33 Migraines and Tension-Type Headaches

Migraines and Tension-Type Headaches

With an estimated three billion individuals world-wide living with migraine or tension-type headache The Global Burden of Diseases, Injuries, and Risk Factors list migraine and tension-type headaches as one of the leading causes of disability worldwide (GBD 2016 Headache Collaborators).


Migraine has two major types.

  1. Migraine without aura is a clinical syndrome characterized by headache with specific features and associated symptoms.
  2. Migraine with aura is primarily characterized by the transient focal neurological symptoms that usually precede or sometimes accompany the headache. Some patients also experience a prodromal phase, occurring hours or days before the headache, and/or a postdromal phase following headache resolution. Prodromal and postdromal symptoms include hyperactivity, hypoactivity, depression, cravings for particular foods, repetitive yawning, fatigue and neck stiffness and/or pain.

Tension-type headache is very common, with a lifetime prevalence in the general population ranging in different studies between 30% and 78%. Tension-type headaches are divided into two categories: episodic and chronic.

TED-ED: What Causes Headaches


A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Red Flag Screen

  • Thunderclap headache – a severe headache reaching at least 7 (out of 10) in intensity within 1 min of onset
  • Fever and meningitis
  • New headache with cognitive change in an elderly patient

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Headache Impact Test 6-item (HIT-6)
  • Migraine-Specific Quality of Life Questionnaire (MSQ v2.1)
  • Patient Perception of Migraine Questionnaire (PPMQ-R)
  • The Migraine Disability Assessment (MIDAS)
  • Headache Disability Index

Physical Examination

Incorporate one or more of the following physical examination tools to determine the likelihood of tension-type headache or migraine and interpret examination results in the context of all clinical exam findings.

  • Cervical Flexion-Rotation Test
  • Trigger point palpation of the cranio-cervical muscles
  • Manual screening of the cervical spine



Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. For patients with persisting headaches, it is important to work with the patient and their physician to develop strategies to manage symptoms. For people who suffer from migraine and tension-type headaches soft tissue irritation and nerve sensitization may be a major contributor to symptoms (Do et al., 2018). Gentle manual therapy of the upper cervical spine may help avoid ongoing nociceptive input into the trigeminocervical complex (Luedtke et al., 2017). Structures to keep in mind while assessing and treating patients suffering from headaches may include neurovascular structures and investing fascia of:

  • Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)
  • Levator Scapula
  • Longus Colli & Capitis
  • Rhomboid Minor and Major
  • Occipitofrontalis
  • Corrugator Supercilii
  • Sternocleidomastoid
  • Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)
  • Temporomandibular Joint
    • Medial Pterygoid
    • Temporalis
    • Masseter
    • Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)
    • Infrahyoid Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as self-massage, and mindfulness-based stress reduction has been shown to be safe and effective for reducing headaches, with little to no side effects (Seminowicz et al., 2020).


Globally physicians, now more than ever are recommending complementary treatment options (i.e., manual therapy, acupuncture, mindfulness-based stress reduction, pain neuroscience education, and exercise) as part of a multi-modal approach to decrease the individual’s headache frequency, intensity, duration and acute medication requirements. Massage therapy specifically is included in several clinical practice guidelines for the treatment of headaches (Busse et al., 2017; Côté et al., 2019)

Massage Sloth: Myofascial Release for Headache

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for tension-type headaches and migraines based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, mindfulness-based interventions, and healthy sleep habits)

References and Sources

Ashina, M. (2020). Migraine. The New England journal of medicine, 383(19), 1866–1876. https://doi.org/10.1056/NEJMra1915327

Barmherzig, R., & Kingston, W. (2019). Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management. Current neurology and neuroscience reports, 19(5), 20. doi:10.1007/s11910-019-0937-8

Busse, J. W., Craigie, S., Juurlink, D. N., Buckley, D. N., Wang, L., Couban, R. J., … Guyatt, G. H. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ: Canadian Medical Association journal189(18), E659–E666. doi:10.1503/cmaj.170363

Carvalho, G. F., Schwarz, A., Szikszay, T. M., Adamczyk, W. M., Bevilaqua-Grossi, D., & Luedtke, K. (2020). Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice. Brazilian journal of physical therapy, 24(4), 306–317. https://doi.org/10.1016/j.bjpt.2019.11.001

Côté, P., Yu, H., Shearer, H.M., Randhawa, K., Wong, J.J., Mior, S., … Lacerte, M. (2019). Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration. Eur J Pain., 23(6), 1051-1070. doi: 10.1002/ejp.1374.

Do, T. P., Heldarskard, G. F., Kolding, L. T., Hvedstrup, J., & Schytz, H. W. (2018). Myofascial trigger points in migraine and tension-type headache. The journal of headache and pain19(1), 84. doi:10.1186/s10194-018-0913-8

Do, T. P., Remmers, A., Schytz, H. W., Schankin, C., Nelson, S. E., Obermann, M., … Schoonman, G. G. (2019). Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology, 92(3), 134–144. https://doi.org/10.1212/WNL.0000000000006697

Dodick, D. W. (2018). Migraine. Lancet (London, England), 391(10127), 1315–1330. doi:10.1016/S0140-6736(18)30478-1

Fernández-de-Las-Peñas, C., Florencio, L. L., Plaza-Manzano, G., & Arias-Buría, J. L. (2020). Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review. International journal of environmental research and public health, 17(11), E4126. https://doi.org/10.3390/ijerph17114126

Foxhall, K. (2019). Migraine: A History. Johns Hopkins University Press. doi:10.1353/book.66229.

GBD 2016 Headache Collaborators (2018). Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. Neurology17(11), 954–976. doi:10.1016/S1474-4422(18)30322-3

Getsoian, S. L., Gulati, S. M., Okpareke, I., Nee, R. J., & Jull, G. A. (2020). Validation of a clinical examination to differentiate a cervicogenic source of headache: a diagnostic prediction model using controlled diagnostic blocks. BMJ open, 10(5), e035245. https://doi.org/10.1136/bmjopen-2019-035245

Gfrerer, L., Hansdorfer, M. A., Ortiz, R., Chartier, C., Nealon, K. P., & Austen, W. G., Jr (2021). Muscle Fascia Changes in Patients with Occipital Neuralgia, Headache, or Migraine. Plastic and reconstructive surgery, 147(1), 176–180. https://doi.org/10.1097/PRS.0000000000007484

Haywood, K. L., Mars, T. S., Potter, R., Patel, S., Matharu, M., & Underwood, M. (2018). Assessing the impact of headaches and the outcomes of treatment: A systematic review of patient-reported outcome measures (PROMs). Cephalalgia: an international journal of headache, 38(7), 1374–1386. doi:10.1177/0333102417731348

Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. (2018). Cephalalgia, 38(1), 1–211. doi:10.1177/0333102417738202

Lemmens, J., De Pauw, J., Van Soom, T., Michiels, S., Versijpt, J., van Breda, E., … De Hertogh, W. (2019). The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis. The journal of headache and pain, 20(1), 16. doi:10.1186/s10194-019-0961-8

Leroux, E. (2016). Migraines: More than a Headache. Dundurn.

Liang, Z., Galea, O., Thomas, L., Jull, G., & Treleaven, J. (2019). Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis. Musculoskeletal science & practice, 42, 67–83. doi:10.1016/j.msksp.2019.04.007

Luedtke, K., Boissonnault, W., Caspersen, N., Castien, R., Chaibi, A., Falla, D., … May, A. (2016). International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Manual therapy, 23, 17–24. doi:10.1016/j.math.2016.02.010

Luedtke, K., & May, A. (2017). Stratifying migraine patients based on dynamic pain provocation over the upper cervical spine. The journal of headache and pain18(1), 97. doi:10.1186/s10194-017-0808-0

Luedtke, K., Starke, W., & May, A. (2018). Musculoskeletal dysfunction in migraine patients. Cephalalgia, 38(5), 865–875. doi:10.1177/0333102417716934

Luedtke, K., Basener, A., Bedei, S., Castien, R., Chaibi, A., Falla, D., … Wollesen, B. (2020). Outcome measures for assessing the effectiveness of non-pharmacological interventions in frequent episodic or chronic migraine: a Delphi study. BMJ open, 10(2), e029855. https://doi.org/10.1136/bmjopen-2019-029855

Millstine, D., Chen, C. Y., & Bauer, B. (2017). Complementary and integrative medicine in the management of headache. BMJ (Clinical research ed.), 357, j1805. doi:10.1136/bmj.j1805

Moraska, A. F., Stenerson, L., Butryn, N., Krutsch, J. P., Schmiege, S. J., & Mann, J. D. (2015). Myofascial trigger point-focused head and neck massage for recurrent tension-type headache: a randomized, placebo-controlled clinical trial. The Clinical journal of pain, 31(2), 159–168. doi:10.1097/AJP.0000000000000091

Moraska, A. F., Schmiege, S. J., Mann, J. D., Butryn, N., & Krutsch, J. P. (2017). Responsiveness of Myofascial Trigger Points to Single and Multiple Trigger Point Release Massages: A Randomized, Placebo Controlled Trial. American journal of physical medicine & rehabilitation, 96(9), 639–645. doi:10.1097/PHM.0000000000000728

Negro, A., Delaruelle, Z., Ivanova, T. A., Khan, S., Ornello, R., Raffaelli, B., … European Headache Federation School of Advanced Studies (EHF-SAS) (2017). Headache and pregnancy: a systematic review. The journal of headache and pain, 18(1), 106. doi:10.1186/s10194-017-0816-0

Orr, S. L., Kabbouche, M. A., O’Brien, H. L., Kacperski, J., Powers, S. W., & Hershey, A. D. (2018). Paediatric migraine: evidence-based management and future directions. Nature reviews. Neurology, 14(9), 515–527. doi:10.1038/s41582-018-0042-7

Palacios-Ceña, M., Ferracini, G. N., Florencio, L. L., Ruíz, M., Guerrero, Á. L., Arendt-Nielsen, L., & Fernández-de-Las-Peñas, C. (2017). The Number of Active But Not Latent Trigger Points Associated with Widespread Pressure Pain Hypersensitivity in Women with Episodic Migraines. Pain medicine (Malden, Mass.), 18(12), 2485–2491. doi:10.1093/pm/pnx130

Seminowicz, D. A., Burrowes, S., Kearson, A., Zhang, J., Krimmel, S. R., Samawi, L., Furman, A. J., Keaser, M. L., Gould, N. F., Magyari, T., White, L., Goloubeva, O., Goyal, M., Peterlin, B. L., & Haythornthwaite, J. A. (2020). Enhanced mindfulness-based stress reduction in episodic migraine: a randomized clinical trial with magnetic resonance imaging outcomes. Pain, 161(8), 1837–1846. https://doi.org/10.1097/j.pain.0000000000001860

Singh, R., VanderPluym, J. H., Morrow, A. S., Urtecho, M., Nayfeh, T., Roldan, V., Farah, M. H., Hasan, B., Saadi, S., Shah, S., Abd-Rabu, R., Daraz, L., Prokop, L. J., Murad, M. H., & Wang, Z. (2020). Acute Treatments for Episodic Migraine. Agency for Healthcare Research and Quality (US). https://doi.org/10.23970/AHRQEPCCER239

Szikszay, T. M., Luedtke, K., & Harry von, P. (2018). Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain – a diagnostic case-control study. The Journal of manual & manipulative therapy, 26(4), 237–248. https://doi.org/10.1080/10669817.2018.1480912

Szikszay, T. M., Hoenick, S., von Korn, K., Meise, R., Schwarz, A., Starke, W., & Luedtke, K. (2019). Which Examination Tests Detect Differences in Cervical Musculoskeletal Impairments in People With Migraine? A Systematic Review and Meta-Analysis. Physical therapy, 99(5), 549–569. doi:10.1093/ptj/pzz007

van der Meer, H. A., Calixtre, L. B., Engelbert, R., Visscher, C. M., Nijhuis-van der Sanden, M. W., & Speksnijder, C. M. (2020). Effects of physical therapy for temporomandibular disorders on headache pain intensity: A systematic review. Musculoskeletal science & practice, 50, 102277. https://doi.org/10.1016/j.msksp.2020.102277

Varatharajan, S., Ferguson, B., Chrobak, K., Shergill, Y., Côté, P., Wong, J. J., … Taylor-Vaisey, A. (2016). 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. European spine journal, 25(7), 1971–1999. doi:10.1007/s00586-016-4376-9

Wells, R. E., O’Connell, N., Pierce, C. R., Estave, P., Penzien, D. B., Loder, E., Zeidan, F., & Houle, T. T. (2020). Effectiveness of Mindfulness Meditation vs Headache Education for Adults With Migraine: A Randomized Clinical Trial. JAMA internal medicine, e207090. Advance online publication. https://doi.org/10.1001/jamainternmed.2020.7090

Xu, S., Yu, L., Luo, X., Wang, M., Chen, G., Zhang, Q., … Wang, W. (2020). Manual acupuncture versus sham acupuncture and usual care for prophylaxis of episodic migraine without aura: multicentre, randomised clinical trial. BMJ (Clinical research ed.), 368, m697. https://doi.org/10.1136/bmj.m697

Zhang, N., Houle, T., Hindiyeh, N., & Aurora, S. K. (2020). Systematic Review: Acupuncture vs Standard Pharmacological Therapy for Migraine Prevention. Headache, 60(2), 309–317. https://doi.org/10.1111/head.13723


Icon for the Creative Commons Attribution-NonCommercial 4.0 International License

Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

Share This Book