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Massage Therapy for Tension Headaches

Perfect Spot No. 1, in the suboccipital muscles of the neck

Trigger points (TrPs), or muscle knots, are a common cause of stubborn and strange aches and pains, and yet they are under-diagnosed. The 13 Perfect Spots are trigger points that are common and yet fairly easy to massage yourself — the most satisfying and useful places to apply pressure to muscle. For tough cases, see the advanced treatment guide.

Under the back of the skull must be the single most pleasing and popular target for massage in the human body. No other patch of muscle gets such rave reviews. It has everything: deeply relaxing and satisfying sensations, and a dramatic therapeutic relevance to one of the most common of all human pains, the common tension headache. And no wonder: without these muscles, your head would fall off. They feel just as important as they are.

Along with lots of other neck muscles, the suboccipital group — usually just called “the suboccipitals” — work overtime to keep your head balanced on top of your spine. In particular, they initiate and control fine movements. This is no small task: if you’re a big person, your head may weigh as much as a 10-pin bowling ball, and it is resting on a foundation only about one third as wide. Consequently, these muscles rarely stop working.

Your head may weigh as much as a 10-pin bowling ball.

The suboccipitals are also partly “antagonized” (balanced) by the jaw muscles. This is an odd arrangement. Generally speaking you’ve got one muscle or group of muscles that pulls one way, and then muscles on the other side of the joint that pull the other way. But the jaw muscles do not affect the spinal joints, and cannot directly work against/with the suboccipitals to balance the head. Nevertheless, they do: muscle studies have shown that the jaw muscles behave much like they would in a more normal push-pull relationship with the suboccipitals. They function together and dysfunction together. Both of these muscle groups routinely harbour trigger points that cause headaches (among other things), and together they are the source of most tension headaches.1 Muscle pain in these groups are also likely triggers for migraines and cluster headaches.2

If I could have only one group of muscles to get massaged regularly, this is the one I’d choose. For example …

A simple success story: treating a tension headache with suboccipital massage

My cat, Cali — alas, no longer with us — once woke me up with a particularly insistent feed-me-now yowl. Normally I found that irritating, but on that occasion she was doing me a favour, because my neck was in a crazy position and I was cooking up a violent headache. Some wee muscles behind my head were in a shortened position, and the longer I lay there, the harder it was going to be to get unstuck. A headache was already spreading across the back of my skull like a toxic spill.

Sleeping is dangerous!

I can only assume it would have been even worse without my furry early warning system, but within an hour my headache was yowling much more loudly and persistently than the cat, who was by then fed and settled in the “cat sauna.” Late in her life, she became inordinately fond of sleeping all morning in the bathroom with the heat lamp on — not very energy efficient, but extremely cute. Presumably it was therapeutic for her cranky ol’ body. I decided to follow her example.

I warmed the back of my head up with one of my big, thick and lovely Thermophore heating pads and then settled in for a dose of urgently needed massage for Perfect Spot No. 1. Then, using a Knobble massage tool, which is just perfect for this location, I applied some (really intense) pressures to my suboccipital muscles. And then I followed that up with a good dose of mobilizations (simple neck circles).

The headache vanished. It’s hard to overstate the degree of success I enjoyed from this simple procedure. It was a severe headache, the kind that could easily ruin a whole day. Success was by no means guaranteed, and I feared the worst. But my self-treatment didn’t just take the edge off — the headache was terminated, quickly and completely. It was gone like it had never happened, and it did not come back.

What does Perfect Spot No. 1 feel like?

In addition to generally producing the best quality of the “deep sweet ache” that most people crave from massage, trigger point referral into the head has a sort of sedative effect that can’t be beat. Just as trigger point referral elsewhere in the body tends to feel “paralyzing,” creating a deadening or heavy feeling that usually spreads out and down like a heavy blanket, trigger point referral from the suboccipitals does this too — but that feeling spreads into the head. With the right pressure, in the positive context of therapeutic massage, that sensation is deliciously soporific.

An incredibly high percentage of the population consistently reports these positive sensations in this location — even many people who aren’t otherwise especially “triggery,” and who may have the idea that massage is kind of pointless. Many times while working on a quiet client — someone who is either really zoned out, or seemingly unaffected and taciturn — I have been interested to see how they react to pressure in the suboccipitals. Clients who haven’t made a sound for fifty minutes suddenly groan with relief and say, “Oh, that’s a good spot.”

Pain produced by trigger points in the suboccipitals is often vague and “ghostly,” as Travell and Simons put it.

How do you treat Perfect Spot No. 1?

The suboccipital group is easy to find. It lies just underneath the back of your skull, in a line from ear to ear. Each person’s personal version of Perfect Spot No. 1 will be found somewhere in that range. While the entire group responds positively to pressure in most cases, there is some variation in quality from one location to another along the ridge.

The exact centre is the one spot where you might not get a positive reaction. There is a small hollow there, right at the top of the spine. To some people, pressure on this spot — which is not actually even muscular — will be sweet bliss. To others, while there is no actual danger, it feels too vulnerable, too “spine-y.” It’s a love-it-or-hate it spot, with roughly 75% of people loving it, 25% feeling uneasy with it. Note that some people can learn to love it, if they feel safe enough.

The rest of the region is all predictably pleasurable, but your partner’s favourite spot might be in the thinner roots of the tissue more on the actual skull, or deeper into the muscle bellies further under the ledge. They might prefer pressure on the thick bands of muscle exactly on either side of the centre, or they might prefer it way out on the sides, just behind the bump of bone under the ear.

To massage someone’s suboccipitals, have them lie down face up. Reach under the base of the skull and press upwards with your fingertips. Start slow, but most people will be able to tolerate strong pressure here. Beware: they won’t want you to stop.

How do you self-treat Perfect Spot No. 1?

It’s a bit tricky to effectively massage your own suboccipital muscles without a tool like the Knobble massage tool, which (as mentioned above) is just perfect for this particular location, but if you don’t have one (yet) it is also awfully nice to just lie down with this muscle group resting on a tennis ball. To some extent you can roll back and forth on that and get some satisfaction. A smaller, more accurate ball might work even better for you, or you could rest the centre point on the pointy end of a “Kong”-style dog toy (probably through a layer of fabric to soften it and keep the rubber from pulling your hair).

Stretching is not all it’s cracked up to be, but it might help to relieve trigger points in the suboccipitals. To stretch these tiny muscles, slowly and respectfully pull your head downwards with your hands, but gently straighten and lift your lower neck at the same time — that is, only tilt the skull forward, not the whole neck.

Another excellent therapeutic exercise for this muscle group is Neck Circles, and heat is nearly always helpful.

Appendix A: Is trigger point therapy too good to be true?

Trigger point therapy isn’t too good to be true: it’s just ordinary good. It can probably relieve some pain cheaply and safely in many cases. Good bang for buck, and little risk. In the world of pain treatments, that’s a good mix.

But pain is difficult and complex, no treatment is perfect, and there is legitimate controversy about the science of trigger points. The phenomenon of sensitive spots on the body is undeniable … but their nature remains somewhat puzzling, and the classic image of a tightly “contracted patch” of muscle could just be wrong. On the one hand, you can measure their electrical activity, take samples of their highly acidic tissue chemistry, and now a new MRI-like technology can now show them as well. On the other hand, some of that may be wrong, and all of it could essentially just be “side effects” of a more basic problem. No one really knows.

What we do know is that people hurt. Muscle pain is clinically significant, but medically obscure. As Dr. David Simons wrote, “Muscle is an orphan organ. No medical speciality claims it.” Many patients can benefit from educating themselves.

The Perfect Spots are based on a decade of my own clinical experience as a massage therapist, and years of extensive science journalism on the topic. Want to know more? This is the tip of the iceberg. I’ve written a whole book about it …

Appendix B: Quick Reference Guide to the Perfect Spots

Notes

1. The relationship between myofascial trigger points and headache is well-established. Good example of research making this connection are two papers by Fernández-de-Las-Peñas et al: “The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck” and “Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache”. My claim that trigger points are not only a cause but the most common cause of headaches is based on my own clinical observations: I don’t think there’s any data to back that up. BACK TO TEXT
2. Calandre et al. Myofascial trigger points in cluster headache patients: a case series. Head & Face Medicine. 2008. PubMed #19116034.

   Although this research was “preliminary and uncontrolled” and is not powerful enough to prove anything, its results were certainly noteworthy — the sort of results that can inspire more research, hopefully. All of 12 patients with chronic cluster headaches (a kind of migraine, nicknamed “suicide headaches”) had myofascial trigger points, and treating them (with injection) produced “significant improvement in 7 of the 8 chronic cluster patients.” The authors speculate that trigger points are not the cause of cluster headaches, but a nasty complicating factor: “chronic pain or repeated acute pain sensitize muscular nociceptors creating active trigger points which, in turn, contribute to potentiate headache pain. This kind of vicious cycle explains why the number of active trigger points has been found to be higher in patients with chronic primary headaches than in healthy subjects or in patients experiencing less frequent headache attacks.”

   BACK TO TEXT

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