calming the muscles down, reducing trigger points, and increasing local delivery of our body’s own healing chemicals.



Chances are, you’re on the dehydrated side anyway so you should be drinking more water as it is. But in terms of muscle tissue, making sure you’re getting enough water is important for ensuring that your muscles get enough oxygen and nutrients to perform to the best of their abilities.


Soft tissue therapy

We have seen evidence that there are more trigger points in those with TTH than those without and that those trigger points are correlated to an increase in the frequency, duration, and intensity of TTH. To make it fun, we also have evidence that completely contradicts that, stating that there is no correlation at all.

My two cents: do the soft tissue work.


We know that soft tissue work can decrease active trigger points and improves range of motion of the joints. It feels good and it encourages rest and relaxation. And plus, it has the potential to be very beneficial, so why not try it.


Mobilizations and Adjustments

Trigger points can cause decreases in range of motion and therefore the joints can get stuck in one place and stop moving. (Fun fact: the reverse is also true – a fun chicken and egg conundrum).


Mobilizations and adjustments are techniques chiropractors use to restore motion in the joint where motion no longer exists, so using these techniques has been shown to decrease the effects of tension-type headaches.


Postural relief exercises

Clinically, we often see forward head posture in those with TTH. This is because of the other factors that contribute to TTH like stress at work, thus leading to computer gremlin posture. Providing your body opportunities to not be a hunchback has been proven to help with TTH.


Brugger’s position of relief

This is one of the best ways to combat computer gremlin posture.


·      Sit at the edge of your chair, feet a bit wider than shoulder-width apart with your toes pointed out.

·      Sit up nice and tall, imagining there is a string coming from the ceiling pulling you up.

·      Arch your back and stick your chest out.

·      Turn your arms out so your palms are facing in front of you.


Ideally, you’d get into this position once an hour for 30-45 seconds each time.


Final thoughts

Tension-type headaches are undoubtably common and disabling. Due to their prevalence, they are a burden to our public health system in terms of job absence and time/resources for our healthcare professionals.


We know that manual therapy can provide significant, long-lasting improvements on TTH, making it one of the most cost-effective and beneficial options we have to kick these headaches once and for all.


If you, or someone you know, has tension-type headaches, I would love to help you get rid of them. If you are in and around Toronto, head on over to to book a free phone consultation so I can help you be headache-free!



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