"By late afternoon it feels like a cap is being tightened around my head. It starts at the base of my neck, spreads to both sides, and never quite lets go all evening." Most patients who come to us with headache use almost exactly these words. No throbbing, no nausea, no need for a dark room; a dull, squeezing pressure that gets heavier in the second half of the day.
That is the classic story of a tension headache, by far the most common headache we see as physiotherapists. Then there is a second group: people who have lived with the same pain for years and now spend four or five days a week on painkillers. The two are not treated the same way. This article is about the neck muscles behind the pain and the vicious circle the second group falls into.
How the pain is described tells us a great deal
A tension headache typically feels like a band gripping both sides of the head at once. The pain is dull and pressing rather than pulsing, usually mild to moderate: it does not put you in bed, but by evening it stops you working properly. Starting at the base of the skull and spreading to the temples is a common pattern.
The timing matters too. Patients rarely wake up with it: the pain builds through the day and peaks in the last hours of a shift, at a screen or on your feet. The light and sound sensitivity, nausea and vomiting of migraine are usually absent or very mild here.
- Both sides or one? Tension headache is mostly bilateral; migraine typically starts on one side.
- How does it feel? Dull, squeezing pressure suggests tension headache; throbbing pain suggests migraine.
- With movement? Stairs or bending forward clearly worsen migraine; tension headache usually stays the same.
- Nausea, vomiting, discomfort with light or noise? Usually absent.
- What time of day? Tension headache builds through the day rather than waking you.
For a neutral overview, the NHS page on tension headaches is clear and reliable. Even so, the distinction belongs in an examination: two headache types can coexist in one person, with a different plan for each.
How neck and shoulder muscles send pain into the head
The pain is felt in the head, but its source is often the neck and shoulder girdle, and we look at three muscle groups. The upper trapezius runs from either side of the neck to the tip of the shoulder and carries the weight of the arm all day. The suboccipital muscles sit between the skull base and the first two vertebrae; small, but never off duty, since they fine-tune head position. Third are the jaw muscles: in patients who clench, masseter and temporalis get tight enough to make the temple ache.
When trigger points develop, the pain does not stay over the muscle itself. The upper trapezius refers it from the back of the neck towards the temple, the suboccipitals from the back of the head around to the eye, the jaw muscles to the temple and in front of the ear. When we press these spots and the patient says "yes, that is exactly where it hits", we are probably in the right place.
We examine the neck of every patient who comes in with headache. But finding a tender muscle in the neck does not mean we have found the cause; the tenderness has to match the pain map the patient describes.
There is also headache that genuinely comes from the neck: cervicogenic headache. It arises from the neck joints and deep muscles, is usually one-sided, is brought on by turning the head, and restricts neck movement measurably. Tension headache is bilateral and changes far less with neck movement. Both can exist in one patient. For more on what posture does to these muscles, the article where we explain the link between neck pain and posture is the natural companion to this one.
What actually triggers it in the patients we see
In Antalya the patient profile changes with the season. In summer: twelve-hour shifts at a hotel reception or in restaurant service, the tray always on the same shoulder, hours under an air conditioning vent. Transfer drivers differ, with hundreds of kilometres a day between airport and hotels and the neck barely moving. In winter, long days at a screen take over.
- Hours at a screen: a monitor below eye level keeps the neck bent forward and the upper trapezius never rests.
- Holding the phone between shoulder and ear; common in reception, cashier and sales work.
- Long hours of driving with seat and steering position badly adjusted.
- Cold air conditioning blowing straight onto the neck and shoulder.
- Broken sleep, night shifts, skipped meals and not enough water.
- Stress and anxiety, which keep jaw, shoulder and neck muscles contracted all day.
- Clenching by day and grinding at night; morning jaw fatigue or wear noticed by your dentist is the clue.
- An uncorrected vision problem or outdated glasses; when the eyes strain constantly, forehead and temple muscles strain with them.
We go through this list with the patient. Almost every time two or three points come straight out of that person's own day. Finding the trigger is half the treatment: whatever we achieve with our hands is undone if the same day repeats unchanged.
The most overlooked cause: the painkiller itself
This is the most important section. Taking painkillers regularly on more than about ten to fifteen days a month, for months on end, can make a headache permanent instead of easing it. This is called medication overuse headache, and it is on the table for a significant share of the chronic headache patients we see.
The cycle works like this. Pain arrives, the patient takes something early, the pain goes. A few weeks later there are fewer pain-free days and the tablets come more often. Eventually the person wakes with a low-grade headache and medication becomes the first task of the day. They read this as "my headache got worse", when its nature has changed. With combination products, especially those with caffeine or codeine, the threshold is lower.
Rather than arguing about numbers, we ask one question: on how many days last month did you reach for a painkiller? Most patients do not know, and their estimate is well below the real figure. This is where a headache diary first proves its worth.
If you have been taking painkillers almost every day for months, what you are dealing with may no longer be only a tension headache. Until you discuss that possibility with a doctor, no physiotherapy programme will give the result it should.
The aim is not to frighten anyone away from medication; used sparingly, painkillers are a good tool. But reducing or stopping them is done with a doctor: pain can worsen during withdrawal, and if migraine sits underneath, preventive treatment has to be planned. As physiotherapists we recognise the suspicion and refer on; we do not decide to stop medication.
What exactly we assess in the examination
Much of the first session is talking: when the pain started, what time of day it comes, work routine, sleep, medication. Then we measure.
- Neck range of motion: which of the six directions is restricted, and which movement increases the pain.
- Deep neck flexor endurance: lying on the back, tucking the chin gently and lifting the head minimally off the surface. If they are weak, the superficial muscles take the load and pain appears by evening.
- Trigger points: tender bands in the upper trapezius, suboccipital, sternocleidomastoid and temporalis muscles, and the referred pain mapped.
- Posture and shoulder girdle: resting position of the shoulder blade, rounded shoulders, upper back mobility.
- The jaw joint: mouth opening, tenderness of the chewing muscles, clicking or deviation. Where we suspect bruxism we work with a dentist.
- Red flag screening, and referral to a doctor if needed.
At the end we can say something clear: how much of the pain looks musculoskeletal and how much sits outside our field. A programme started without that distinction wastes time.
What physiotherapy does and does not do
The hands-on work reduces tension in the neck and shoulder girdle: suboccipital release, soft tissue work on the upper trapezius and chewing muscles, upper back mobility, and trigger point treatment where needed. In most patients this lowers intensity and frequency. If you are curious which techniques we mean, the article where we explain how manual therapy works is a good place to start.
The lasting part lies in exercise and in how the day is organised: deep neck flexor training, stabilisation for the muscles that hold the shoulder blade, upper back mobility. Not a few sessions a week, but small correct repetitions done daily.
- A break rhythm: stand up every forty-five minutes, move neck and shoulders for two or three minutes. A phone reminder is the easiest way.
- Screen height: top edge of the monitor at eye level. On a laptop, raise it and use a separate keyboard.
- A headset: drop the habit of wedging the phone between shoulder and ear.
- Heat: fifteen to twenty minutes on neck and shoulders once or twice a day, at a temperature that does not burn the skin.
- Sleep and water: a fixed bedtime visibly reduces headache frequency in most patients. In an Antalya summer, fluid intake is a problem more often than expected.
- A headache diary: date, duration, intensity, medication taken, suspected trigger. After four weeks you hold data more useful than a single examination.
Honestly, physiotherapy helps in tension headache but it is not magic. If sleep disorder, anxiety, depression or uncontrolled medication use are in the picture, hands-on treatment alone will not take you far and the programme has to run alongside a doctor's preventive treatment. Saying so is accepting the limit of our work, and it protects the patient's time.
When you should see a doctor without delay
Most headaches are benign. Some signs are exceptions, and booking a physiotherapy appointment would be the wrong order.
- The worst headache of your life; one that explodes into place within seconds.
- Headache with fever, a stiff neck or confusion.
- Headache after a head injury, or one that keeps worsening for days afterwards.
- Neurological signs: loss of vision, double vision, difficulty speaking, facial drooping, weakness in an arm or leg.
- A new headache after fifty, more urgent still with tenderness at the temple or jaw pain on chewing.
- A history of cancer, or illness or medication that suppresses the immune system.
- Pain clearly worse with coughing, straining or bending; pain that wakes you at night and keeps worsening.
If any of these apply to you, a medical assessment comes first. In our clinic this screening is the first step of the examination too: seeing one, we refer the patient on instead of starting a programme.
If your headache has lasted more than two weeks, or you spend several days a week on painkillers, you are welcome to come in for an examination. Depending on what we find, we either start a programme for the neck and shoulder girdle or tell you plainly that the right address is a medical assessment.
