What’s eating you?
Many people consider tension headaches a part of life they can’t control. The usual response to a tension headache is managing the symptoms; Pop a pain killer, down some water, or maybe take a nap. But did you know that there are things you can do to reduce the risk of them happening?
First it’s important to differentiate between migraine and tension headaches. Sufferers of migraines tend to experience severe, pulsing, pain on only one side of the head. There are other common symptoms like nausea, photophobia (light causes discomfort), and phonophobia (sound causes discomfort). Tension type headaches (TTH) typically have fewer symptoms other than pain in the head. They are often a diagnosis of exclusion, meaning that other types of headaches need to be ruled out first before an official diagnosis can made. Compared to migraines, TTH tend to be lower grade, last longer, and include both sides of the head. In studies, episodic tension type headaches are defined as more than 10 ever but fewer than 15 a month and can be described as mild to moderate in pain intensity, nonpulsing, both sides of the head, and feels like a tight band or a tightening sensation around the head. Chronic tension type headaches are defined as the same quality of pain but 15 or more headaches a month for at least 6 months and maximum one associated symptom similar to migraine (for example, photophobia). Episodic type are vastly more common (38.3% vs 2.2%) in the population. Tension headaches of either type are found in every demographic but are most common in women and people in their 40s.
Many people with any type of headache will medicate with a pain killer. However, doing this too much and too often can result in something called a medication overuse headache. This is when in response to frequent use of pain killers the patient actually develops headaches. An indication that a person has developed medication overuse headaches is if there are over 15 days in a month with headaches and medication use (acetaminophen, ibuprofen, triptans, opioids, or ergotamines for example) for over three months the headaches get worse with more frequent medication use, and get better with the discontinuation of the medications. It is important to consider that the relief medication in someone with frequent chronic headaches may actually be worsening the problem. In such a case, starting a treatment plan to reduce the underlying causes and triggers of the headaches will be very helpful in reducing medication use, and therefore the severity and frequency of headaches.
Upstream Causes
So what are those modifiable underlying causes?
There are both peripheral and central nervous system factors that may contribute to TTH. One of the most common and most important to address is musculoskeletal and fascial causes. Muscular and fascial pain tends to feel dull, achy, broad, non-localized, and radiating. People with TTH tend to have more muscle tension and significant more muscle tenderness in the whole body- not just the muscles around the head – than those without headaches. They also have more hyper-responsive spots in the muscles called “trigger points” than non-headache experiencing controls.
People with TTH also tend to have more nitric oxide levels than those without headaches. Nitric oxide is a molecule involved in regulation of blood flow and blood vessel function, including in the brain. When people previously diagnosed with chronic headaches were given nitric oxide, it immediately reproduced TTH pain. When given a compound that inhibits nitric oxide, patients that experience chronic TTH had immediate release of tight muscles and a reduction in headache severity. Most likely, patients with chronic TTH have both increased amounts of nitric oxide (perhaps from an inability to get rid of it) as well as increased sensitivity to it. Another central factor is that the brains of people that experience chronic TTH are more sensitized (meaning their brains may more attention to and magnify the stimulus of) pain receptors and nerves from the body. This means that their brains pay more attention to the pain stimuli from tender neck, head, and back muscles than people who don’t experience chronic tension headaches. It is not clear why this is. Mostly likely, they’ve experienced more muscle tension and pain over time and their brain changes in response to this chronic stimulus, or a vitamin deficiency that affects nerve health, or both.
Vitamin deficiencies may also play a role in the development of TTH. Vitamin D deficiency has been associated with many chronic conditions including both chronic tension headaches and migraines. Vitamin D deficiency is often associated with chronic pain, so it’s thought that this association may indicate that the deficiency causes increased muscle tenderness as well as perceived pain. What isn’t clear however, is if treating with vitamin D benefits patients with chronic TTH. With any vitamin deficiency, it’s important to assess why that deficiency occurred in the first place. What I often see in practice is that either the patient’s diet is poor – and so they are getting less exposure to nutrient dense foods – or the patient’s gut is dysfunctional causing poor absorption of nutrients. Additionally, there is a chance that the problem is a dysfunction of that person’s utilization of a nutrient, and not the availability of that nutrient. While it is very interesting that this association between vitamin D deficiency and TTH has been repeatedly observed, it doesn’t necessarily mean that supplementation is the answer. However, it does suggest some possible contributing factors to the development of chronic TTH.
Another interesting association is with B12 deficiency and H. Pylori infection. B12 deficiency is associated with neurological symptoms, including tension type headache. The absorption of B12 is dependent on adequate stomach acid levels. Low stomach acid is a fairly common finding in people, especially in people with gut issues. I most often see it manifested as heartburn like sensations. Low stomach acid is often a product of decreased parasympathetic nervous system function in a stressed-out person. So if I see a B12 deficiency in a meat eating or supplementing vegetarian, the first thing I assess is stomach acid and the gut. Similarly, H. Pylori is a bacterium that is found in the stomach, and if it proliferates can cause ulcers and affect stomach acid levels. This in turn affects B12 levels by inhibiting its absorption. H. Pylori is also associated with headaches, although more strongly to the migraine type than tension type. Overall however, this further supports vitamin deficiencies and specifically gut health related vitamin deficiencies as a possible contributing factor to chronic TTH.
VERY interestingly, B12 is also related to nitric oxide. In the body, B12 acts as a “scavenger” of excess nitric oxide, so a deficiency of B12 would result in too much nitric oxide, which as previously discussed is associated with both chronic tension headaches and migraines.
So ultimately, the underlying cause of TTH is likely multifactorial, including an increase in tension in the muscular system, an increase in the perception of that tension and pain from chemical, stress and emotional factors, and nutrient status or possibly gut health.
How to stop beating your head against the wall and get some relief
So how do we go about treating chronic tension type headaches based on this information?
Interestingly, postural intervention over a 3 week physiotherapy course did not result in relieved headaches even when posture improved. This could be because the study wasn’t long enough, but it also supports the data that people with chronic TTH’s brains are more sensitized and respond to pain stimuli in a different way. In my opinion, this study wasn’t long enough given the type of intervention, because a brain that became sensitized can become desensitized again, but the average stimulus received must be changed for long enough for the brain to change. The brain didn’t become sensitized overnight (or in 3 weeks), so it’s going to take longer than 3 weeks for the brain to change back. This is supported by a meta-analysis looking at therapeutic stretching and exercising efficacy for tension type headaches (and contained studies with average treatment length that was longer) and found that it was significantly more effective than placebo at reducing the pain of tension headaches and TMJ (jaw) pain.
***For videos on stretching and exercising that I normally recommend to anyone with upper back and neck pain including acute and chronic tension headaches, please see a list at the end of this article!***
An important part of the development of chronic TTH is the role that stress has on both muscle tension and the perception of pain and tension in the brain. Stress increases muscle tension and decreases the inhibition of pain sensations, which is to say the muscles are tighter and the brain is more aware of it. An important part of long term treatment and prevention of headaches is relaxation techniques. One study showed relaxation and biofeedback resulted in a 50% reduction in headache activity. Adding cognitive behavioral therapy (CBT) to this further reduced headache activity, although CBT alone without relaxation training was not as effective as relaxation training alone.
Massage has been found acutely helpful for tension headaches, but research is more mixed on long term or for prevention. Some studies found no different between placebo and massage for reduction in headache frequency. One study found that two 30 minute massages a week for 4 weeks was effective at reducing frequency of headache in patients with chronic tension headaches when compared to their own baseline frequency. Another study showed decrease in severity, duration and frequency after 6 weeks of twice weekly 45 minute massages when compared to participants baseline. Interestingly, this study showed that immediately after the massages headache frequency went up (possibly due to short term sensitizing of nerve fibers) but after that the benefit persisted even after the participants weren’t getting massages anymore. What I think we can draw from this literature is that massage for most people is effective acutely for tension headaches and for some people could be helpful to reduce the frequency, severity, and duration of chronic tension headaches long term. From my own clinical experience, I think massage is an important adjunctive treatment when starting to teach your body a new normal of baseline muscle tension. Massage reduces muscle tension by stretching out the tissue and increasing blood flow to the muscle, but it also works on the nerves that measure and affect muscle tension. I have found it incredibly effective for when people are starting out on a stretching regimen, because it relaxes the muscles. Then, when that client does their stretching later they get way more out of the stretch.
Acupuncture is another potential treatment that affects blood flow to muscles, nerve health, and muscle tension. One study found acupuncture has also been found effective for increasing the pain threshold of suffers of chronic TTH, but no effect on frequency. This means that the person was better able to handle the pain of a headache but didn’t affect how often they were getting headaches. Another study found laser acupuncture 3 times a week for 10 total sessions effective at reducing frequency and severity compared to placebo controls, with results persisting up to 3 months after finishing treatment. It’s important to note, however, that participants in these studies did not receive individualized treatments and all participants in the studies received the same points. While this helps analyze treatment efficacy in a study, Traditional Chinese Medicine acupuncture is individualized and treats each patient’s specific underlying causes and tender points, so individuals may find more benefit with individualized Traditional Chinese Medicine acupuncture than the set treatment regimen of a study.
Several nutrient deficiencies have been associated with chronic tension headaches, but is supplementing with them helpful? Magnesium is a nutrient most people in North America are deficient in, and a symptom of magnesium deficiency is increased muscle tension, which is in turn associated with tension headaches. One study did find that magnesium supplementation was effective at treating tension headaches, and another found that IV magnesium was beneficial as acute relief for headaches of all types. Vitamin D supplementation has not been investigated much in the literature, and what studies have been done were on individuals who had been diagnosed with a vitamin D deficiency that was affecting bone health, called osteomalacia. In this population, along with calcium supplementation, vitamin D has been found effective at treating chronic TTH. Because of this, it is important to determine vitamin D status (and assess for bone health) in an individual experiencing chronic TTH. There have been no studies that I can find on vitamin B12 supplementation in tension headache patients, although it has been found beneficial in migraine sufferers, so it would be reasonable to assess and treat a vitamin B12 deficiency in someone with TTH and see what happens! I also think it is important to address why vitamin deficiencies are occurring. The gut is where the body accesses nutrients – so if absorption or the diet is poor, many body systems will start operating sub-optimally because they don’t have access to the supplies they need to function. I think the gut and diet always need to be considered no matter the complaint, and research suggests that chronic TTH are no different.
In my experience, the best treatment plan for any chronic pain issue (and arguably most chronic health issues) is a multi-pronged treatment plan. Any pathological process that has been going on for a while is going to involve several systems, so a treatment plan that addresses several systems is going to be more effective. A treatment plan is also going to be more effective if it’s targeted to that individual patient in particular. To accurately do this, it is best to go checked out by your conventional, functional medicine, or naturopathic doctor to assess what body systems are involved in your chronic tension headaches and get individualized treatments for them. Though based on the evidence, most people would benefit from reducing muscular tension, so starting with relaxation, stretching, and exercise is a fantastic place to start!
Here are some stretching and exercising videos that I commonly recommend to anyone with upper back and neck tension including chronic headaches. Remember when you are starting a stretching routine that stretches should NOT hurt, they should feel like a satisfying discomfort. So if your stretch hurts, assess your form and back off on intensity until it’s a tolerable discomfort. Make sure that you feel your stretches across all of that muscle and not just over a joint; stretching joints is bad. If you only feel your stretch over a joint, reassess the angle and form of your stretch. When starting an exercise program, make sure you’ve cleared with your doctor that you can safely exercise, always start with no weights to make sure your form is correct and that exercise doesn’t hurt or exacerbate any injuries. Make sure to modify any exercise that doesn’t work for your body by using less weight, only doing one limb at a time, going slower, or do a different exercise that works the same muscle groups and you know works for you.
References
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