Headaches plague most of the population in some form: 78% experience tension headaches, and one in every four U.S. households has a migraine sufferer.

Headaches plague most of the population in some form: 78% experience tension headaches, and one in every four U.S. households has a migraine sufferer. Headaches can occur as the result of 1) distention, traction or dilation of intracranial or extracranial arteries; 2) traction or displacement of large intracranial veins or their dural envelop; 3) compression traction or inflammation of cranial and spinal nerves; 4) spasm, traction or inflammation or trauma to cranial and or inflammation or trauma to cranial and cervical muscles; 5) meningeal irritation and raised intracranial pressure or 6) other possible mechanisms such as activation of brainstem structures.

Clinical considerations During Diagnosis

  • Pain intensity or quality
  • Location
  • Duration and time intensity

Classification of Most Headaches

  • Migraine
  • Tension
  • Cluster
  • Miscellaneous/Uncommon

Headaches are usually benign but occasionally it can be from a serious illness such as a brain tumor, subarachnoid hemorrhage, meningitis or giant cell arteritis.

Headache Symptoms that Suggest a Serious Underlying Disorder

  • Described as the “Worst headache ever”
  • First severe headache
  • Subacute worsening over days or weeks
  • Abnormal neurologic examination
  • Fever severe or unexplained systemic signs
  • Vomiting proceeds a headache
  • Induced by bending. Lifting, coughing
  • Disturbs sleep or present immediately upon awakening
  • Known systemic illness
  • Onset after age 55

(Source: Harrison’s Principles of Internal Medicine, Braunwald, Fauci, Kasper, Hauser, Longo and Jameson, 15th Ed., McGraw Hill, 2001)

Non-Pharmacological Treatment Options

Cognitive Behavioral Therapy
Herbal Medicine
Massage Therapy



Needle acupuncture in tension-type headache: a randomized, placebo-controlled study, Karst M, Reinhard M, Thum P, et al., Department of Anesthesiology, Medical School of Hannover, Hannover, Germany, Cephalalgia 21(6):637-42, 2001 Jul

No significant differences between the control and treatment groups were observed immediately, at 6 weeks, or at 5 months after treatment with respect to the outcome measures for tension headache. There was a significant but weak improvement in quality of life parameters (tested using a clinical global impressions scale, Nottingham Health Profile, Everyday-Life-Questionnaire, Freiburg Questionnaire of Coping with Illness, and a von Zerssen Depression Scale) after real acupuncture treatment. Headache frequency and depression are stronger predicting factors of outcomes than differences between placebo and verum in acupuncture studies on tension-type headaches. 

Acupuncture for idiopathic headache, Melchart D, Linda K, Fischer P, et al., Centre for Complementary Medicine Research, Department of Internal Medicine II, Tehcnische Universitat, Kaiserstr. 9, Munich, Germany, 80801

Cochrane Database of Systematic Reviews. 1:CD001218, 2001

In eight of the 16 trials comparing true and sham acupuncture in migraine and tension-type headache patients, true acupuncture was reported to be significantly superior. In four trials there was a trend in favor of true acupuncture, and in two trials there was no difference between the two interventions. 10 trials comparing acupuncture with other forms of treatment yielded contradictory results. Overall, in the studies that met criteria for inclusion, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches.

Acupuncture for recurrent headaches: a systematic review of randomized controlled trials, Melchart D, Linda K, Fischer P, et al., Department of Internal Medicine, Klinikum rechts der Isar, Technische Universitat, Germany, Cephalalgia 19(9): 779-86 1999 Nov

Articles reporting randomized or quasi-randomized trials were reviewed to determine whether there is sufficient evidence supporting acupuncture as an effective treatment for recurring headaches. Twenty-two trials that included 1042 patients were evaluated. However, quantitative meta-analysis was not possible due to trial heterogeneity and insufficient reporting. Results from these studies suggest that acupuncture has a role in the treatment of recurring headaches, although the quality and amount of evidence is not fully convincing. There is urgent need for well-planned, large-scale studies to assess effectiveness and efficiency of acupuncture under real life conditions.

Acupuncture for chronic headache in primary care: large, pragmatic, randomized trial, Vickers AJ, Rees RW, Zollman CE, et al, Integrative Medicine Service, Sloan-Kettering Cancer Center, BMJ. 328:744-7, 2004

Headache score at 12 months was lower in the acupuncture group (a 34% reduction from baseline) than in controls (16% reduction). Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year. Compared to controls, patients who received acupuncture used 15% less medication and took 15% fewer days of sick leave. Acupuncture led to persisting, clinically relevant benefits for patients with chronic headache, particularly migraine.

A randomized, controlled trial of acupuncture for chronic daily headache, Coeytaux RR, Kaufman JS, Kaptchuk TJ, et al., Headache. 45(9):1113-23, 2005 Oct.

Medical management plus acupuncture resulted in an improvement of three points on the Headache Impact Test and eight or more points on Short Form 36 Health Survey. After six weeks, patients receiving acupuncture were 3.7 times more likely to have less headaches.


Effect of peppermint and eucalyptus oil preparations on neurophysiologic and experimental algesimetric headache parameters, Gobel H, Schmidt G, Soyka D., Neurological Clinic, University of Kiel, Germany, Cephalalgia. 14(3):228-34; discussion 182, 1994 Jun

The combination of peppermint oil, eucalyptus oil and ethanol increased cognitive performance and had a muscle-relaxing and mentally relaxing effect, but had little influence on pain sensitivity. Analgesic sensitivity increased with the placebo at a statistically significant level. The other three test preparations lowered pain sensitivity, but only the solution containing ethanol and peppermint yielded significant reductions. The essential plant oil preparations often used in empiric medicine can thus be shown by laboratory tests to exert significant effects on mechanisms associated with the pathophysiology of headache.


A review and clinical perspective on the use of EMG and thermal biofeedback for chronic headaches, Chapman SL, Pain Control and Rehabilitation Institute of Georgia, Decatur, GA, 33030, USA. 

The studies done to date suggest a high degree of short-term efficacy of biofeedback, which has been maintained on long-term follow-ups. While comparisons of biofeedback with relaxation generally have shown approximately equivalent effectiveness, the two forms of therapy may be differentially effective with different subjects. Clinical outcome research suggests that biofeedback in general may be more effective in younger anxious subjects who show no chronic habituation to drugs, and that there is little apparent benefit from repeating biofeedback for more than about 12 sessions maximum.

Age comparisons in acquiring biofeedback control and success in reducing headache and pain, Sarafino EP, Goehring P., Department of Psychology, College of New Jersey, Ewing 08628-0718, USA, Annals of Behavioral Medicine. 22(1):10-6, 2000 Winter

Using 56 studies dealing with adults and children results show that both children and adults reported substantial improvements in headache activity with both types of biofeedback treatments, with children show greater improvement than adults. Further analyses revealed that biofeedback control and headache improvement are strongly correlated and that headache activity continued to decrease in the weeks following treatment.


Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial, Boline PD, Kassak K, Bronfort G, et al., Northwestern College of Chiropractic, Center for Clinical Studies, Minnesota, USA, Journal of Manipulative & Physiological Therapeutics. 18(3):148-54, 1995 Mar- Apr

During the treatment period, both groups improved at very similar rates in all primary outcomes. In relation to baseline values at 4 weeks after cessation of treatment, the spinal manipulation group showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medication usage and an improvement of 16% in functional health status. By comparison, the amitriptyline therapy group showed no improvement or a slight worsening from baseline values in the same four major outcome measures. All group differences were clinically important and statistically significant. Of the patients who finished the study, 82.1% in the amitriptyline therapy group reported side effects that included drowsiness, dry mouth and weight gain. 4.3% of the patients in the spinal manipulation group reported neck soreness and stiffness. The results show that amitriptyline therapy was slightly more effective in reducing pain at the end of the treatment period but was associated with more side effects. Four weeks after the cessation of treatment, however, the patients who received spinal manipulative therapy experienced a sustained therapeutic benefit in all major outcomes in contrast to the patients that received amitriptyline therapy, who reverted to baseline values. The sustained therapeutic benefit associated with spinal manipulation seemed to result in a decreased need for over-the-counter medication.

Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial, Bove G, Nilsson N., Center for Biomechanics, Department of Anatomy and Cell Biology, Odense University, Denmark

No significant differences between the manipulation and control groups were observed in any of the 3 outcome measures. However, by week 7, each group experienced significant reductions in mean daily headache hours (manipulation group [MG] reduction from 2.8 to 1.5 hours; control group [CG] reduction from 3.4 to 1.9 hours) and mean number of analgesics per day (MG reduction from 0.66 to 0.38; CG reduction from 0.82 to 0.59). These changes were maintained through the observation period. Headache pain intensity was unchanged for the duration of the trial. As an isolated intervention spinal manipulation did not appear to have a positive effect on episodic tension-type headache.

Efficacy of spinal manipulation for chronic headache: a systematic review, Bronfort G, Assendelft WJ, Evans R, et al., Department of Research, Wolfe-Harris Center for Clinical Studies, Nort hwester Health Sciences University, Bloomington, MN 55431, USA, Journal of Manipulative & Physiological Therapeutics. 24(7): 457-66, 2001 Sep

There is moderate evidence that SMT has short-term efficacy similar to amitriptyline in the prophylactic treatment of chronic tension-type headache and migraine. SMT does not appear to improve outcomes when added to soft-tissue massage for episodic tension-type headache. There is moderate evidence that SMT is more effective than massage for cervicogenic headache. This conclusion rests upon a few trials of adequate methodological quality. In order to make firmer conclusions, future testing needs to meet more rigorous standards with follow-up periods of sufficient length.

Cognitive Behavioral Therapy

Placebo-controlled evaluation of abbreviated progressive muscle relaxation and of relaxation combined with cognitive therapy in the treatment of tension headache, Blanchard EB, Appelbaum KA, Radnitz CL, et al., Center for Stress and Anxiety Disorders, State University of New York at Albany, 12203, Journal of Consulting & Clinical Psychology 58(2): 210-5, 1990 Apr

Active treatment involving either PMR or PMR with cognitive therapy (PMR+Cog) was superior to psuedomeditation as measured by significantly larger decreases in both the headache and medication index in the PMR and PMR+Cog therapy groups. The addition of cognitive therapy did not lead to a significantly higher percentage of the sample being clinically improved than PMR alone. However, data reveal a trend in increased improvement with the addition of cognitive therapy (significant at the 94.5% level). PMR seems to be superior to a credible attention placebo, while adding cognitive stress coping yields an advantage over PMR alone.

Behavioral self-management in an inpatient headache treatment unit: increasing adherence and relationship to change in affective distress, Hoodin F, Brines BJ, Lake AE 3rd, et al., Head Pain Treatment Unit at Chelsea Community Hospital, Michigan USA, Headache. 40(5):377-83, 2000 May

Adherence increased significantly for relaxation practice and life-style modification of diet, exercise and sleep regulation for headache prevention. Beck Depression Inventory scores decreased significantly and a greater decrease in depression by the end of the program was reported by subjects who practiced relaxation more compared with those who practiced relaxation least. Behavioral self-management variables, rather than headache reduction, were significantly associated with patients’ reduction in affective distress.

Behavioral and nonpharmacologic treatments of headache, Lake AE 3rd, Michigan Head-Pain and Neurological Institute, Ann Arbor, Michigan, USA, Medical Clinics of North America. 85(4): 1055-75, 2001 Jul.

Controlled studies of cognitive behavioral therapy (CBT) for migraine show that biofeedback and relaxation therapy have a prophylactic efficacy of about 50%, roughly equivalent to proprandiol. Meanwhile, cluster headache responds poorly to behavioral treatment. It should be noted that persistent overuse of symptomatic medication impedes the effectiveness of behavioral and prophylactic medical therapies. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. CBT has earned an important place in the comprehensive treatment of patients with episodic migraine/tension-type headache and severe, treatment-resistant chronic daily headache. 

Herbal Medicine

A double-blind placebo-controlled trial of intranasal capsaicin for cluster headache, Marks DR, Rapoport A, Padla D, et al., Clinical Immunology Unit, Massachusetts General Hospital, Boston 92114, Cephalalgia. 13(2): 73-4, 1993

Headaches on days 8-15 of the study were significantly less severe in the experimental group compared to the placebo group. Furthermore, episodic cluster headache patients appeared to benefit more than chronic cluster headache patients. The results indicate that intranasal capsaicin may provide a new therapeutic option for the treatment of this disease.


Homeopathic prophylaxis of headaches and migraine? A systematic review, Ernst E., Department of Complementary Medicine, School of Postgraduate Medicine and Health Sciences, University of Exeter, United Kingdom, Journal of Pain & Symptom Management. 18(5): 353-7, 1999 Nov

Following a search of randomized, placebo-controlled trials, four studies were deemed of satisfactory methodological quality. While one study suggested that homeopathic remedies were effective, the other three methodologically stronger studies did not support this claim. The paucity of trial literature and qualified methodology prevents decisive conclusions at present. However, current research does not suggest that homeopathy is more effective than placebo in the prophylaxis of migraine or headache.

The long-term effects of homeopathic treatment of chronic headaches: one year follow-up and single case time series analysis, Walach H, Lowes T, Mussbach D, et al., Department of Environmental Medicine and Hospital Epidemiology, University Hospital Freiburg, Germany, British Homeopathic Journal. 90(2):63-72, 2001 Apr

The improvement seen at the end of the 12- week trial was stable after 1 year. No differential effects measured at follow-up could be seen in treatment group. Patients with no treatment following the trial had the most improvement after 1 year. Patients with double diagnoses and longer treatment duration tended to have clearer improvements than the rest of the patients. It is concluded that approximately 30% of patients in homeopathic treatment will benefit after 1 year of treatment.


Treatment of chronic tension-type headache with hypnotherapy: a single-blind time controlled study, Melis PML, Rooimans W, Spierings ELH, et al.

Headache Section, Division of Neurology, Brigham and Women’s Hospital, Boston Massachusetts, Headache 31:686-689, 1991

Significant reductions in the number of headache days, the number of headache hours and in the headache intensity were demonstrated. It should be noted that patients reduced minor headaches while the more severe headaches persisted. A significant reduction in anxiety scores was observed while depression remained unchanged. Other beneficial effects include: greater ability to relax, changed perception of pain, and prevention of the build up of tension during the day. Observed improvement was gradual, implying that the flow-off technique should be seen as a skill in which effectiveness depends on the amount of practice.

Treatment outcomes expectancies and hypnotic susceptibility as moderators of pain reduction in patients with chronic tension-type headache, Spinhoven P, ter Kulie MM., Leiden University, The Netherlands, International Journal of Clinical & Experimental Hypnosis. 48(3):290-305, 2000

Pain reduction post-treatment and at follow-up was significantly associated with hypnotic susceptibility independent of generic expectations of treatment outcome and treatment condition. Moreover, it was found that early responders to treatment had significantly higher hypnotic susceptibility scores than non responders. There were no significant differences in hypnotic susceptibility between late responders and either early or non responders. However, it should be noted that almost one fourth of those who were non responders failed to attend follow-up.

Autogenic training and cognitive self-hypnosis for the treatment of recurrent headaches in three different subject groups, ter kuile MM, Spinhoven P, Linssen AC, et al., Department of Psychiatry, University of Leiden, The Netherlands, Pain. 58(3): 331-40, 1994 Sep.

During treatment, there was a significant reduction in the Headache Index scores of the subjects in contrast with the controls. As post-treatment and follow-up, almost no significant differences were observed between the 2 treatment conditions with respect to Headache Index scores. In both treatment groups, high-hypnotizable subjects achieved a greater reduction in headache pain at post-treatment and follow-up than did the low-hypnotizable subjects. It is concluded that a relatively simple and highly structured relaxation technique for the treatment of chronic headache subjects may be preferable to more complex cognitive hypnotherapeutic procedures. The level of hypnotic susceptibility seems to be a subject characteristic, which is associated with a more favorable outcome in subjects treated with autogenic training or cognitive self-hypnosis training.

Massage Therapy

An open study comparing manual therapy with the use of cold packs in the treatmentof post-traumatic headache, Jensen OK, Neilsen FF, Vosmar L, Department of Rheumatology, County Hospital of Aarhus, Denmark, Cephalalgia. 10(5):241-50, 1990 Oct

Massage therapy and cold packs significantly reduced the pain index in both groups. Massage yielded a larger reduction in the pain index than cold packs, but the difference was not statistically significant. It is concluded that both cold packs and massage effect a reduction in post-traumatic headache.

An exploratory study of reflexological treatment for headache, Launso L, Brendsturp E, Arnberg S., Department of Social Pharmacy, Royal Danish School of Pharmacy, Copenhagen, Denmark, Alternative Therapies in Health & Medicine. 5(3): 57-65, May

Overall, patients reported improved energy levels, ability to interpret their own body signals and ability to understand the reason for headaches. At 3 months follow up 81% of patients reported that they were helped by the treatments or were cured of their headache problems. Following the study, 19% of those taking medication for their headaches were able to stop medication support.


A comparison of frontal electromyographic biofeedback training, trapezius electromyographic biofeedback training, and progressive muscle relaxation therapy in the treatment of tension headache, Arena JG, Bruno GM, Hannah SL, et al., Biofeedback and Psychophysiological Disorders Clinic, Department of Veterans Affairs Medical Center, Augusta, GA 30904-6285, USA, Headache. 35(7):411-9. 1995 Jul-Aug

Post-treatment assessment at 3 months indicated significant decreases in overall headache activity of at least 50% in 50% of subjects in the frontal biofeedback group, 100% in the trapezius biofeedback group, and 37.5% in the relaxation therapy group. Otherwise, the three treatments did not differ on secondary measures of headache improvement (number of headache-free days, peak headache activity, and medication index).

Placebo-controlled evaluation of abbreviated progressive muscle relaxation and of relaxation combined with cognitive therapy in the treatment of tension headache Blanchard EB, Appelbaum KA, Radnitz CL, et al., Center for Stress and Anxiety Disorders, State University of New York at Albany, 1535 Western Avenue, Albany New York, 12203, Journal of Consulting and Clinical Psychology. 58(2):210-215, 1990

Active treatment involving either PMR or PMR with cognitive therapy was superior to either treatment condition as measured by significantly larger decreases in both the headache and medication index than either control group. The addition of cognitive therapy did not lead to a significantly higher percentage of the sample being clinically improved than PMR alone. However, data reveal a trend in increased improvement with the addition of cognitive therapy (significant at the 94.5% level). PMR seems to be superior to a credible attention placebo, while adding cognitive stress coping yields an advantage over PMR alone.

The role of regular home practice in the relaxation treatment of tension headache, Blanchard EB, Nicholson NL, Taylor AE, et al., Center for Stress and Anxiety Disorders, University at Albany, State University of New York 12202 , Journal of Consulting & Clinical Psychology. 59(3):467-70, 1991 Jun

Both treated groups showed significant reduction in headache activity, whereas the symptom monitoring group did not change. The 2 treated groups did not differ. On a measure of clinically significant reduction in headache activity (at least 50% reduction in headache activity), however, the group receiving home practice instruction (50%) showed a trend (p = .056) to improve more than those receiving PMR without home practice (15%).

Long-term follow-up of relaxation training for pediatric headache disorders, Engel JM, Rapoff MA, Pressman AR., Occupational Therapy Program, University of Wisconsin-Madison 53706, Headache. 32(3):152-6, 1992 Mar

All participants at 51 months post-treatment reported some increases in headache activity. Participants in the three relaxation treatment groups, however, had significantly more headache-free days and less severe headaches compared to the control group. There were no significant effects of treatment for headache duration, medication intake, and rest time due to headache.

(Source for Research: Continuum Center for Health and Healing, New York, NY, http://www.healthandhealingny.org)