Massage Therapy for Tension Headaches

Trigger points (TrPs), or muscle “knots,” are a common cause of stubborn & strange aches & pains, and yet they are under-diagnosed. The 14 Perfect Spots (jump to list below) are trigger points that are common & yet fairly easy to self-treat with massage — the most satisfying & useful places to apply pressure to muscle. For tough cases, see the advanced trigger point therapy 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. These muscles have to be workaholics.

Trigger points in the suboccipital muscle group are the most common cause of tension headaches.

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.^{[citation needed]} They function together and dysfunction together. Both of these muscle groups routinely harbour trigger points that are linked to headaches and migraines,123 and I personally believe they cause a great many headaches — maybe more than any other cause.4

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

The yowly one

Not in yowly mode.

My cat once woke me up with a particularly insistent feed-me-now yowl. Normally I would have been irritated, but on that day she was doing me a favour, because my neck was in a crazy position and I was cooking up a violent headache. It 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 more than the cat, who was by then fed and settled in the “cat sauna.” Late in her life, she became fond of sleeping in the bathroom with the heat lamp on — presumably it was therapeutic for her cranky ol’ body. I decided to follow her example and 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 intense5 pressure 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. Such is the power of massaging the suboccipitals (sometimes).

The “Knobble II” by Trigger Point Products is a good shape for self-massage of the suboccipital area.

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 sedative feeling that can’t be beat. Just as trigger point referral elsewhere in the body often feels pleasantly “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 into your head. With the right pressure, in the positive context of therapeutic massage, that sensation is deliciously soporific.

Many people report these positive sensations in this location, even those who aren’t otherwise especially “triggery,” and who may have the idea that massage is kind of pointless (a strange attitude, but it’s out there). When I worked as a massage therapist, I often observed that even quiet and unresponsive clients — taciturn, or just really zoned out — would clearly react to pressure in the suboccipitals. A client who hadn’t made a sound for fifty minutes would suddenly groan with relief and say, “Oh, that’s a good spot.” It’s that reaction that originally inspired this series of articles: it’s the prototypical “perfect spot” for massage.

Pain produced by trigger points in the suboccipitals is also often vague and “ghostly,” as Travell and Simons put it.6

How do you treat Perfect Spot No. 1?

The suboccipital group is easy to find. It lies just underneath the back of your skull, where it overhangs the neck, in a line from ear to ear. Each person’s personal version of Perfect Spot No. 1 will be found somewhere in that arc. 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 (higher on the back of the 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).

Another good therapeutic exercise for this muscle group is “neck circles,” and heat is usually more helpful than cold (although that always depends on your preferences).

Stretching is not all it’s cracked up to be, in general9 or as a treatment for trigger points,10 and for biomechanical reasons it’s tough to stretch the suboccipitals firmly: the chin can only drop so far.11 But you can elongate them, some people will get more out of it than others, and it is worth a try.

To stretch these tiny muscles as well as you can, slowly and respectfully pull your head downwards with your hands, but gently straighten your lower neck at the same time — that is, only tilt the skull forward (not your whole neck). Add a little bit of rotation to add some tension to one side or the other.

Muscle attachment areas of the skull… a lot of them, especially on the underside. Most of the muscles on the bottom of the skull are also neck muscles. Click to zoom.

Do you have a trigger point under your skull? Or is that just a cervical myodural bridge?

Brace yourself for humility! This is a fantastic example of how hard it is to be sure of anything in medicine.

Cervical myodural bridges are an inconsistent anatomical feature of the neck in some people. They are connections between the spinal cord wrapping (dura mater) and the muscles of the upper neck — basically some rogue gristle. Exactly what is connected and how tightly is debatable and is probably quite different from person to person, like all anatomy.12 The clinical implications are unclear, but they surely exist.13 CMBs probably explain why some people can flex their upper neck more comfortably than others, and it probably causes some headaches.

Obviously there’s not much to be done about a CMB, but you can at least get some sense of whether or not this might be a problem for you just by strongly flexing your upper neck (tuck your chin down firmly): if it’s uncomfortable, there’s a good chance you have pesky myodermal bridges!

Or just trigger points. Which are also sensitive to stretch.

It’s probably impossible to tell the difference between a neck that is sore because of trigger points and one that is sore because of a CMB. Some people might get suboccipital trigger points because of the irritation of a CMB always tugging on their spinal cord, so “all of the above” is definitely a possibility — and a fine example of how trigger points in this area could be just about invincible.

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About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

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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. Their nature remains somewhat puzzling, and the classic image of a tightly “contracted patch” of muscle tissue may well be wrong. What we do know is that people hurt, and it can often be helped.

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 …

Not too good to be true.

Just ordinary good. Trigger point therapy isn’t a miracle cure, but it is a valuable life skill. Practically anyone can benefit at least a little & many will experience significant relief from stubborn aches & pains. The first few sections are free.

Appendix B: Quick Reference Guide to the Perfect Spots

This index is also available on its own page.

Notes

1. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Trigger points in the suboccipital muscles and forward head posture in tension-type headache. Headache. 2006 Mar;46(3):454–60. PubMed 16618263 ❐
2. Do TP, Heldarskard GF, Kolding LT, Hvedstrup J, Schytz HW. Myofascial trigger points in migraine and tension-type headache. J Headache Pain. 2018 Sep;19(1):84. PubMed 30203398 ❐

   There is good evidence that people who get headaches — both migraine and “tension” — also have a lot of trigger points in the musculature of the head and neck. Unfortunately, we still have no idea which came first, the chicken or the egg: headaches might be causing trigger points, or trigger points might be causing headache. There is evidence pointing each direction, but all of it is all low quality and inconclusive. However, the simple correlation is relatively unambiguous: they are linked, we know that much at least.

   Although the authors of this review are likely somewhat biased — “believers” in the clinical significance of trigger points, and interpreting the evidence through that lens — their conclusions are appropriately cautious, acknowledging the limitations of the evidence.

3. Calandre EP, Hidalgo J, Garcia-Leiva JM, Rico-Villademoros F, Delgado-Rodriguez A. Myofascial trigger points in cluster headache patients: a case series. Head & Face Medicine. 2008 Dec 30;4(32):32. PubMed 19116034 ❐ PainSci Bibliography 55349 ❐

   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 severe primary headache, 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.”

4. My claim here that trigger points are not only a cause but the most common cause of headaches is mostly based on my own clinical observations. There is no good quality data to back that up at this time. The evidence I just cited cannot support the “most” part. But I am placing my bet: in time, I think the evidence will show that the relationship is in fact a strong, bottom-up causal relationship.

5. I already know from lots of experience that strong massage pressure is safe and appropriate for me — please be cautious with strong pressure!
6. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999.
7. Sun F, Yuan QL, Zhang YG. Large Buttocks Hematoma Caused by Deep Tissue Massage Therapy. Pain Med. 2015 Jul;16(7):1445–7. PubMed 26176792 ❐ PainSci Bibliography 51701 ❐
8. Note that superficial bruising from massage is common and different from rupturing "arteries and veins." Many techniques can cause significant breakage of the capillaries and other very small vessels just under the skin. It’s unsightly and intimidating, and of course some of the techniques may *also* cause larger and deeper contusions, but most of it is relatively harmless subcutaneous bruising. I don’t approve of techniques that do this, but it’s definitely not in the same league as breaking larger vessels.
9. Stretching is not a pillar of fitness: no type of stretching is a warm up, prevents or treats soreness or injury in general, or enhances peformance (but it can actually backfire). It can increases flexibility, but the value of flexibility is low, even for most athletes. Stretch seems to have almost no value in treating any common kind of chronic pain. For more information, see Quite a Stretch: Stretching science has shown that this extremely popular form of exercise has almost no measurable benefits.
10. Although stretching is the first thing everyone tries to do for stiff, sore muscle, in practice results are erratic and usually minor at best. If trigger points are “mini cramps,” stretching might help some of them — or it might be more like trying to untie knots in a bungie cord by pulling on them. See the stretching article for more on this interesting stretching sub-topic.
11. Neck flexion is stopped by the chin hitting the chest, sharply limiting suboccipital stretch in most people. Although mildly stretchable in some people, it’s impossible for others, and an awkward and limited stretch for most. Many other muscles are similarly awkward to stretch, some of them just more or less impossible — see The Unstretchables.
12. Palomeque-Del-Cerro L, Arráez-Aybar LA, Rodríguez-Blanco C, et al. A Systematic Review of the Soft-Tissue Connections Between Neck Muscles and Dura Mater: The Myodural Bridge. Spine (Phila Pa 1976). 2017 Jan;42(1):49–54. PubMed 27116115 ❐

    This review of 26 studies found “strong evidence” and concluded that it “proved” that there are connections between some suboccipital muscles and the dura mater, while there is “limited evidence” and “controversy” about others. They conclude: “There is a continuity of soft tissue between the cervical musculature and the cervical dura mater.”

13. Enix DE, Scali F, Pontell ME. The cervical myodural bridge, a review of literature and clinical implications. J Can Chiropr Assoc. 2014 Jun;58(2):184–92. PubMed 24932022 ❐ PainSci Bibliography 53727 ❐