It usually starts mid-afternoon, on a day you've been at the desk since eight. A dull band of pressure around both sides of your head, a tight, tender patch at the base of your skull, and shoulders sitting somewhere up near your ears. It isn't bad enough to stop you working, so you don't stop. You take something, you get through, and it turns up again on Thursday.
That pattern is the most common headache there is. It's also the one most often treated at the wrong end: the head, rather than the neck, the shoulders and the daily habits that keep setting it off.
Honestly? Nobody can point to one thing. Health authorities describe tension headaches as multifactorial (a mix of genetic, biological and environmental factors) and state openly that the exact cause isn't known 1. The NHS adds one reassuring point: a tension headache is not a sign of an underlying condition 3.
Where the sources part ways is on muscle tension itself. One government reference states that tension headaches occur when the neck and scalp muscles become tense or contract 2. Another states the opposite just as plainly: that these headaches are not caused by muscle contractions, but that muscle tension can make the pain worse 1. A third doesn't list posture as a cause at all 3.
Partly, and the honest answer depends on which source you read. What all of them agree on is that the neck and shoulders are involved somewhere. The pain is typically worse in the scalp, the temples or the back of the neck, and often in the shoulders too 2. On examination the nervous system is normal, but tender points in the neck and shoulder muscles are a common finding 2. Sore neck and shoulders are listed alongside the headache itself as part of the picture 1.
What that means in practice: treating the neck and shoulders is reasonable, supported and often helpful, but a tension headache is not simply a neck problem, and anyone promising to fix "the cause" outright is claiming more than the evidence does.
A separate condition, cervicogenic headache, is driven by the neck itself, and the research treats it as a different entity with its own management 6. If your headache is one-sided, clearly triggered by neck movement or position, and travels from the back of the head forward, that's the page worth reading next.
For a lot of people this isn't two problems, it's one experience, and it makes more sense treated as one. Holding your head in a single position for a long stretch without moving is a recognised trigger: typing, computer work, fine detail work with your hands 2. So is sleeping with your neck in an awkward position 2. Poor posture at work, at home or while driving, and eye strain from long periods of reading or screen use, sit on the trigger list too 1.
None of that causes a headache in isolation. But it does explain why the headache and the sore neck so often arrive on the same afternoon, and why treating only the headache tends not to change the pattern. If your day is mostly screen-based, our page on text neck covers the postural side in more detail.
The common triggers are all unremarkable, which is why they get missed: stress, anxiety or low mood; not enough sleep; poor posture at work, at home or driving; bright or noisy environments; eye strain from long reading or screen use; smoking; dehydration; and caffeine withdrawal 1. Sleep problems and caffeine appear on the NHS list too 3.
Most people have more than one running at once. That's usually the useful finding: not which single trigger is to blame, but which two or three stack up on the days you get a headache.
Tension headaches that turn up nearly every day are their own pattern, and they're managed differently. For chronic tension-type headache, the strongest guideline-grade review on headaches associated with neck pain recommends low-load endurance neck and shoulder exercise, or relaxation training with stress-coping therapy, or multimodal care that combines spinal mobilisation, neck exercises and postural correction 6. Note how much of that isn't hands-on treatment. If headaches have been part of most weeks for months, our chronic pain management approach is built for that longer-running picture.
This is the distinction that most changes what you should do next, and the two do get confused.
| Tension-type headache | Worth checking for a different headache type | |
|---|---|---|
| Where | Both sides of the head, face or neck 3 | One-sided or throbbing pain 3 |
| What it feels like | Pressing or tightening: a band or vice around the head, dull rather than pulsing 2,3 | Throbbing or pulsing 3 |
| Other symptoms | Usually no nausea or vomiting 2; the affected area may feel tender to touch 3 | Nausea or vomiting, sensitivity to light or noise 3 |
| Can you keep going? | Usually yes: daily activity doesn't make it worse 3 | Activity often makes it worse 3 |
| How long | 30 minutes to seven days 2,3 | Varies |
If your headaches look more like the right-hand column, that's worth raising with your GP. It may be a different type of headache that responds to different treatment 3. The third possibility, a headache coming from the neck joints themselves, is covered on our cervicogenic headache page.
There's no scan or blood test for a tension headache. It's diagnosed by talking with you and examining you 1. The UK guideline says a brain scan shouldn't be ordered just for reassurance once tension-type headache is diagnosed 8. A mild to moderate headache with no other symptoms, which settles with home treatment within a few hours, may need no testing at all 2.
If yours are regular, expect to keep a headache diary for at least eight weeks: how often they come, how long and how bad, what comes with them, what you took and what might have set them off 8. Tests are for pain that doesn't go away 1. A referral to a neurologist (a brain and nerve specialist) follows if the cause is unclear or the usual measures aren't working 1 3.
Assessment comes first, and it's mostly about pattern rather than pathology: where the pain sits, how long it lasts, what your days look like, how your neck and shoulders move and where they're tender. From there:
What the evidence honestly supports. A meta-analysis of physiotherapy interventions for headache found a statistically significant reduction in tension-type headache pain, and the authors then state plainly that those reductions do not reach clinically relevant effect sizes, that 19 of 26 appraised trials carried a high risk of bias, and that the overall level of evidence is low 5. A broader umbrella review reached a similar place: exercise could be effective, but on moderate-to- limited quality evidence, and manual therapy's evidence is more limited still 4. The network meta-analysis findings apply to the short term only 7.
So: worth doing, most useful when exercise is part of it, and not a cure. We'd rather tell you that before you book than after.
Government health sources list rest, a heat pack and massaging the neck as reasonable first steps 1, and specifically suggest a low, firm pillow plus heat or cold packs when neck pain and headaches come together 3. This isn't trial-grade evidence. It's low-risk, low-cost self-care that's easy to try and easy to stop.
In the network meta-analysis, TENS combined with physiotherapy was the most effective option for reducing headache intensity compared with no treatment, at moderate confidence, but in the short term only 7. It's included here because the finding is real, not because it replaces the two approaches above. Worth raising at your assessment if it interests you.
For chronic tension-type headache specifically, relaxation training with stress-coping therapy is one of the recommended options 6. Regular exercise, yoga or meditation, biofeedback and cognitive behavioural therapy all appear on the mainstream management list 1. Some of that sits outside physiotherapy. Where it's the right fit, we'll say so and point you in the right direction rather than stretch our scope.
Over-the-counter pain relief is the usual first line 1,2,3, and amitriptyline is sometimes used preventively for frequent headaches 3. Physiotherapists don't prescribe or administer medication. Those conversations belong with your GP or pharmacist. The one thing worth knowing regardless: taking pain-relief medicines more than two to three times a week 1, or more than three days a week 2, can itself start causing headaches. It's a common and frustrating trap.
A tension headache is not an injury that heals, so The Well Motion Recovery Path™ is about changing a pattern. You move up a phase when your headaches shift, whatever the calendar says.
How long it usually takes. A single headache lasts 30 minutes to seven days 2,3. Changing the pattern takes longer. One small trial in people with neck pain and tension headache found lower headache impact scores after 6 weeks of manual therapy and stabilisation exercise, with no later follow-up 11. The strength training trial above ran for 20 weeks 9. Some people learn to manage these headaches without clearing them.
A few things have been tested in trials for cutting how often these headaches turn up:
Most tension headaches aren't a sign of anything sinister 3. These are the things that should prompt an actual assessment rather than another week of managing it yourself.
Seek urgent medical care for a headache that comes on suddenly and severely; a headache with vomiting, confusion, neck stiffness, fever, a change in vision or a seizure; a headache after a head injury; a headache that's worse when you lie down or cough; one that has been progressively worsening over weeks; a morning headache with persistent nausea; or any new or different headache during pregnancy 1.
Book in with your GP if you have jaw pain when eating, blurred or double vision, a sore scalp, or numbness or weakness in your arms or legs 3, or if your headache is one-sided and throbbing, comes with nausea or light sensitivity, or stops you doing normal things 3.
Come and see us when the headaches are recurring, your neck and shoulders are part of it, you're reaching for pain relief more than two or three times a week 1, or the pattern hasn't shifted despite you doing the sensible things. None of that is an emergency. It's just the point where working it out with someone beats guessing on your own.
We start by listening: how it began, what makes it worse, and what it's stopping you from doing. Then we examine the area, explain what we find in plain English, and agree a plan with you. Your first visit is 40 minutes at Engadine and 30 minutes at our other clinics.
We see patients at Engadine, Mount Annan, Narellan and Appin, and at home through our mobile physiotherapy service. If you have private health cover, here's how health fund rebates work for physiotherapy.
For the headache in front of you: rest, a heat pack, massaging the neck, and something to drink if you've been short on fluids 1. If neck pain is part of it, a low, firm pillow and heat or cold packs are specifically suggested 3. For the pattern rather than the episode, that's where neck and shoulder exercise, hands-on treatment and sorting out your triggers come in, and physiotherapy is named among the standard management options 1. The one thing to avoid is leaning on pain relief more than two to three times a week, which can start generating headaches of its own 1.
That location is typical rather than unusual. The pain of a tension headache is often worst in the scalp, the temples or the back of the neck, and frequently in the shoulders as well 2. On examination, tender points are commonly found in the neck and shoulder muscles 2. Holding your head in one position for long stretches (screen work, detailed handwork) and sleeping with your neck at an awkward angle are both recognised triggers 2. So base-of-skull pain usually points at the neck and shoulders, which is the part we can actually assess and work on.
It's within the usual range. A tension headache lasts anywhere from 30 minutes to seven days 2, and health services describe them as lasting at least 30 minutes but sometimes several days 3. So three days isn't a red flag by itself. What would change the answer is any of the escalation signs above: sudden severe onset, vomiting, confusion, neck stiffness, fever, vision changes, or a headache that's steadily worsening 1,3. And if three-day headaches are becoming routine rather than a one-off, that's the pattern worth assessing.
There's no test for it, but the shape of the headache is a reasonable guide. A stress-related tension-type headache typically sits on both sides of the head, face or neck, feels like something pressing on or tightening around your head, and the area may be tender when touched 3. Stress, anxiety and low mood sit at the top of the recognised trigger list 1. The practical answer is to track it for a few weeks. Most people find their headache days line up with particular workloads, sleep patterns or deadlines. And where stress is the main driver, relaxation training with stress-coping therapy is one of the specifically recommended options for chronic tension-type headache 6.
Spinning, swimming or off-balance, often set off by rolling over, looking up, or standing quickly. Usually an inner-ear problem, not a head one, and usually treatable with vestibular physiotherapy.
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