The purpose of this document is to inform people who are suffering from headaches and neck pain about chiropractic treatment. Each year, more than 22 million people consult chiropractors. Of these, 7.7 million, or 35%, are seeking relief from back pain from various causes, including accidents, sports injuries, and muscle strains. Other complaints include pain in the neck, arms, and legs, and headaches. Do you frequently experience pain and/or discomfort on the sides or back of your head? Have you been feeling tightness or tension in your neck as well? If so, it is likely that you are suffering from tension headaches. Since the cause of tension headaches and neck pain is highly associated with each other, the effects, functional limitations, and impact on one’s quality of life are similar for both conditions. Oftentimes, it can lead to a vicious cycle of chronic tension-type headaches and status migraine with little hope of relief. In order to better understand this cycle, it is essential that we become familiar with the characteristics of tension headaches and neck pain, followed by an investigation into the common causes of the conditions. Through acquiring this knowledge, those who suffer from these debilitating conditions can take the first step in actively breaking free from the cycle, as it will allow them to make more informed decisions in seeking appropriate treatment. This manual is an essential tool for high-quality treatment of tension-type headaches and neck pain, and in order to gain maximum benefit, readers are strongly advised to use it in conjunction with the treatment itself.

Overview of tension headaches and neck pain

Tension type headaches and neck pain are prevalent and burdensome conditions that affect the vast majority of our population. The lifetime prevalence in the U.S. is around 30-78% for tension type headaches and 15-17% for chronic daily tension type headaches. A higher prevalence of tension type headaches has been reported in women. Neck pain often coexists with tension type headaches and its prevalence in the past 6 months has been reported to be as high as 68.4%. It is also more prevalent in women and prevalence seems to increase with age. Tension type headaches and neck pain are often associated with trigger points located in the muscles of the head and neck, and are commonly described as muscle tightness or spasming in quality. The pain is usually mild to moderate in severity, but can be disabling in the case of chronic tension type headaches and severe neck pain. Tension type headaches usually present as bilateral head pain of a pressing or tightening quality, but may be of mild to moderate intensity. These characteristics are in contrast to chronic migraines which are debilitating and usually present with associated symptoms such as nausea, vomiting, photophobia, and phonophobia.

Common causes of tension headaches and neck pain

Guideline 1: We should be informed by this text. Guideline 2: There are many causes of chronic tension headaches and neck pain. Guideline 3: There are many ways to initiate the onset of tension headaches and neck pain. Guideline 4: The text is rather complex by having subcategories of the causes of tension headaches and neck pain. Guideline 5: The coherence is there from the beginning to the end of the text.

There are many causes of chronic tension headaches and neck pain, but the most common are trigger points in the neck and shoulder muscles, forward head posture, and reduced movement of the lower neck joints. Poor work postures involving computer use and sustained or repetitive activities are often the culprits. An acute injury such as whiplash from a car accident or a fall can initiate the onset of chronic headaches and neck pain. In some cases there may be a more serious underlying pathology such as infection, tumor, or nerve compression in the upper neck, but these are rare.

Impact of tension headaches and neck pain on daily life

The burden of this illness on the individual is very high, and they often feel frustrated and hopeless in their attempts to improve the situation. Extensive research in tension-type headache has shown variation in the relative prevalence of the different factors associated with headache. In most epidemiological studies, the most commonly associated factors are raised muscle tenderness in the head and neck, and frequent use of analgesics. Factors such as anxiety, depression, and poor sleep are relatively less common. However, these factors are shown to be more prevalent in chronic tension-type headache than in the episodic form. In chronic tension-type headache, the symptoms are present on more days than not, and the presence of medication overuse often leads to a very disabling illness.

The impact of tension headaches and neck pain on daily life is substantial. Depression is common among sufferers. Concentration may be impaired, and they may avoid activities that can worsen their headaches. Work, household tasks, and family and social activities are all likely to be adversely affected. Major life events or changes such as a marriage, birth of a child, or a new job can sometimes act as a trigger to improve or worsen the symptoms. This can be an important consideration in the assessment of someone with chronic headache.

Non-Medical Treatment Options

Massage therapy: Although there have been very few scientific studies into the effects of therapeutic massage for tension headache neck pain treatment, it is a therapy which is often thought to be effective by those who suffer from this type of headache. The intention of massage is to reduce tension in the soft tissues, stimulate the relaxation response and improve the general state of well-being. These effects can be beneficial in providing relief from headache, as well as in preventing headache and neck pain from occurring. However, it should be noted that things may get worse before they get better. People with chronic tension in the neck and shoulder muscles may feel a bit achy and sore for a day or two after the massage. A persistent approach with repeat massage over a period of weeks may bring some lasting relief.

Breathing exercises: When we are stressed we often breathe more quickly and less deeply than we should. This can cause changes in oxygen and carbon dioxide levels in the body which can lead to feelings of dizziness and light-headedness, which can bring on tension headache. It can also cause tightness in the chest and shoulder muscles, which may contribute to neck pain. Learning to breathe in a slow, rhythmic and controlled manner can help to reverse these effects. A useful method is to lie on the floor with the knees bent, placing one hand on the upper chest and the other on the abdomen. By breathing in and out through the nose and making the abdomen rise and fall with each breath, the chest should move as little as possible. This is slow, controlled diaphragmatic breathing and is a useful skill to practice for 10-15 minutes, 3 to 4 times per day to start with. It is a good way to calm down if feeling stressed or agitated and can also be helpful as a means of getting off to sleep. Learning to notice when breathing becomes fast and shallow and using this as a cue to take a few minutes of diaphragmatic breathing may prevent headache or neck pain from occurring. In some cases it may be worthwhile to try a relaxation method which includes both breathing exercises and muscle relaxation, such as yoga or a general exercise class, where the atmosphere is calm and encouraging.

Progressive Muscle Relaxation: This is a skill which takes time and practice to master, but the benefits are worth it. By learning to tense up and then relax each muscle group in the body, starting with the feet and working upwards, it is possible to become more aware of muscle tension and to learn how to let go of it, and allow a state of relaxation to take over. When practiced regularly, it is possible to bring about a state of deep relaxation and to reduce the general level of muscle tension in the body. This can be useful in providing relief from tension headache and neck pain, as well as in preventing these symptoms from occurring when under stress. This method is not suitable for those who have severe muscle pain and initial practice should be supervised by a therapist.

Relaxation techniques for tension headache and neck pain relief. These are a range of methods and therapies that help reduce muscle tension and anxiety, and in so doing, provide relief from the pain of tension headache and neck pain. Relaxation techniques can also prevent the headache and neck pain from occurring. In clinical trials, people with tension headache have reported good pain relief after learning these techniques. You need to set aside around half an hour a day to practice relaxation. It can take some weeks before you notice an improvement. It is worth persevering as the more you practice, the more the relaxation response is likely to be in evidence during times of stress or muscle tension. Consequently, you are more likely to be able to prevent headache and neck pain occurring. Techniques for relief of headache and neck pain include:

Relaxation techniques for tension headache and neck pain relief

Cognitive Behavioural Therapy is aimed at helping people to change the way they think, with the idea that if you change the way you think, you can change the way you feel. It has been shown to be effective for chronic headaches and more recent onset headaches in reducing how often they occur and how severe they are. Sessions usually comprise of education about headaches, training in relaxation methods, and changing stress-inducing thought patterns and problem-solving to develop healthier ways to cope with stress. The training in relaxation methods can involve teaching of techniques previously mentioned and may also involve the use of imagery by visualizing a calming and relaxing experience to escape the stress and tension.

Deeply relaxing and emotional stress reduction can have a positive effect on muscular tension and the resulting discomfort and pain. There are numerous methods to relax which include: progressive muscle relaxation, in which each muscle group is systematically relaxed; diaphragmatic breathing, in which you breathe deeply and slowly using your diaphragm thereby reducing the effects of hyperventilation; and Autogenic training, which is similar to meditation and results in a state of calm and tranquility. The effectiveness of these methods is hard to quantitatively measure, but they have been shown to be effective when used in conjunction with other methods to relieve muscular tension and reduce the frequency and intensity of headaches. A trained professional such as a physiotherapist can teach you these methods and direct their use for your specific condition.

Physical therapy exercises for pain management and stiffness

Passive modalities: your therapist may decide to use modalities such as heat, ice, ultrasound and electrical stimulation. Heat and/or ice are easy self-treatments that can be effective at easing pain and reducing inflammation. Heat helps by stimulating blood flow to the area of pain which in turn supplies fresh nutrients and washes out the build-up of waste products. Heat also has a relaxing effect which can soothe discomfort. Ice is a simple and effective self-treatment for neck pain and headache. It can be used for 10-15 minutes every few hours, it helps to reduce the inflammation and pain from acute injuries. A bag of frozen peas works well because it can be molded to the shape of the neck. Ultrasound is a deep heating treatment which is often used to warm the area before hands-on therapy. Electrical stimulation (e.g. TENS) is used to relieve pain and reduce muscle spasm. This is done by sending a light electrical current to certain areas of the neck.

Physical therapy is an important treatment modality for most patients with neck pain. A physical therapy program that emphasizes a combination of active and passive treatments is most effective.

When the aim is to alleviate pain and discomfort, an exercise program can be the best approach. It is general knowledge that patients with pain avoid activity, however inactivity has been shown to increase pain and can lead to a loss of muscle strength and flexibility. A program that increases endurance and strength will result in reduced pain, improved function and fewer recurrences of neck pain and tension headaches.

Lifestyle modifications to prevent tension headaches and neck pain

– Elimination of factors that cause headaches and neck pain in one way or another will simplify and improve other treatments for headaches and neck pain. – Reducing or controlling triggers that can cause headaches or neck pain is a very important strategy. This is because if successful, you can prevent headaches and neck pain from occurring initially. – Maintain good posture. Good posture reduces stress on your head and neck. If you sit at a desk a lot, get up and move around at least once an hour. Sit in a chair with good lumbar support. Keep your head and shoulders erect. When reading or typing, keep the material at eye level so you do not have to bend your head forward. An ergonomic chair or an ergonomic assessment of your workstation may be helpful. This is one of the best home physical therapies to improve your posture.

Medical Treatment Approaches

Clinically, there is a lack of good evidence to support a single type of medication as being superior for the treatment of tension headache. Generally, it is only worth embarking upon preventative medication if simple management strategies such as trigger point therapy, posture correction, and stress management have failed. The decision to use or not use medication is usually based on the degree of interference with the patient’s normal activities and professional life, as well as the quality of life. If a decision is made to use medication, it should be given in conjunction with other therapies and should be regularly reviewed with a plan to discontinue it because long-term use of medication often results in medication overuse headache, which is a primary cause of chronic daily headache. With recent concerns over stroke and heart attack risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs), it is best to avoid long-term use of these medications. Antidepressants have been shown to be effective for tension headache. The mechanism through which they work is not entirely understood; however, it is likely to do with an effect on the central neurotransmission of pain. Amitriptyline in doses of 10-115 mg daily taken at night has the best evidence of any medication being effective for the prevention of tension headache. A widespread concern in today’s healthcare climate is that people are spending money seeking medical procedures to treat chronic musculoskeletal pain conditions, which are either unaffordable or pose a high risk with little chance of a successful outcome. It is important to be aware that tension headache is not a pain condition which surgically intervenes well, with no surgical technique having been developed specifically to treat it. Invasive procedures should be a last resort for severe headache disorders, and it is difficult to consider any tension headache which is not associated with severe functional impairment as falling into this category.

Over-the-counter medications for headache and neck pain relief

Muscle relaxants – while these agents are available only by prescription, medications such as diazepam are sometimes used for treatment of chronic pain and stiffness. There is some evidence that a short course of low dose diazepam can be more effective than simple analgesics for treating acute neck pain.

Excedrin Tension Headache – as one of the most studied and effective OTC medications, it contains a combination of aspirin, acetaminophen and caffeine which makes it an ideal choice in many tension headache sufferers to relieve pain and restore alertness or functional capacity lost during the course of headache.

Simple analgesics – such as aspirin, paracetamol or ibuprofen (or anti-inflammatory dose of aspirin or paracetamol) may relieve the acute pain and useful for the prevention of headaches. These medications should be used with caution by individuals with other medical conditions, and are not recommended during pregnancy.

The nonprescription medication options to consider when treating neck pain and tension headache typically fall into three broad categories:

Prescription medications for chronic pain and stiffness

Prescription medications, when appropriately prescribed and monitored, may be effective in treating chronic headaches and neck pain. However, the cost and the potential for harm should be carefully weighed against the benefit, and a good faith effort at a defined trial of one or more medications should be sought. Nonsteroidal anti-inflammatory drugs (NSAIDs), especially COX-2 inhibitors, have been found to be effective in managing chronic neck pain. While the cardiovascular risks of NSAIDs are well documented, the risks may be somewhat less for the COX-2 inhibitors. Muscle relaxants may be beneficial in that they may enhance the effect of other medications used to treat muscle tension and insomnia, and have the added benefit of improving sleep. However, their use, especially for long-term management, is controversial. This is in part due to questions about their efficacy, side effects, and the risks of chronic opioid use due to the common practice of combining the two medications. Tizanidine and cyclobenzaprine have been FDA approved for treatment of muscle spasm associated with musculoskeletal conditions, and are commonly used in low doses. Tizanidine is a centrally acting alpha-2 adrenergic agonist, and has some evidence for efficacy in fibromyalgia. Cyclobenzaprine, which is structurally similar to tricyclic antidepressants, may have effects on pain processing in addition to its muscle relaxing properties.

Interventional procedures for severe tension headaches and neck pain

Recognizing that chronic tension-type headaches and neck pain are often perpetuated by myofascial trigger points and too much muscle tension, a variety of medical procedures have been employed in the treatment of these conditions. These procedures primarily target the muscles thought to be responsible for the pain. The procedures range from injections of botulinum toxin and corticosteroids to mechanically breaking up the trigger points with injections of anesthetics, saline, or corticosteroids. Although some of these methods are routinely employed, most lack well-designed investigational studies to determine their effectiveness in eradicating the headache and neck pain. Corticosteroid injections into the occipital muscle insertions and the anesthetic injections into the suboccipital region have been shown to be effective in the short term. In a small study, botulinum toxin was injected into the temple and posterior neck muscles, producing significant relief compared to placebo. It is the author’s opinion that the most direct and effective means of eliminating the myofascial trigger points is still dry needling. This can be done either with injections of anesthetic or saline or with injections of nothing i.e. “dry” needling. This author has had great success with a “popping” technique in which a needle is quickly inserted in and out of the trigger point. Finally, in cases where the neck pain is strongly believed to be originating from the intervertebral joints, radiofrequency neurotomy can be used to temporarily alter the pain fibers from the medial branch of the dorsal primary ramus.

Alternative therapies for holistic treatment options

There are many treatment options for tension headache and neck pain. Often these treatments are tried in combination to achieve the best therapeutic effect. Treatments fall into two general categories, medications and non-drug therapies. Medications can be effective as an initial treatment that is combined with non-drug therapies when the initial treatment fails. A comprehensive best-evidence review for the treatment of neck pain was recently published by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Recommendations are provided by three evidence categories (strong, moderate, weak) based on the number and quality of scientific studies. In some cases, it was clear that the strength of the recommendation was based on expert consensus. In this instance, we have identified those recommendations as such. In section 3.4 of the Task Force’s findings, a variety of alternative treatments are suggested with mostly weak or moderate evidence to support their use. This is not to say that these treatments are ineffective, it simply indicates that more quality research is necessary to determine their usefulness for patients with neck pain. Oftentimes, patients find these treatments to be highly effective, and the treatment itself is less invasive than that of other medical therapies. This section of the review is most valuable when patients have unsuccessfully attempted other nonsurgical and surgical treatments for neck pain and are seeking an alternative.

Singapore’s Approach to Tension Headache and Neck Pain Treatment

Healthcare facilities and specialists in Singapore Singapore’s public healthcare system offers headache sufferers affordable treatments within both primary and tertiary healthcare settings. All Singaporeans owning a national identification card are assigned to a specific government-subsidized primary care clinic or general practitioner. Primary care physicians have the ability to diagnose and initiate treatment for tension headache and neck pain patients. However, options to visit specialists in government outpatient specialist clinics, polyclinics and public hospitals make it easy for patients to gain access to neurologists or other consultant physicians. It is essential that the accurate diagnosis of tension-type headache be followed up by referral to a specialist if treatment is unsuccessful. Currently, the Asian, Australasian and Pan-Asian Clinical Research Headache Networks consist of added expertise from doctors running clinical research in headache in Singapore and Asia. This can help ensure that headache sufferers will receive the most up-to-date treatments developed from clinical research.

This healthcare system ensures that tension headache and neck pain patients receive necessary treatments in a convenient and efficient manner throughout Singapore. Given that 71% of tension headache sufferers have utilized healthcare services for headache in the past year, we feel that Singapore’s organized and efficient healthcare systems can serve as a model for other countries seeking to improve headache care.

Healthcare facilities and specialists in Singapore

There are several healthcare facilities available in Singapore, where individuals with neck pain and tension headache can seek specialized treatment. This may be on an inpatient or outpatient basis. These facilities offer comprehensive diagnosis, multidisciplinary treatment and rehabilitation. For some patients, especially those with acute neck pain or tension headache attacks, treatment at these facilities may be more appropriate and effective than visiting a clinic or private specialist practice. Services available include pain management programs, physiotherapy, biofeedback, trigger point injections and pain relieving medication to stop persistent pain or pain attacks. Patients requiring specialist intervention or treatment for headache and/or neck pain related conditions, such as rheumatoid arthritis, cervical spondylotic myelopathy or cervicogenic headache, may need to be referred by a general practitioner or polyclinic doctor to see a rheumatologist, neurologist or orthopaedic surgeon at a restructured hospital. This might involve some waiting time for an appointment to be scheduled. At the primary care level, individuals suffering from tension headache or neck pain may seek treatment at a polyclinic or private general practitioner (GP) clinic. Treatment is usually effective for tension headache and neck pain and can help to prevent them from becoming chronic or recurrent conditions. A number of well qualified physiotherapists practicing in Singapore can also be consulted to provide further advice or treatment on neck pain and tension headache conditions. They are able to treat a wide range of cases and some offer home therapy services for patients with mobility difficulties. Chiropractic treatment is another medical alternative for individuals seeking help to relieve neck pain or tension headache in a private clinic setting. For a list of chiropractors or physiotherapists registered in Singapore, visit the website for Allied Health Professions Council, under “registrants”.

Availability of non-medical and medical treatment options

Availability of non-medical treatment options starts with a lot of patients being treated by paracetamol and other simple analgesics. If they are used in excessive amounts and too frequently, a medication overuse headache might develop. It is important to follow the prescribed dose for a period of 2 weeks. If the treatment is ineffective or if tension headache is present on 15 days per month or more, a preventive treatment should be considered. Although there are no trials showing the effect of specific lifestyle advice (diet, rest, stress, and posture), it makes sense to address these issues in the context of the individual patient. However, it should be made clear to the patient that this approach might not help headache but is likely to be beneficial for their general health. There are a number of non-specific non-medical treatments for headache: various physical treatments, psychological therapies, and alternative treatments. A physical treatment that may help headache is spinal manipulation. Although there have been no trials supporting this in tension headache, it is known to be effective in migraine. If it is not effective after a short trial (4 sessions), it is unlikely to help and should be discontinued. Physiotherapy, involving a variety of treatment techniques, is often an effective treatment that provides long-term benefit. In the context of tension headache, the most commonly used psychological therapy is likely to be relaxation training. This is an effective treatment, and in tension headache, the beneficial effect may be notable within a short period of therapy. Patients can learn to do this themselves without therapist involvement, so it is a cost-effective treatment. Cognitive-behavioral therapy is a psychological therapy that attempts to change the way a patient thinks or behaves. It has been shown to be effective in a variety of chronic non-malignant pain conditions and would be expected to be beneficial in tension headache. However, it is a time-consuming treatment because an individual must be willing to invoke change, and it may not directly target headache symptoms. There are many alternative therapies, and it is known that headache sufferers will try almost anything if they feel it might alleviate their headache. A trial of any treatment, providing it is safe, with an open mind may be the best advice, as placebo response rates are high in headache. However, because the pathophysiology of tension headache is not fully understood, we cannot know how these treatments act on headache symptoms.

Support groups and resources for individuals with tension headaches and neck pain

Individuals with tension headache, neck pain, and associated disorders in Singapore are able to find a few sources of support. One form of support comes from the hosted education and support group for headache sufferers. These groups help individuals gain a greater understanding of the nature of their headache and neck pain problem. Individuals are taught problem-solving strategies in dealing with their headache or with the impact of their headache on their daily life. The group setting also provides an avenue for individuals to share their personal experiences with headache disorders and to give and receive encouragement to one another. This can be especially helpful in breaking the isolation which headache and neck pain sufferers often feel. Currently, the Neurology Departments in both the Singapore General Hospital and Tan Tock Seng Hospital run such groups. Interested individuals should seek further information from the respective hospitals. Another good way for individuals to help themselves is by further understanding their headache and neck pain problem, the various available treatments, and by being more actively involved in the management of their problem. The patient who is more informed and involved tends to have better treatment outcomes. A good source of information would be our NNI patient education booklets. Topics covered include Migraine, Sleep Disorders, Stroke, Parkinson’s Disease, Epilepsy, Neurology in general, and many others. These booklets are freely available at the National Neuroscience Institute. More information can be found at the NNI website.