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Massage Therapy for Tension Headaches

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

1,500 words, updated 2012
by Paul Ingraham, Vancouver, Canada bio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

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.


Pain Location Problems Related Muscles
almost anywhere in the head, face and neck, but especially the side of the head, behind the ear, the temples and forehead headache, neck pain, migraine suboccipital muscles (recti capitis posteriores major and minor, obliqui inferior and superior)
“Big Red Books” Reference: Volume 1, Chapter 17
see chart of all spots below

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.

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

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

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

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

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

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The yowly one

Not in yowly mode.

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 more 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.

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

The “Knobble II” by Trigger Point Products is a particularly 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 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.

A 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. 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.”

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

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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).


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The Knobble

The simple massage tool that saved my head in the story above. (Buy one of these bad boys from TriggerPointProducts.com).

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The Knobble

The simple massage tool that saved my head in the story above. (Buy one of these bad boys from TriggerPointProducts.com).

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.

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

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 …

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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, and many will experience significant relief from stubborn aches and pains. The first several sections are free.

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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, and many will experience significant relief from stubborn aches and pains. The first several sections are free.

Appendix B: Quick Reference Guide to the Perfect Spots

1Perfect Spot No. 1 — Massage Therapy for Tension Headaches

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. Read more (this page!)

for pain: almost anywhere in the head, face and neck, but especially the side of the head, behind the ear, the temples and forehead    related to: headache, neck pain, migraine    muscle(s): suboccipital muscles (recti capitis posteriores major and minor, obliqui inferior and superior)   

2Perfect Spot No. 2 — Massage Therapy for Low Back Pain

This Perfect Spot lives in the “thoracolumbar corner,” a nook between your lowest rib and your spine — right where the stability of the rib cage gives way to the relative instability of the lumbar spine. Muscle tends to bunch up around this joint between the last of the thoracic vertebrae and the first of the lumbar. The sweet spot consists of trigger points in the upper-central corner of the quadratus (square) lumborum muscle and in the thick column of muscle that braces the spine. Read more 

for pain: anywhere in the low back, tailbone, lower buttock, abdomen, groin, side of the hip    related to: low back pain, herniated disc    muscle(s): quadratus lumborum, erector spinae   

3Perfect Spot No. 3 — Massage Therapy for Shin Splints

Perfect Spot No. 3 is in your shins — seemingly an unlikely place for muscle knots! But there is meat there, and if you’ve ever had shin splints then you know just how vulnerable that meat can be. Even if you’ve never suffered so painfully, your shins probably still suffer in silence — latent trigger points in the upper third of the shin that don’t cause symptoms, but are plenty sensitive if you press on them. Read more 

for pain: in the shin, top of the foot, and the big toe    related to: shin splints, drop foot, anterior compartment syndrome, medial tibial stress syndrome    muscle(s): tibialis anterior   

4Perfect Spot No. 4 — Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain

Deep within the Anatomical Bermuda Triangle, a triangular region on the side of the neck, is the cantankerous scalene muscle group. Massage therapists have vanished while working in this mysterious area, never to be seen again. The region and its muscles are complex and peculiar, and many lesser-trained massage therapists have low confidence working with them. Read more 

for pain: in the upper back (especially inner edge of the shoulder blade), neck, side of the face, upper chest, shoulder, arm, hand    related to: thoracic outlet syndrome, lump in the throat, hoarseness, TMJ syndrome    muscle(s): the scalenes (anterior, middle, posterior)   

5Perfect Spot No. 5 — Massage Therapy for Tennis Elbow and Wrist Pain

Just beyond your elbow, all the muscles on the back of your forearm converge into a single thick tendon, the common extensor tendon. At the point where the muscles converge, in the muscles that extend the wrist and fingers, lies one of the most inevitable myofascial TrPs in modern civilization: Perfect Spot No. 5. It is constantly and greatly aggravated both by computer usage today and by the use of a pen in simpler times — and by the occasional tennis match, then and now. Read more 

for pain: in the elbow, arm, wrist, and hand    related to: carpal tunnel syndrome, tennis elbow (lateral epicondylitis), golfer’s elbow (medial epicondylitis), thoracic outlet syndrome, and several more    muscle(s): extensor muscles of the forearm, mobile wad (brachioradialis, extensor carpi radialis longus and brevis), extensor digitorum, extensor carpi ulnaris   

6Perfect Spot No. 6 — Massage Therapy for Back Pain, Hip Pain, and Sciatica

When you have back pain, buttock pain, hip pain, or leg pain, much or even all of your trouble may well be caused by trigger points in the obscure gluteus medius and minimus muscles, a pair of pizza-slice shaped muscles a little forward of your hip pocket. Other muscles in the region are usually involved as well, such as the gluteus maximus, piriformis, and the lumbar paraspinal muscles. However, the gluteus medius and minimus are a bit special: their contribution to pain in this area is particularly significant, and yet people who have buttock and leg pain rarely suspect that much of it is coming from muscle knots so high and far out on the side of the hip. Read more 

for pain: in the low back, hip, buttocks (especially immediately under the buttocks), side of the thigh, hamstrings    related to: sciatica, trochanteric bursitis, low back pain    muscle(s): gluteus medius and minimus   

7Perfect Spot No. 7 — Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome

Your masseter muscle is your primary chewing muscle — not the only one, but the main one — and it covers the sides of the jaw just behind the cheeks. It’s also the main muscle that clenches your jaw and grinds your teeth, unfortunately, and it’s one of the most common locations for trigger points in the entire human body. It is probably an accomplice in most cases of bruxism (that’s Latin for “grinding your teeth”) and temporomandibular joint syndrome (a painful condition of the jaw joint), plus other unexplained painful problems in the area. Read more 

for pain: in the side of the face, jaw, teeth (rarely)    related to: bruxism, headache, jaw clenching, TMJ syndrome, toothache, tinnitus    muscle(s): masseter   

8Perfect Spot No. 8 — Massage Therapy for Your Quads

A lot of quadriceps aching, stiffness and fatigue emanates from an epicentre of “knotted” muscle in the lower third of the thigh, in the vastus lateralis, a huge muscle — one of your biggest — that dominates the lateral part of the leg. Stretching it is effectively impossible, but massage is an option: although often shockingly sensitive, Perfect Spot No. 8 can also be quite satisfying. It also often complicates or contributes to other problems in the area, especially runner’s knee (iliotibial band syndrome). Read more 

for pain: in the lower half of the thigh, knee    related to: iliotibial band syndrome, patellofemoral pain syndrome    muscle(s): quadriceps (vastus lateralis, vastus lateralis, vastus medialis, rectus femoris)   

9Perfect Spot No. 9 — Massage Therapy for Your Pectorals

The “pecs” are popular muscles. Of the 700+ muscles in the human body, the pectoralis major is one of the dozen or so that most people can name and point to. It also harbours one of the most commonly-encountered and significant — yet little known — trigger points in the human body, and can produce pain much like a heart attack in both quality and intensity. Read more 

for pain: anywhere in the chest, upper arm    related to: “heart attack,” respiratory dysfunction    muscle(s): pectoralis major   

10Perfect Spot No. 10 — Massage Therapy for Tired Feet (and Plantar Fasciitis!)

The tenth of the Perfect Spots is one of the most popular of the lot, and right under your feet — literally. It lies in the center of the arch muscles of the foot. This is one of the Perfect Spots that everyone knows about. No massage is complete without a foot massage! Read more 

for pain: in the bottom of the foot    related to: plantar fasciitis    muscle(s): arch muscles   

11Perfect Spot No. 11 — Massage Therapy for Upper Back Pain

This “spot” is too large to really be called a “spot” — it’s more of an area. The thick columns of muscle beside the spine are routinely littered with muscle knots from top to bottom. Nevertheless, there is one section of the group where massage is particularly appreciated: from the thick muscle at the base of the neck, down through the region between the shoulder blades, tapering off around their lower tips. There is no doubt that this part of a back massage feels even better than the rest — even the low back, despite its own quite perfect spots, cannot compete. Read more 

for pain: anywhere in the upper back, mainly between the shoulder blades    related to: scoliosis    muscle(s): erector spinae muscle group   

12Perfect Spot No. 12 — Massage Therapy for Low Back Pain (So Low That It’s Not In the Back)

At the top of the gluteal muscles lies a Perfect Spot among Perfect Spots: a sneaky but trouble-making brute of a TrP that commonly forms in the roots of the gluteus maximus muscle, just below the pit of the low back, but experienced as low back pain. This is the kind of spot that the Perfect Spots concept is really all about — not only does it tend to produce a profound and sweet ache when massaged, but the extent of the pain that spreads out around it is almost always a surprise. Read more 

for pain: in the lower back, buttocks, hip, hamstrings    related to: low back pain, sciatica, sacroiliac joint dysfunction    muscle(s): gluteus maximus   

13Perfect Spot No. 13 — Massage Therapy for Low Back Pain (Again)

Some of the Perfect Spots are perfect because they are “surprising” — they aren’t where you thought they’d be, and it’s delightful to discover the real source of pain. Others are perfect because they are exactly where you expect them to be — and what a relief it is to be able to treat them. Perfect Spot No. 13 is perhaps the ultimate, the quintessential “right where I thought it was” trigger point: right at the very bottom of the thick columns of muscle, in the “pit” of the low back. Read more 

for pain: in the low back, buttocks, hamstrings    related to: low back pain, sciatica, sacroiliac joint dysfunction    muscle(s): erector spinae muscle group at L5   

14Perfect Spot No. 14 — Massage Therapy for Shoulder Pain

I avoided adding Spot 14 to this series for many years, because it’s a little tricky to find. But precision is not required: although there is one specific spot that’s especially good, nearly anywhere just under the ridge of bone on the shoulder blade is worthwhile, and often a surprising key to pain and stiffness everywhere else in the shoulder… but especially all the way around on the other side, facing forward. Read more 

for pain: any part of the shoulder, and upper arm    related to: frozen shoulder, supraspinatus tendinitis    muscle(s): infraspinatus, teres minor   

Notes

  1. The relationship between myofascial trigger points and headaches is well-established. Good examples 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