Tension-Type Headaches: Understanding the Causes, Treatment and Exercise
Understanding Tension-Type Headaches
Tension-type headache (TTH) is one of the most common forms of headache. It is typically experienced as a pressing or tightening sensation on both sides of the head, often described as a band of pressure around the forehead or skull. The pain is usually mild to moderate and, unlike migraine, is not typically made worse by routine physical activity.
For some people, tension-type headaches occur only occasionally. For others, they become frequent or even chronic, significantly affecting concentration, sleep, work, exercise, and quality of life.
The name tension-type headache can be somewhat misleading. These headaches are not simply caused by “tight muscles.” The mechanisms are more complex and may involve increased tenderness of the muscles and tissues around the head and neck, changes in pain sensitivity and processing, stress, sleep, physical activity, and other biological and psychosocial factors.
From a clinical perspective, the neck and jaw are also important areas to consider. Some patients with tension-type headaches demonstrate cervical stiffness, muscular tenderness, reduced movement, or temporomandibular dysfunction (TMD). These findings do not necessarily mean that the neck or jaw is causing the headache, but they may represent clinically relevant factors that can be addressed as part of treatment.
This is where a comprehensive examination becomes important. Rather than assuming that every tension-type headache has the same cause, the practitioner should first determine whether the presentation is consistent with TTH, screen for other headache disorders and potential red flags, and then identify the physical and functional factors that may be contributing to the individual's symptoms.
Within Motion Specific Release (MSR), manual therapy is combined with appropriate examination, joint and soft-tissue procedures, fascial approaches, and progressive exercise. The objective is not simply to release “tight muscles,” but to reduce symptoms, improve movement and function, and give the patient practical strategies for managing their condition over time.
Article Index:
Understanding Pain and Sensitization
Tension-type headache is more complex than its name suggests. Although tenderness and increased muscle tension are commonly found around the head, neck, and shoulders, the pain cannot be explained simply by “tight muscles.” Both peripheral tissues and the nervous system's processing of pain appear to be involved.
Peripheral Pain Sensitivity
Muscles, fascia, joints, and other tissues contain sensory nerve endings that respond to mechanical, chemical, and thermal stimuli. When tissues become irritated or sensitized, inflammatory and neuroactive substances such as bradykinin, serotonin, prostaglandins, and Substance P can influence nociceptor activity and lower the threshold at which sensory input is perceived as painful.
In patients with tension-type headache, increased tenderness is frequently found in the pericranial muscles, including regions of the temporalis, suboccipital, cervical, and upper shoulder musculature. However, tenderness does not necessarily mean that these tissues are damaged or inflamed. It may reflect increased sensitivity within the pain system.
When Pain Processing Changes
With frequent or chronic headaches, the nervous system itself may become increasingly sensitive. Repeated nociceptive input can contribute to changes in how sensory information is processed within the spinal cord, trigeminal system, brainstem, and higher centres involved in pain perception.
This process is commonly referred to as central sensitization.
As sensitivity increases, stimuli that would normally produce little discomfort may become painful, and existing pain may feel more intense or persist longer. This helps explain why chronic tension-type headache cannot always be traced to a single muscle, joint, postural position, or structural abnormality.
What This Means Clinically
For the practitioner, the important point is that pain is not simply a measure of tissue damage. A patient may have considerable muscular tenderness without significant structural injury, while stress, sleep disturbance, reduced physical activity, previous pain experiences, and other factors can influence how the nervous system responds to sensory input.
Posture can still be clinically relevant, but it should be considered as one potential contributing factor rather than the cause of tension-type headache. The same applies to cervical mobility, muscle endurance, temporomandibular function, and other physical findings.
This broader understanding changes the treatment objective. Rather than attempting to identify and “release” a single structure responsible for the headache, treatment can address the combination of factors contributing to the individual's presentation.
Manual therapy may help reduce pain and improve movement in some patients, while exercise can progressively improve strength, endurance, mobility, and tolerance to physical load. Education, sleep, stress management, regular physical activity, and appropriate medical management may also play important roles.
The goal is not simply to treat tight muscles. It is to improve function while reducing the factors that keep the pain system sensitized.
Symptoms and Clinical Examination
Tension-type headache can vary considerably in frequency and duration. Episodic attacks may last from 30 minutes to seven days, while chronic tension-type headache may persist for hours, days, or even become unremitting.
The pain is typically described as pressing, tightening, or band-like rather than pulsating. It is usually mild to moderate in intensity and commonly affects both sides of the head. Patients may describe the sensation as pressure around the forehead, temples, or back of the head, sometimes accompanied by tenderness in the scalp, jaw, neck, or shoulders.
Increased pericranial tenderness is one of the more important physical findings associated with tension-type headache. The International Classification of Headache Disorders specifically recognizes TTH occurring both with and without pericranial tenderness.
Tension Headache vs. Migraine
Distinguishing tension-type headache from migraine is an important part of the clinical assessment, although the distinction is not always clear-cut and some patients experience both disorders.
Typical characteristics of tension-type headache include:
Bilateral pain
Pressing or tightening rather than pulsating pain
Mild to moderate intensity
Pain that is not usually aggravated by routine activities such as walking or climbing stairs
No vomiting
Usually no nausea in episodic TTH
No more than one of photophobia or phonophobia
Possible tenderness of the muscles around the head, jaw, neck, and shoulders
Migraine more commonly presents with moderate to severe pain, pulsating quality, aggravation with physical activity, nausea or vomiting, and sensitivity to light and sound. Migraine may also occur with neurological aura, although aura is not present in all migraine patients.
The distinction matters because a headache that resembles TTH should not automatically be assumed to originate from muscular tension or the cervical spine.
Clinical Examination
The examination should begin with a detailed headache history. Important questions include onset, frequency, duration, location, pain quality and intensity, aggravating and relieving factors, associated neurological symptoms, medication use, previous headache history, trauma, sleep, stress, and changes in the headache pattern.
The physical examination should then be guided by the history and clinical presentation.
For patients with associated neck pain, stiffness, reduced movement, or suspected cervical involvement, examination may include cervical active and passive range of motion, palpation, joint assessment, muscle function, and appropriate orthopaedic testing.
Pericranial tenderness can also be assessed through palpation of areas including the temporalis, masseter, sternocleidomastoid, suboccipital, splenius, and upper trapezius regions. Importantly, tenderness should be interpreted as a clinical finding rather than proof that a particular muscle is causing the headache.
Cervical Examination - Orthopaedic Testing
This video demonstrates a structured examination of the cervical region, including inspection, palpation, active and passive range of motion, and orthopaedic testing.
For patients with tension-type headache accompanied by neck symptoms, a cervical examination can help identify mobility restrictions, tenderness, movement-related symptoms, and other musculoskeletal findings that may be relevant to management.
When Is a Neurological Examination Appropriate?
A neurological examination is not required in its entirety for every patient with an established, stable pattern of tension-type headache. However, neurological screening becomes particularly important when the history or presentation raises concern for another headache disorder or secondary cause.
A more detailed neurological examination may be indicated with new or unusual headache patterns, focal weakness or sensory changes, visual or speech disturbances, altered coordination, abnormal reflexes, cranial nerve findings, or other neurological symptoms.
Cranial Nerve Examination - 12 Cranial Nerves
This video demonstrates a systematic cranial nerve examination. It can be incorporated when the patient's history or symptoms indicate the need for a more detailed neurological assessment.
Upper Limb Neuro Exam
Upper-limb neurological testing may be appropriate when headache or neck symptoms occur with arm pain, numbness, tingling, weakness, altered reflexes, or suspected cervical radiculopathy or peripheral nerve involvement.
Red Flags and Referral
Before treating a presumed tension-type headache, practitioners should remain alert for findings that suggest a secondary headache requiring medical investigation. A sudden severe headache, a significant change from the patient's usual headache pattern, new neurological deficits, headache associated with systemic illness or fever, recent significant trauma, or other unusual clinical findings should prompt further investigation or referral rather than routine musculoskeletal treatment.
Manual Therapy and MSR
Manual therapy can be a useful component of care for some patients with tension-type headache, particularly when the clinical examination identifies cervical pain or restricted movement, pericranial tenderness, temporomandibular dysfunction, or other musculoskeletal findings that appear relevant to the patient's symptoms.
Research suggests that manual therapy may reduce headache intensity, frequency, and headache-related disability in some patients with tension-type headache. However, treatment effects vary, and no single manual technique has been shown to address every presentation.
Within Motion Specific Release (MSR), the objective is therefore not simply to locate and release “tight” tissues. Examination findings are used to determine which regions may be clinically relevant and which procedures are appropriate for the individual patient.
Treatment may incorporate myofascial techniques, joint mobilization or manipulation, fascial approaches, and acupuncture or acupressure concepts, combined with progressive exercise and self-management strategies.
The neck, upper shoulder region, and temporomandibular system are particularly relevant areas to examine. However, findings in these regions should not automatically be interpreted as the cause of the headache. Instead, they represent potential treatment targets when they reproduce symptoms, restrict function, or appear clinically relevant within the broader examination.
Posture should be approached in the same way. A sustained working position may aggravate symptoms in some individuals, but there is insufficient evidence to regard forward-head posture or rounded shoulders as a universal cause of tension-type headache. The more useful objective is to improve movement variability, physical capacity, strength, endurance, and tolerance to the positions and activities required by the patient.
4 Point Neck Pain Protocol
In this video, Dr. Abelson demonstrates an MSR protocol addressing soft-tissue and joint findings commonly encountered in patients with neck pain and restricted cervical movement.
For patients with tension-type headache who also demonstrate clinically relevant cervical findings, these procedures may be incorporated to reduce pain, improve mobility, and make active rehabilitation easier to perform.
The protocol should be adapted to the individual rather than applied automatically to every patient with headache.
MSR Ten‐Point TMJ Protocol
Temporomandibular disorders (TMD) and headache frequently coexist. Patients may present with combinations of jaw pain, facial pain, muscular tenderness, restricted or painful jaw movement, and headache.
The MSR Ten-Point TMJ Protocol demonstrates manual procedures directed toward the muscles and soft tissues of the temporomandibular region.
When TMD findings are present in a patient with tension-type headache, treatment of the jaw and associated musculature may form part of the overall management strategy. Importantly, the presence of jaw tension does not establish that TMD is the sole cause of the headache.
Fascial Expansion: MSR Headache Protocol
This video demonstrates how fascial anatomy is incorporated into the MSR approach to headache management. Dr. Abelson reviews relevant fascial relationships involving the head, neck, and jaw and demonstrates how these concepts can be combined with manual therapy and selected acupuncture or acupressure points.
These procedures should be viewed as part of a broader clinical strategy rather than as a direct method of correcting a specific fascial abnormality or eliminating the underlying cause of tension-type headache.
Cervical Joint Mobility and Tension-Type Headache
Cervical mobility should be assessed when the patient's history and examination indicate neck involvement. Some patients with tension-type headache also experience neck pain, stiffness, restricted movement, or tenderness, making the cervical spine a reasonable component of treatment.
Joint mobilization or manipulation may be considered when clinically appropriate. These interventions may influence pain and mobility through a combination of mechanical, neurological, and contextual mechanisms, rather than simply “putting joints back into place” or removing pressure from nerves.
The response to treatment should guide continued use. If a manual intervention produces a meaningful improvement in pain, movement, or the patient's ability to exercise and function, it may be useful as part of the treatment plan. If it does not, the clinical strategy should be reconsidered.
Chiropractic Adjustments
In this video, Dr. Abelson demonstrates cervical manipulation techniques that may be used in appropriately selected patients.
Spinal manipulation is one of several manual therapy options available for patients presenting with headache and associated cervical findings. Patient preference, clinical indications, contraindications, expected benefit, and informed consent should all be considered when deciding whether manipulation is appropriate.
Neck Adjustments or Neck Mobilization - The Choice Is Yours!
Manipulation is not the only option for addressing cervical joint mobility. Mobilization uses controlled, graded movements of the cervical spine and may be preferred by some patients or selected by the practitioner based on the clinical presentation.
In this video, Dr. Abelson demonstrates cervical joint mobilization and discusses the choice between mobilization and manipulation.
Both approaches should be considered tools within a broader treatment strategy, with the ultimate objective of improving movement and function while supporting the patient's progression toward active rehabilitation.
Exercise and Self-Management
Exercise is an important component of managing tension-type headache, particularly when the examination identifies reduced cervical mobility, muscular tenderness, decreased strength or endurance, physical deconditioning, or associated neck and shoulder symptoms.
The objective is not simply to stretch tight muscles. A progressive exercise program can help improve mobility, muscular strength and endurance, movement confidence, and tolerance to everyday physical demands. Regular physical activity may also have broader benefits for sleep, stress regulation, general health, and pain modulation.
Exercise should be individualized to the patient. Depending on the clinical findings, a program may incorporate:
Cervical and upper-thoracic mobility
Neck and shoulder strengthening and endurance
Gentle stretching where appropriate
Coordination and motor-control exercises
Temporomandibular exercises when TMD is present
Progressive aerobic activity
Strategies to increase movement and reduce prolonged static positions
As symptoms and physical capacity improve, exercises can be progressively modified rather than following a single standardized headache program.
Pain Relief For Problem Headaches
In this video, Miki Burton RMT demonstrates self-treatment techniques directed toward the suboccipital region at the base of the skull.
Tenderness in this region is common in patients with neck pain and headache. Gentle self-treatment may provide short-term symptom relief for some patients and can be incorporated alongside mobility, strengthening, and other active strategies.
PNF Neck Stretches
PNF techniques combine muscle contraction with controlled movement or stretching and can be used to improve cervical mobility when restricted movement is identified during the examination.
In this video, the exercises demonstrate a practical method of working on neck mobility and muscular control. The intensity and range should be adjusted to the individual rather than attempting to force additional flexibility.
5 Minute Neck Pain Relief
This short routine combines movements that can be used when headache is accompanied by neck stiffness or muscular tension.
Rather than viewing the routine as a method of “resolving” tension-type headache, it can be used as a simple self-management strategy to encourage movement, reduce stiffness, and help patients remain active during periods of increased symptoms.
Patients can adjust the frequency and intensity according to their response. Exercises that consistently aggravate headache or produce neurological symptoms should be reassessed.
6 Effective - TMJ Exercises
Temporomandibular disorders can coexist with headache, particularly when patients also report jaw pain, clenching, muscular tenderness, restricted jaw movement, or symptoms associated with chewing.
In this video, Miki Burton RMT demonstrates six exercises directed toward the muscles and movement of the temporomandibular region.
For patients with relevant TMD findings, these exercises may be incorporated into a broader rehabilitation program to improve jaw mobility, muscular control, and tolerance to functional activities. They are not necessary for every patient with tension-type headache and should be selected according to the clinical examination.
Progression Matters
The long-term objective is to help the patient become less dependent on passive treatment and increasingly confident in managing their condition through movement and activity.
Manual therapy may help create an opportunity for comfortable movement, but exercise and self-management allow the patient to build on those changes. As tolerance improves, rehabilitation can progress from mobility and symptom-management exercises toward greater strength, endurance, aerobic activity, and the physical demands of work, recreation, and daily life.
Breaking the Cycle
Tension-type headache is not simply the result of tight muscles, poor posture, or a single dysfunctional joint. It is a multifactorial condition influenced by the interaction between peripheral tissues, pain processing, physical function, stress, sleep, activity, and other individual factors.
For the practitioner, this makes careful examination essential. The goal is to determine whether the presentation is consistent with tension-type headache, recognize findings that require further investigation or referral, and identify the factors that can realistically be addressed through treatment.
Within Motion Specific Release (MSR), manual therapy may be used to address relevant cervical, muscular, fascial, or temporomandibular findings when present. Mobilization, manipulation, myofascial procedures, fascial approaches, and acupuncture or acupressure can all be considered within the clinical context, but no single technique should be viewed as the solution for every headache.
Exercise and self-management are equally important. Improving mobility, strength, endurance, physical activity, and tolerance to everyday demands can help patients become progressively less dependent on passive care and more confident in managing their condition. The article already establishes this progression from symptom management toward greater strength, endurance and everyday function.
Ultimately, breaking the cycle of tension-type headache means understanding the individual rather than simply treating the headache. By combining sound clinical reasoning with appropriate manual therapy, progressive exercise, education, and self-management, treatment can focus not only on reducing symptoms, but on helping patients return to the activities that matter to them.
References
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Bendtsen L. Central sensitization in tension-type headache: possible pathophysiological mechanisms. Cephalalgia. 2000;20(5):486-508. PMID: 11037746.
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Fernández-de-las-Peñas C, Cuadrado ML, Arendt-Nielsen L, Simons DG, Pareja JA. Myofascial trigger points and sensitization: an updated pain model for tension-type headache. Cephalalgia. 2007;27(5):383-393. PMID: 17359516.
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Repiso-Guardeño A, Moreno-Morales N, Armenta-Pendón MA, Rodríguez-Martínez MDC, Pino-Lozano R, Armenta-Peinado JA. Physical therapy in tension-type headache: a systematic review of randomized controlled trials. Int J Environ Res Public Health. 2023;20(5):4466. PMID: 36901475.
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van der Meer HA, Speksnijder CM, Engelbert RHH, Lobbezoo F, Nijhuis-van der Sanden MWG, Visscher CM. The association between headaches and temporomandibular disorders is confounded by bruxism and somatic symptoms. Clin J Pain. 2017;33(9):835-843. PMID: 28002094.
Varatharajan S, Ferguson B, Chrobak K, et al. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016;25(7):1971-1999. PMID: 26851953.
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DR. BRIAN ABELSON DC. - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
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