A tension headache usually sits on both sides of your head as a band of pressure and does not throb. One that starts in the neck is more often on one side, begins low at the back of the head and follows a neck position. They overlap a lot, and an examination is where sorting them out starts.
What a tension headache usually feels like
Most people know this one. It feels like a band or a steady pressure around the head, on both sides at once, rather than a pulse or a throb. It is usually mild to moderate: enough to notice and to wear on you, rarely enough to send you home. Walking to the station or taking the stairs does not tend to make it worse, and it does not tend to make you feel sick, although bright light or a noisy room can be harder to put up with while it lasts.
That description is not ours. The International Headache Society’s classification, The International Classification of Headache Disorders, 3rd edition (2018), describes frequent episodic tension-type headache as typically on both sides of the head, pressing or tightening rather than pulsating, mild to moderate, not made worse by routine physical activity, and not accompanied by nausea, though sensitivity to light or to sound may be present.
When the neck is where it starts
A headache that comes from the neck tends to behave differently. It favours one side, and it is normally the same side from one headache to the next. It begins low at the back of the head and works forward, over the top or towards the forehead. It is set off by a position you have held for too long or by turning your head, and it often arrives with a stiff neck that will not turn as far one way as the other.
The same classification describes cervicogenic headache, in section 11.2.1, as headache caused by a disorder of the cervical spine or its soft tissues, usually but not always with neck pain. It lists pain locked to one side, the typical headache brought on by pressure on the neck muscles or by head movement, and pain spreading from back to front as features that tend to set it apart from migraine and tension-type headache, and then says plainly that none of them is unique to it.
How a problem in the upper neck ends up felt in the head is explained at more length in can a headache really start in your neck?
A headache behind your eyes is the one people ask about most, and it has more than one likely source. After a long day at a screen it can be eye strain, and an optometrist is the person who checks your eyes and whether your glasses still suit the distance you work at. It can come with a blocked nose and a heavy face during a cold, when the sinuses are involved. It can be migraine. It can be a tension-type headache felt across the forehead and behind the eyes. And it can be pain referred forward from the top of the neck. Which one it is depends on everything that comes with it, so the eyes are worth checking as well as the neck. A headache with a painful red eye, blurred vision or halos around lights is a different matter altogether, and it is in the hospital list at the foot of this page.
Telling them apart takes more than the headache
The descriptions above are tidy, and real headaches often are not. One person can have more than one kind, sometimes in the same week. The classification itself notes that frequent tension-type headache often exists alongside migraine without aura, and that when the pain comes from the muscles of the neck rather than its joints, the headache should probably be counted as tension-type. The reference book itself draws the line loosely.
Migraine is part of this picture too. It is often throbbing, often comes with feeling sick or needing a dark room, and neck pain can come with it too, so neck pain alongside a headache does not settle where the headache comes from. Finding out whether you have migraine, and what to take for it, is a conversation for your GP. If your neck turns out to be part of the story, anything done here runs beside your GP’s care rather than in place of it. Migraine is not a condition this clinic manages.
What sorts one kind from another is an examination. At a first appointment with Dr Laith Musallam, chiropractor, that starts with the story: where the headache begins, which side, what brings it on, what you take for it and how often, and anything that means your GP should see you first. Then the neck itself: how far it turns and bends, whether pressing on the joints and muscles at the top of it brings on your familiar headache, how the deep muscles that hold your head up cope with sustained effort, and how your shoulders and upper back are sitting. The findings are explained to you on the day.
The page on headaches that start in the neck sets out what that condition is and how it is assessed here, and care for headaches and neck pain describes what the appointments themselves involve. If the stiff neck bothers you more than the headache does, start with the page on neck pain instead.
Things worth trying, whichever kind it is
None of these is treatment. They are ordinary things worth trying on your own, whichever kind of headache it turns out to be.
- Breaks from the screen. Stand up now and then, look at something on the far side of the room or out of a window, and let your shoulders drop. A reminder in your calendar makes it easier to remember on a busy day.
- Screen height. Set the top of the screen at about eye level and roughly an arm’s length away, so you are not tipping your chin down or pushing it forward to read. On a laptop that usually means a stand and a separate keyboard.
- Sleep. Short or broken nights come up again and again when people describe their headaches. A steadier bedtime and a pillow that keeps your head level with the rest of you are both worth a look.
- Water, meals and coffee. A skipped lunch, an afternoon without a drink, and coffee that swings between a lot and none are all worth noticing.
- A headache diary, described below.
The diary is the one item here the classification speaks to directly. Its comment on frequent tension-type headache says that where it exists alongside migraine, both need to be identified, preferably with a diagnostic headache diary, and that telling the two apart matters partly to avoid overusing medication, which can cause headaches of its own. Write down when each one starts, which side it sits on, what you were doing, what you took and whether it changed anything. Bring it with you, whoever you see.
The desk side of all this, from chair height to where the phone sits, has a guide of its own: why does my neck hurt after a day at my desk?
Stop and get it checked if a headache starts behaving differently from your usual ones, if pain spreads into an arm, if pins and needles, numbness or weakness appear, if dizziness or a change in your sight comes with it, or if the headache keeps climbing rather than easing. The list at the foot of this page says where each of those goes.
When to get it looked at
Call an ambulance if there is any confusion, sudden weakness or numbness in the face, arm or leg on one side, facial drooping, slurred speech, sudden trouble speaking, seeing or understanding, loss of vision, a seizure, or a sudden loss of balance or coordination. Call an ambulance or go to a hospital emergency department straight away if a headache comes on suddenly and severely (the worst you have ever had), if a headache arrives with fever, a stiff neck or a rash, or if a headache follows a knock to the head. Go to a hospital emergency department straight away if a headache comes with a painful red eye, blurred vision or halos around lights.
Go to a hospital emergency department straight away for back or neck pain after a serious fall or a high-impact accident, such as a car accident; back or neck pain with a fever or feeling generally unwell; or new back or neck pain if your immune system is weakened, for instance by long-term steroids or chemotherapy, if you inject drugs, or if you have recently had a spinal injection, spinal surgery or a dental procedure. Go to a hospital emergency department straight away if you have weakness in one arm that is severe or getting worse, or numbness in an arm that is spreading or getting worse quickly. Go to a hospital emergency department the same day if you have new clumsiness in both hands, or new unsteadiness on your feet.
See your GP first if you have a brand-new type of headache, if your usual headache has changed its pattern, if your first bad headaches have started after the age of 50, if they are worse lying down or when you cough or strain, if you are taking pain relief for headaches more than a couple of days most weeks, or if you think you may have migraine and have never been assessed.
See your GP promptly, before booking here, if you have pins and needles, numbness or weakness in an arm or hand, a history of cancer, unexplained weight loss, pain at night that will not settle in any position, or known osteoporosis with new severe pain.
Otherwise, if headaches keep coming back through the working week, if they arrive with a stiff neck, or if you are simply not sure which kind you have, that is a reasonable time to have your neck assessed.