Headaches

Not all headaches are created equal

Headaches are one of the most common reasons people visit a doctor, and one of the most complex to sort out. There are dozens of headache types, and many patients have more than one kind happening simultaneously. What I focus on is the musculoskeletal contribution, the structural and mechanical factors in the neck, skull, and upper back that are often driving or amplifying the headache cycle.

This doesn't mean your headache is "just" a muscle problem. It means that even when a headache has a neurological, hormonal, or vascular component, the musculoskeletal system is usually involved and treating it can make a real difference.

The types I see most

Cervicogenic headache. This is a headache that originates in the neck. Dysfunction in the upper cervical spine, particularly at C1 (atlas), C2 (axis), and C3, refers pain up over the head, into the temple, behind the eye, or across the forehead. It's usually one-sided, starts at the base of the skull, and comes with neck stiffness or restricted range of motion. These respond extremely well to OMM.

Tension-type headache. The most common headache type in the general population. It feels like a band of pressure around the head, is typically bilateral, and is often associated with muscle tension in the neck, shoulders, and jaw. Stress, posture, and sleep position all contribute. There's significant overlap between tension-type headache and cervicogenic headache, and many patients have elements of both.

Migraine with musculoskeletal triggers. Migraine is a neurological condition with complex pathophysiology. But many migraine patients notice that their attacks are triggered or worsened by neck tension, poor sleep, or jaw clenching. Addressing these mechanical triggers won't cure the migraine, but it can reduce the frequency and severity of attacks.

Occipital neuralgia. Irritation of the greater or lesser occipital nerves produces sharp, shooting pain from the base of the skull into the scalp. It can be caused by muscle compression (the occipital nerves pass through the suboccipital and upper trapezius muscles), trauma, or upper cervical dysfunction.

Temporomandibular joint. This joint connects your jaw to your skull, just under the ear. Sometimes this can cause pain right in that area, as well as ear pain and referred headaches. This is easily diagnosed and treated with OMM.

The musculoskeletal connection

The upper cervical spine has a unique relationship with the head. The C1 and C2 vertebrae are responsible for about 50% of cervical rotation, and the suboccipital muscles that connect the skull to the upper cervical spine are packed with proprioceptive nerve endings, more than almost any other muscle group in the body. When these structures are dysfunctional, they don't just cause local pain. They alter proprioceptive input to the brainstem, which can influence dizziness, visual focus, and headache signaling.

The dura mater, the membrane surrounding the brain, has direct fascial connections to the upper cervical spine. Tension in the suboccipital region can literally pull on the dura. This is not theoretical anatomy. It's the likely mechanism behind many cervicogenic headaches and one of the reasons OMM is so effective for this population.

How we approach it

I start with a detailed history: headache pattern, frequency, triggers, associated symptoms, and what's been tried. Then a structural exam of the cervical spine, cranial base, temporomandibular joints, thoracic spine, and sacrum. Yes, the sacrum. The dura is a continuous tube from the cranium to the sacral canal, and sacral restrictions can influence cranial mechanics.

OMM is the primary treatment. Techniques range from high-velocity low-amplitude thrust for cervical joint restrictions to gentle cranial osteopathy for the cranial base and sacrum. Myofascial release for the suboccipitals, upper trapezius, and SCM. Muscle energy for the upper cervical segments. The specific approach depends on what I find on exam.

For patients with migraine, OMM works alongside, not instead of, neurological management. Many patients find that when their cervical mechanics are well-maintained, they need less medication and have fewer breakthrough headaches.

For occipital neuralgia, ultrasound-guided nerve blocks can provide significant relief by targeting the occipital nerves with a local anesthetic and corticosteroid combination.

When to seek care

If your headaches are frequent (more than once or twice a week), if they're getting worse over time, if they're not controlled with over-the-counter medication, or if they come with neck stiffness or jaw pain, you should be evaluated. Also come in if your headache pattern changes suddenly, if you have the worst headache of your life, or if headaches come with neurological symptoms like vision changes, weakness, or speech difficulty, these warrant urgent evaluation.

What you can do right now

Check your posture at your desk. A forward head posture, where your head sits in front of your shoulders, increases the load on the suboccipital muscles by two to three times for every inch of forward displacement. Bringing the screen up and the chin back can reduce headache frequency.

Address your jaw. If you clench or grind at night, the tension in the masseters and temporalis muscles feeds directly into the headache cycle. A night guard can help, and so can awareness of daytime clenching.

Move your thoracic spine. A stiff upper back forces the cervical spine to compensate, increasing mechanical stress at the cranial base. Seated rotations, cat-cow, and gentle extensions over a foam roller can all help.

Stay hydrated. Dehydration is one of the simplest and most commonly overlooked headache triggers. If you're getting headaches in the afternoon, start with a glass of water before reaching for a pill.