Fifty million Americans have chronic headaches – they are one of the most common physical problems in the range of human experience. Muscular tension, sinus infection, vascular spasm/dilation and chemical imbalances can all contribute to a headache. A headache can range in degree from irritating to debilitating. Massage therapists have the tools to significantly help someone who suffers from the more common types of chronic headaches.

The first step in the assessment of a client with a headache is to rule out any dangerous physical causes, such as a tumor, meningitis or aneurysm. Some questions during your performance of an intake that could ascertain these are:

  • Is this the first headache you’ve ever had?
  • Is this the worst headache you’ve ever had?
  • Is this noticeably different from your usual headaches?
  • Do you also have high fever, aches and pains, earache, dizziness or fainting?
  • Could this be the result of a head trauma?

Yes to any of these questions should yield an immediate referral to the client’s physician. Massage is contraindicated in the case of a headache due to an infection or a central nervous system injury.

Another important question to ask is:

  • Could you be dehydrated?

Many headaches are caused by the chemical imbalance resulting from dehydration. With a lack of water, the salinity, and therefore osmotic pressure, of the cerebrospinal fluid in the cranium rises. This painful head pressure can be relieved with adequate hydration.

Once you’ve established that you are not dealing with a headache stemming from a physical cause, determining the type of headache will help you select the most effective treatment for your client. In general, there are three types of chronic headaches:

  1. Tension Headaches – These are the most common type of headache and they are characterized by tension, soreness and pain in the neck, shoulders, head and face. It can feel like a vice gripping the entire head.
  2. Vascular Headaches – These are headaches where the pain comes from excessively dilated blood vessels in the meninges. The pain throbs with the client’s pulse. Common vascular headaches include:
    • Migraine Headaches – These headaches can be disabling. These begin with vasoconstriction followed by extreme vasodilation. They are usually one-sided and typically include intense pulsing and pounding in the head accompanied by nausea, vomiting and mood, visual and sound disturbances. Migraines can last for hours, days or weeks.
    • Cluster Headaches – These are the least common type of headache and they come in clusters. The clusters can be grouped over a short or a long period of time. They can be several times a day for a couple of days, for a few weeks or they can appear yearly. The symptoms of a cluster headache include a stabbing sensation in one eye, with tearing of that eye and that sided nostril, as well as agitation.
  1. Sinus Headaches – This often accompanies an illness such as a sinus infection or sinusitis. Pain is generally around the eyes, cheeks, nose and forehead. The pain is deep and constant, and movement usually exacerbates it.

Massage therapy offers some important benefits to headache sufferers. Massage can help:

  • relieve actual headache pain.
  • prevent headaches by reducing tension and improving circulation.
  • realign a structural imbalance.

A structural imbalance is often the root cause of chronic headaches. While massaging tense muscles can bring temporary headache relief, correcting a structural cranial imbalance can bring headache relief for good. The relaxation garnered from a massage can bring a great deal of relief to a headache sufferer. While easing stress can benefit most types of headaches, there are two additional factors that come into play in a successful treatment.

  1. Release of contracted muscles: A skilled massage therapist will be able to recognize and effectively release the contracted musculature contributing to the headache. The tops of the shoulders and back of the neck are typical areas of tightness in headache sufferers. The blood vessels supplying oxygen to these muscles are constricted, and so the muscles are working with an inadequate supply of nutrients. This combination of muscle spasm and inadequate blood supply is the main cause of pain in tension headaches.
  2. Structural Alignment: If a therapist only works with the back of the neck and shoulders, he/she will be encouraging the structural imbalance which may be the original culprit of the headache. Techniques to move the head, neck and shoulders back into structural alignment are best employed prior to extensive muscle release work for long lasting benefits. After correcting the alignment, addressing the causative postural deviation may be the lifestyle change necessary to prevent future headaches.
    • According to Don McCann, MA, LMT, LMHC, in the May/June 2004 edition of the Massage Message, “When the head, neck and shoulders are released back into an improved structural alignment, the musculature in the back of the neck and tops of [the] shoulders will have already relaxed because it is no longer compensating for the forward head posture. The work on the soft tissue of the back of the neck and tops of shoulders can then be deeper and more effective.”
    • For a vascular headache, a structural alignment has the additional benefit of improving the flow of cerebral spinal fluid and circulation of blood to the cranium. This can have long lasting benefits for the relief of a migraine or cluster headache.

Muscular Release for Headaches

Below is an ordered series for muscular release that a massage therapist can follow to effectively assist and/or create a structural change. This headache protocol is suggested by McCann.

  1. Release the anterior shoulder and neck muscles. Have the client lie supine and work the pectoralis major and minor and then the subclavius directly under the clavicle. Then work the sternocleidomastoid and the three scalene muscles. This reduces the pull on the cervical vertebrae allowing them to shift back into alignment. While working the scalenes, rotate the head and work anterior and progress posteriorly. This will restore range of motion in head rotation, and allow a full release of the tightened musculature. WHEN TREATING THE NECK AREA, THERAPISTS MUST BE AWARE OF THE CAUTIONS AND CONTRAINDICATIONS ASSOCIATED WITH THIS REGION.
  2. Release the top of the shoulder. Have the client lie on one side. Traction the shoulder and release the top of the shoulder and supraspinatus by working from the coracoid process to the superior angle of the scapula. Do not put a shearing pressure on the cervical vertebrae in this position – the pressure is directed toward the feet.
  3. Massage the posterior fibers of the neck. Work from the base of the cranium into the tops of the shoulders by starting with the splenius capitus, then the levator scapula and then the trapezius. Again, do not put shearing pressure on the cervical vertebrae, but rather, apply pressure toward the feet.
  4. Work the occipital ridge. Working the tightened fibers just under the ridge of the occiput will release the occiput, the atlas and the axis.
  5. Massage the cranium. Carefully work the soft tissue that encompasses the head, being careful not to pinch any cranial nerves. Be sure to include massage around the sutures and the temporalis muscle.
  6. Follow with lengthening strokes along the back. This is a nice way to finish, using long strokes down the entire back to reduce any additional pulling on the back of the neck and shoulders.

Structural Alignment for Headaches

Cranial-sacral therapy (CST) is the ideal modality massage therapists can use to obtain structural realignment. Not only can cranial-sacral therapy reduce the symptoms of headaches, but it can also create the structural change necessary to prevent future ones from occurring.

One of the founding principles of CST is that the bones of the cranium are not static, but are created for movement. The sutures that bind the skull bones together are not completely fused, but actually allow for slight movement in response to intracranial pressure. The structural shifts that occur with cranial-sacral work increase the flow of cerebrospinal fluid around the cranium, down the spinal column and around the sacrum, which can effectively reduce intracranial pressure that causes headaches.

These recommendations assume that the practitioner uses cranial-sacral therapy in his/her practice. If you are not educated in this modality, we suggest appropriate training before attempting to mobilize the cranium. The following guidelines are courtesy of the Institute for Integrative Healthcare Studies’ Cranial-Sacral Fundamentals by Mary Sullivan, L.Ac. and Real Bodywork.

  • A majority of headache sufferers will present with an occiput that is immobile. Using cranial-sacral techniques to mobilize a restricted occiput will result in a softening of tissue at the base of the occiput and free up movement of the atlas and axis.
  • Headaches that are more prevalent on the side of the head and/or are associated with temperomandibular joint syndrome (TMJ) can benefit greatly from cranial-sacral techniques that release the temporal bone and the mandible.
  • Headaches that are related to the sinuses can benefit greatly from cranial-sacral techniques that release the maxilla, the zygoma, the frontal bone, the palatines, the sphenoid and the vomer bones. Sinus headaches are likely caused by fluid pressure that stretches the small nerves in the sinuses. Sinuses appear to be the primary outlet for built up cerebrospinal fluid.
  • Cranial-sacral techniques that align the parietal bones can be very helpful for headaches on the vertex of the head and for clients that are easily angered.
  • Cranial-sacral techniques that free the sphenoid bone can be the key to migraine relief. Migraines may be due to membrane restriction that squeezes minor blood vessels in the cranium. The sphenoid bone is referred to as the keystone of the skull, and its release can create a major structural realignment.
  • Eyestrain and forehead headaches respond well to the cranial-sacral techniques that adjust and decompress the frontal bone.
  • All types of headaches can be assisted by basic cranial-sacral techniques including release of the cranial base, the 4th ventricle hold and still point induction.

With the correct combination of techniques, a skilled massage therapist can provide his/her clients with significant headache relief. A diligent intake is critical in screening out headaches that need to be assessed by a physician and headaches that can simply be relieved by drinking water. Comprehensively inquiring about your client’s symptoms will guide you to choose the most beneficial muscular releases and cranial adjustments.

Using this dual approach model allows the massage therapist to proceed in a holistic manner — by addressing the symptoms and the origin. Headache symptoms are the manifestations of an imbalance, and muscular release techniques can effectively address these symptoms. A structural misalignment is a typical root cause, or origin, of chronic headaches. Research has shown that seeking proper postural education is an effective way to implement the lifestyle changes that will allow this dual approach treatment to hold. Incorporating these skills into your treatment protocol will allow you to confidently welcome headache sufferers into your massage practice.

Recommended Study

Massage for Headaches & Neck Pain
Cranial-Sacral Fundamentals

More Information:

Headaches: Massage Benefits and Precautions