Headache disorders are becoming more prevalent in our society today. In the U.S. alone, migraines affect 10% to 12% of the population, and tension-type headaches (TTH) afflict more than 38%.¹ In terms of lost annual productivity, migraines account for 57% of lost days of work and TTH 43%, imposing an economic burden on employers.¹

PTs are also seeing more patients referred to physical therapy with a diagnosis of chronic headache, TTH, or cervicogenic headache. These patients can be difficult to treat when the real source of the headache is unknown to the patient and the PT. The source of pain may not be obvious during the initial evaluation, challenging the PT with where to begin treatment. However, differences among the types of headaches commonly seen in the clinic can guide the PT to an appropriate treatment. Diagnostic criteria can lead to evidence-based practices.

Headache is sometimes described as a psychophysiological disorder.² It can be a psychosomatic process with both stress and illness components. Some researchers have related headache response to the general adaptation system or stress response first proposed many years ago where the body maladapts to stressors, producing a headache.² Migraine sufferers may also have comorbidities such as depression, panic disorder, or sleep disturbance.³

Headache Classification

PTs should be able to differentiate between the types of headaches for patients who enter the clinic. For example, oftentimes, we will see prescriptions for chronic TTH or cervicogenic headache, when what the patient actually describes during the medical history review sounds more like migraine headache. Appendix 1 displays an example of a medical history form that may be used to differentiate these two types of headache for this population of patients.

This screening form can help the therapist and patient gain some insight into possible causes of the headaches. It can also serve as a baseline measure for pain and stress levels, and it can give patients a chance to verbalize their goals for physical therapy. Diagnosing what type of headache these patients have is beyond our scope of practice. We need to be part of the medical team working with patients to help them manage their headaches. And as PTs, we are responsible for teaching patients common causes for headaches and how they can help themselves. This history form can help start these important discussions.

As PTs, we need to be able to recognize the type of headache our patients have to know how to best treat them. If we are not sure if it’s a TTH or migraine, how will we know how to proceed? Will we be helping the headache or exacerbating the symptoms? Therefore, we will begin by discussing the different types of headaches that are commonly diagnosed and the differences between them. However, patients often present with more than one type of headache pattern. Very often, they will exhibit characteristics of more than just TTH. Some experts even argue that migraine and tension headaches are actually ends of a spectrum instead of being different types of headache.⁴

A typical migraine attack has four phases: the premonitory phase, which can be hours or days before the headache occurs; the aura phase, which happens immediately before the headache; the headache itself; and the headache resolution.⁴ However, a patient does not have to have an aura to have a migraine. Nor is it necessary for the patient to have the migraine headache after the aura. A patient may completely skip one of the phases of the headache but still be diagnosed as having a migraine disorder.

During the premonitory phase, patients may describe a characteristic change in mood or behavior. They may also report a migraine coming on by a general feeling of impending unease.⁴ Some patients also will have minor bouts of depression or even food craving during this phase.

The aura phase may or may not be present in a migraine patient. It usually consists of focal neurologic symptoms and can last anywhere from 5 to 20 minutes. Usually, the patient will report visual disturbances or possibly motor phenomena, such as muscle twitching around the eyes, but language may also be affected.⁴ The migraine headache will usually occur within 60 minutes from the end of the aura, but the headache can be absent. In fact, in one study, migraine headache followed an aura only 80% of the time.⁵

Typical symptoms during a migraine headache will include unilateral pain that is throbbing in nature and moderate to marked in severity. Physical activity usually aggravates the headache. This is very important with respect to our education piece with the patient. A patient who comes to us for help with headache management needs to learn how to tell the difference between a “usual” headache and a migraine headache, so he or she knows when to reach for prescribed abortive medication for migraine during the window of opportunity when it will be most effective. If patients are unable to discern whether or not they are having a migraine and do not take their medication as prescribed, it will not work properly, and they will have poor control over their migraine.

One characteristic that can help differentiate a migraine from other types of headaches is that the onset is usually gradual.⁴ Most patients think that a migraine should be of sudden onset and excruciating in nature, but that is not the case. Migraines typically begin between the hours of 5 a.m. and noon. The median duration of an untreated attack is 24 hours, with a usual duration of 4 to 72 hours in adults and 1 to 48 hours in children.⁴

Other common symptoms associated with migraine are anorexia, nausea, sensory sensitivities like photophobia or phonophobia, blurry vision, nasal stuffiness, diarrhea, abdominal cramping, pallor, sweating, polyuria, and sensations of hot or cold.⁴ Some patients will also complain of stiffness in the neck, fatigue, anxiety, and faintness. No two migraines are the same, so symptoms may change with each headache onset, depending on the triggers, time of day, and level of arousal.

During the resolution phase, the headache has been treated. The patient may be tired, irritable, or listless. However, some patients may actually report feeling euphoric or refreshed.⁴ Again, each patient and each headache are different.

The TTH is the most common type of headache disorder seen.⁶ TTH can vary from rare to frequent episodes, and it can even develop into a continuous and disabling headache.⁴ TTH is more prevalent in women, and it tends to decline with age.⁴ This type of headache does not have premonitory symptoms or an aura phenomenon. The patient will typically complain of pain that is dull and achy — not pulsatile like that of a migraine.^4,6 It is usually of mild to moderate intensity and bilateral in contrast to the moderate-to-severe, unilateral symptoms of migraines.⁶

Patients with TTH will also describe a feeling of tightness or a band-like pressure around their heads. TTH pain can involve frontal, temporal, or occipital regions and can move from one region to another during the attack, and it usually does not keep the patient from performing their usual activities. This is quite different from migraine headache where physical activity will tend to aggravate the symptoms. A common precipitating factor for TTH is lack of sleep. TTH can be misdiagnosed as a sinus headache or as cervicogenic headache, the most commonly referred headache type for PTs.

Headaches that occur for 15 or more days per month are chronic.⁷ This is sometimes associated with overuse of over-the-counter medications that contain caffeine.⁷ This is most often called a “rebound headache.” Medical and pharmacological intervention is often the best treatment option initially.⁷

Many headache sufferers do not even seek treatment. One in two patients chooses to discontinue his or her treatment due to dissatisfaction with the results. One third of headache sufferers have a co-existing depression or anxiety disorder.⁷ In general, many patients are non-adherent with long-term medication treatment. A 2005 investigation found that about 50% of patients discontinued their treatment. In patients who are on long-term prophylactic medication for headache management, the figure is similar.³ This important statistic should alert us as PTs about the need to educate our patients to help them be adherent with the medication regimen established by the referring physician.

One-third to one-half of headache patients are non-adherent to some extent with their medication usage as prescribed by their clinician.³ We need to be functioning as part of the collaborative medical team to treat headache patients and reiterate the importance of medication usage. We also need to help patients with self-management of their headaches. Patients are being asked to manage other chronic conditions, such as hypertension and diabetes, and headaches are no different. As with any long-term disorder or diagnosis, patients need to take responsibility for lifestyle changes, identifying triggers, and reclaiming locus of control. Patients should be persuaded to form an alliance with the healthcare team to manage their condition for the long term.³

Pharmaceutical Interventions

Drug therapy is the primary intervention for migraine headache disorders. For these patients, beta blockers, calcium-channel blockers, antidepressants, and anticonvulsants are commonly used for preventative therapy.^4,7,8 For abortive treatment in migraine, analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and triptans are common choices.^4,7 In TTH patients, amitriptyline (Elavil) is commonly prescribed as a prophylactic therapy, and analgesics and NSAIDs are again used for abortive treatment.^4,7,8 Many other medications are commonly used for migraine.

A good reference to keep at hand for personal use to understand the mechanism of action for most medications used for this patient population is Management of Headache and Headache Medications, by Lawrence Robbins, MD.⁷ This source is easy to understand, and one can quickly look up a medication to get a good description. PTs need to understand the differences between prophylactic and abortive therapy to reinforce the proper use of medication. And in the face of any uncertainty, refer the patient back to the physician or pharmacist to address any concerns.

Physical Therapy Interventions

Physical therapy is a viable option for many patients unable to afford high-cost medications or for situations when medications may be contraindicated or do not work. Many PT interventions are appropriate for the treatment of TTH. Modalities may include the use of heat (moist hot pack or ultrasound), cold packs, transcutaneous electrical stimulation (TENS), and interferential stimulation. Stretching and exercise may help improve the patient’s posture, as can mechanical traction, if it is tolerated. Trigger point release or myofascial release, as tolerated, may also be of benefit to headache patients.

With the patient with migraine, treatments become more complicated. The source of the migraine headaches may not be completely understood; the PT may function as an educator in a supportive role within the larger health-care team. The PT can teach the patient positive coping techniques in several areas: Instruct patients on how to start a “headache diary,” which can help them to recognize triggers, patterns of headaches, and responses to medication usage. It can also be useful for diagnosing medication disuse or overuse. Appendix 2 displays a sample headache diary.

Patients should also be instructed on what has been described as “sleep hygiene.” A disruption in a person’s typical sleep pattern, that is, too much or too little, can trigger a migraine.⁴ Just as skipping sleep can trigger migraines, so can skipping a meal or prolonging the time between meals.¹¹ Some migraine patients will also report having “let down” headaches where the actual migraine takes place after the stress has passed.⁷ These are often detected by looking at the patient’s diary, which makes it an invaluable tool.

Patients should learn to avoid typical triggers to migraine-type headaches, such as alcohol (especially red wine), cigarette smoke, bright sunlight or fluorescent lighting, smells such as fresh paint, too much or too little caffeine, aged cheese, foods containing a high concentration of nitrates, aspartame, monosodium glutamate, chocolate, or stress.¹ This list is not exhaustive, but it can provide patients with a starting point when trying to determine possible precipitating factors. The goal is to shift the locus of control from the healthcare team to patients. Giving them the sense that they can manage their symptoms and regain some sense of control over their headaches is an important step in the process of pain management.

Behavioral Therapies

Behavioral therapies are within the practice guidelines for physical therapy and have solid research showing significant impact on headache management.^7,9,10 This includes teaching patients how to handle stress through coping techniques and modifying their response to stressors. PTs can also help patients with relaxation training. Specific techniques include progressive muscle relaxation, autogenic training (warmth and heaviness), meditation, passive relaxation, and diaphragmatic breathing.^2,8,11 These behaviors can help reduce sympathetic nervous system arousal, shortening the duration of a headache if not necessarily preventing the actual headache from happening.

Biofeedback is also an acceptable form of behavioral therapy, and its value is supported by the literature.^2,3,9,10 The feedback can be given to the patient via visual or audio output. The TTH patient is instructed to try to diminish EMG activity or tension in the muscles of the head, neck, or shoulders. The treatment is different, and not as understood, in the migraine patient.

Cognitive behavior treatment is another behavioral therapy that is effective with patients with headaches. Patients learn to become aware of their response to stressors, their interpretation of the events that happen around them, and how they respond, including their usual behavior patterns and coping mechanisms.² Patients often do not notice how destructive their behaviors can be until they are asked to report how many times a day they have negative or self-destructive thoughts. This can be an eye-opening learning experience for both the patient and therapist.

Research has demonstrated a significant correlation between the use of cognitive behavior research and symptom management.^2,8-10 This has clinical implications for PTs whose practice is appropriate and conducive to teaching and reinforcing these behavioral techniques with their patients. In a 1999 study, there was a 32% to 49% decrease in headaches with migraine patients when behavioral techniques were used as treatment.⁹ In a similar 2001 study, a 37% to 50% reduction in headache occurrence was found using behavioral techniques with TTH patients.¹⁰ Upon follow up 5 years later, 91% of the patients with migraine and 78% with TTH still retained significant improvement with symptom management and decreased frequency of headaches.^7,9,10 When medication and behavioral therapies are used together, even better outcomes are achieved.² One investigation reported a larger reduction in headache activity — 64% of headache patients with the diagnosis of TTH — when stress management was used with a tricyclic antidepressant medication than when each of these treatments was used alone.

Other typical therapeutic PT interventions have equivocal support. For example, research in 1998 reported that spinal manipulation showed no positive effect as an isolated intervention for the treatment of TTH.⁶ The patients in this study were instructed to keep headache diaries to track the intensity of their headaches as well as pain medication use. Groups that received the manipulations and friction massage reported a reduction in analgesic use and in headache hours of 1.5 per week. However, the intensity of the headaches experienced was unchanged by treatment.⁶ This was promising in terms of diminished duration of the headache, which in turn, decreases the disability and time lost due to inability to function.

Other Therapeutic Interventions

The Cochrane Collaboration published a systematic review in 2004 with other findings about noninvasive treatment techniques. This review reported that spinal manipulation may significantly impact prophylactic headache management in patients with migraine type and cervicogenic type headaches.¹ However, manipulation did not seem as effective prophylactically with TTH as the use of the medication amitryptyline. This review also revealed limited evidence to support the application of transcutaneous electrical nerve stimulation (TENS) and pulsating electromagnetic fields for prophylactic management of migraine. The use of TENS and therapeutic touch for TTH also had only weak supporting evidence.

In this same report, there was some evidence that gentle exercise and spinal manipulation may be beneficial for cervicogenic headache. None of the results were definitive, and the data was not able to be pooled due to the heterogeneity of the studies. The take home message is that there needs to be higher quality studies performed on the role of modalities, manipulation, mobilization, and exercise in the treatment of headache patients.

A Practical Approach

What does the evidence support for noninvasive treatment options for migraine-type and TTH patients seeking physical therapy? No definitive evidence supports the use of heat modalities, such as ultrasound, yet; although some patients will report relief with hot compresses when used at home. Weak evidence supports the use of TENS for prophylactic treatment of migraine and TTH. Stronger evidence supports the use of spinal manipulation for symptomatic improvements with cervicogenic headache and prophylactic treatment of migraine. Interventions, such as stretching for the upper trapezius muscle, levator scapulae, and pectoralis muscles, will help with postural deficits. Strengthening weaker components, such as scapular stabilizers or pectoralis muscles, can help to balance the patient’s posture and create better alignment, thus taking pressure off the spine. Education on sleep positioning to maintain a more neutral cervical spine can benefit these patients as well.

Body mechanics education is also crucial for TTH patients, especially for patients who are lifting throughout the day, driving for long periods of time, or caring for small children. All of these situations can cause patients to make compensations with their posture — frequently without them noticing how compromised they are. Another important area that requires education is ergonomics. Repetitive stress to the upper extremity and cervical spine can easily be overlooked and may often be a trigger for TTH.

By simply examining the patient’s diary weekly, the PT may be able to find precipitating factors and behavioral patterns that can be avoided. For example, reminding patients to stretch on a long flight during a business trip, wear sunglasses when it’s particularly bright outside, get up from their desks to stretch and move at work every hour, and correcting their body mechanics when bending over a crib to lift their infants multiple times during the day may prove beneficial.

More focused research is needed in the area of noninvasive and nonpharmacological treatments for this patient population. Combination therapy, where PT is an adjunct to prophylactic medication, is promising, but has yet to be explored in detail. These patients need education about the proper use of their medications so they are adherent. More behavioral/cognitive treatment can help discover the cause of the headaches and to educate patients. The current PT treatment techniques, though not proven to be statistically significant on their own in the treatment of migraine or TTH, pose no threat or risk to the patient and may be beneficial. More studies need to address these interventions in conjunction with the rest of the healthcare team to produce better outcomes for these patients.