Headaches: What Type Do You Have — and What Actually Helps?
By Jess Milsom | Movement Health & WellnessMost of us have had a headache. Plenty of us have had one so bad it derailed the day. But here's something that gets missed far too often: headache isn't a diagnosis — it's a symptom. And treating the wrong type the wrong way means you can end up managing something indefinitely that could actually be addressed.
This post covers the most common headache types, how to tell them apart, what the current research says about treatment, and — critically — when a headache is a sign of something more serious that needs immediate attention.
How Headaches Are Classified
The International Classification of Headache Disorders, 3rd edition (ICHD-3) divides headaches into two broad categories: primary and secondary.
Primary headaches are conditions in their own right — the headache is the disorder. This includes tension-type headache, migraine, and cluster headache.
Secondary headaches are a symptom of something else — a structural problem, infection, vascular event, or other underlying cause. Cervicogenic headache (originating from the neck) falls here, as do the serious conditions discussed in the red flags section.
Getting this distinction right matters, because primary and secondary headaches can have overlapping symptoms. A practitioner who skips a thorough history and examination is taking a shortcut that doesn't serve you.
1. Tension-Type Headache (TTH)
Tension-type headache is the most common headache disorder globally. It presents in two forms: episodic (fewer than 15 headache days per month) and chronic (15 or more days per month for more than three months).
Symptoms
Location: Bilateral — both sides of the head
Character: Pressing or tightening, like a band around the head; not throbbing
Severity: Mild to moderate
Duration: 30 minutes to several hours, sometimes days
Associated features: Generally absent — no nausea, no vomiting, minimal sensitivity to light or sound
Activity: Not worsened by routine physical activity (distinguishes it from migraine)
Common triggers: Stress, poor sleep, prolonged static postures, eye strain, dehydration
What the Evidence Says About Treatment
Manual therapy and physical therapy have a solid evidence base for TTH. A 2024 systematic review and network meta-analysis of 32 RCTs involving 2,405 participants found that manual therapy was superior to Western medicine (predominantly analgesics) for reducing headache intensity in TTH patients (Qin et al., 2024). A 2025 systematic review and meta-analysis examining physiotherapy approaches specifically for chronic TTH confirmed significant reductions in pain intensity, frequency, and disability (Jofph, 2025).
Myofascial release is another well-supported approach. A 2024 systematic review and meta-analysis (Lu et al.) pooling data from eight databases found that myofascial release techniques produced meaningful reductions in headache pain intensity and associated disability in TTH patients.
Spinal manipulation within a multimodal care plan is supported by a 2026 clinical practice guideline developed from an umbrella review of evidence from 2017–2023 and refined by a 57-member Delphi panel (Trager et al., 2026). The guideline is clear: spinal manipulation is recommended for TTH as part of multimodal care, not as a standalone treatment.
Aerobic exercise is also recommended by the 2023 VA/DoD Clinical Practice Guideline for headache management (Sico et al., 2024), one of the most current and comprehensive guidelines available.
Pharmacological options for episodic TTH include NSAIDs and paracetamol as first-line short-term options. However, overuse of analgesics (more than 10–15 days per month depending on the drug) is itself a cause of chronic daily headache — a phenomenon called medication overuse headache — and is worth being aware of.
Emerging Research
Research is increasingly pointing toward central sensitisation as a key mechanism in chronic TTH — the nervous system becomes sensitised to pain signals over time, making headaches easier to trigger and harder to settle. This has implications for treatment: pure structural approaches become less effective as the chronicity increases, and mind-body and stress regulation strategies become more important.
2. Cervicogenic Headache (CGH)
Cervicogenic headache is a secondary headache — the pain originates from structures in the cervical spine (neck joints, muscles, nerves) and is referred into the head. It is commonly misdiagnosed as migraine or TTH, which means many people are treated for the wrong thing for years.
It is one of the conditions most commonly managed in a chiropractic or physiotherapy setting, and one of the areas where manual therapy has the strongest evidence base.
Symptoms
Location: Unilateral (one side) — this is a key distinguishing feature
Origin: Pain starts at the back of the skull or neck and spreads forward to the forehead, temple, or eye
Neck involvement: Restricted cervical range of motion, stiffness, and usually neck pain alongside the headache
Provocation: Pain is reproduced or worsened by sustained neck positions or specific neck movements
Palpation: Tenderness over specific cervical segments on examination
Duration: Can be episodic or constant
No autonomic features: No eye drooping, no tearing, no nasal congestion (which distinguishes it from cluster headache)
CGH often presents in desk workers, people with poor workstation setups, and athletes who load the neck repetitively — swimmers, cyclists, rugby players, and surfers who spend time paddling with the neck in extension are common presentations.
What the Evidence Says About Treatment
The evidence base for nonpharmacological management of CGH is among the strongest of any headache type.
A 2024 systematic review (Patil et al.) identified eight high-quality RCTs published between 2017 and 2023 on nonpharmacological physiotherapy interventions for CGH, all demonstrating meaningful improvements in headache intensity, strength, and quality of life.
A 2025 systematic review and network meta-analysis (Xu & Ling) in Frontiers in Neurology specifically compared the safety and efficacy of different manual therapy interventions for CGH, finding spinal manipulation and mobilisation both effective, with combined multimodal approaches generally producing the best outcomes.
The most current clinical practice guideline on this topic — developed in 2026 by Trager et al. from an umbrella review and Delphi consensus process — makes a strong recommendation for spinal manipulation as a primary intervention for CGH. This is the clearest evidence-supported indication for spinal manipulation in headache management.
Deep neck flexor strengthening is also strongly supported. Weakness and dysfunction of the deep cervical flexors (the small stabilising muscles at the front of the neck) is consistently found in CGH patients, and targeted rehabilitation of these muscles produces sustained reductions in headache frequency and intensity.
Myofascial release has demonstrated effectiveness for CGH specifically (Lu et al., 2024), and multimodal approaches — combining manipulation, mobilisation, soft tissue work, and exercise — generally outperform single-modality treatment.
A 2026 network meta-analysis (Koonalinthip et al., European Journal of Pain) is the most comprehensive comparison of all available CGH treatments to date, further reinforcing the role of physical intervention as the primary management strategy.
Emerging Research
There is growing interest in pain neurophysiology education (PNE) as an adjunct to physical treatment for CGH, with a 2023 RCT (Ghasemi et al.) demonstrating that combining PNE with standard physiotherapy produced superior outcomes to physiotherapy alone. Minimally invasive interventions (nerve blocks, radiofrequency ablation) are being systematically reviewed for refractory cases (2026 systematic review, Dove Medical Press), but physical management remains first-line.
3. Migraine
Migraine is a neurological disorder — not just a bad headache. It is one of the leading causes of disability worldwide, affecting roughly 15% of the population, and is significantly underdiagnosed and undertreated. It is also frequently confused with tension-type or cervicogenic headache.
Symptoms
Migraine often progresses through four phases:
Prodrome (hours to days before): Mood changes, food cravings, fatigue, neck stiffness, frequent yawning — many people don't recognise these as part of the migraine.
Aura (30–40% of migraineurs): Visual disturbances (flashing lights, blind spots, zigzag lines), sensory changes, or speech difficulty lasting up to 60 minutes and fully resolving before or as the headache begins. If aura symptoms are new, prolonged beyond 60 minutes, or don't resolve — this warrants urgent assessment.
Headache phase:
Location: Typically unilateral (one side), though can be bilateral
Character: Throbbing or pulsating
Severity: Moderate to severe
Duration: 4–72 hours untreated
Associated features: Nausea, vomiting, marked sensitivity to light and sound — these are near-diagnostic
Activity: Worsened by routine physical activity (a key distinguishing feature from TTH)
Postdrome: A "migraine hangover" — fatigue, cognitive fog, and low mood lasting up to 24 hours after the headache resolves.
What the Evidence Says About Treatment
Pharmacological management: The acute first-line pharmacological treatment remains triptans (e.g., sumatriptan), which are highly effective when taken early. For prevention, the field has been transformed in recent years.
CGRP-targeting therapies represent the most significant advance in migraine management in decades. Calcitonin gene-related peptide (CGRP) plays a central role in migraine pathophysiology, and monoclonal antibodies that block it — erenumab, fremanezumab, galcanezumab, and eptinezumab — have demonstrated sustained efficacy with favourable tolerability.
In March 2024, the American Headache Society (AHS) published a consensus position statement formally recognising CGRP-targeting therapies as first-line options for migraine prevention — no longer a last resort after failing older medications (AHS, 2024). The International Headache Society's global practice recommendations published the same year align with this position (Puledda et al., 2024). The 2023 VA/DoD Clinical Practice Guideline also endorses CGRP antibody therapy for migraine prevention and gepants for acute treatment (Sico et al., 2024).
Exercise has emerged as a genuinely effective non-pharmacological option. A 2024 systematic review and network meta-analysis (Reina-Varona et al., Headache) of 28 studies involving 1,501 participants found that yoga and high-intensity aerobic exercise outperformed pharmacological treatment alone for reducing migraine frequency. High-intensity aerobic exercise and moderate-intensity continuous aerobic exercise also significantly reduced migraine duration compared to medication alone. This is a remarkable finding that changes how we should counsel migraine patients about exercise.
Critically, the fear that exercise triggers migraines — while true for some individuals acutely — should not discourage a structured exercise programme, which appears protective over time.
Manual therapy has a supporting role, particularly in migraine patients who also have neck involvement. The 2023 VA/DoD CPG notes that physical therapy is a valid adjunct treatment.
Behavioural approaches — cognitive behavioural therapy (CBT), biofeedback, and relaxation training — have a strong evidence base. A 2025 systematic review of 50 adult RCTs found CBT, relaxation training, and mindfulness each reduced migraine frequency, while integrated behavioural programs produced the strongest disability outcomes.
Emerging Research
The CGRP story continues to evolve rapidly, with Phase IV trials now underway. Lasmiditan (a ditancan) offers an alternative for acute treatment in those who cannot tolerate triptans. Research is also increasingly focused on optimal exercise dosing for migraine — a 2025 multilevel network and dose-response meta-analysis (PeerJ) is among the first to quantify exercise parameters rather than just modality.
4. Cluster Headache
Cluster headache is rare — affecting approximately 0.1% of the population — but it is arguably the most severe pain condition in medicine. It has historically been referred to as a "suicide headache" due to its intensity. Understanding it is important so that anyone who has it isn't dismissed or mismanaged.
It is classified as a trigeminal autonomic cephalalgia (TAC) — a group of primary headaches characterised by severe unilateral head pain alongside prominent autonomic features on the same side.
Symptoms
Location: Strictly unilateral, centred around one eye, temple, or forehead
Character: Excruciating, burning, or stabbing — consistently rated 9–10/10
Duration: Short — 15 to 180 minutes per attack
Frequency: Episodic clusters occur in bouts (weeks to months) with periods of remission; chronic cluster headache has no remission
Autonomic features (same side as pain): Eye tearing, redness, drooping eyelid (ptosis), nasal congestion or runny nose, sweating or facial flushing, pupil constriction
Restlessness: A distinguishing feature — patients pace, rock, or cannot keep still. Migraine sufferers typically prefer to lie still in a dark room; cluster headache patients cannot.
Timing: Often nocturnal, waking patients from sleep; attacks are highly regular within a cluster period
What the Evidence Says About Treatment
The 2023 European Academy of Neurology (EAN) guidelines on cluster headache — developed from a systematic review and GRADE consensus — make two strong (Level A) recommendations for acute treatment:
100% oxygen at a minimum flow of 12 L/min for 15 minutes
6 mg subcutaneous sumatriptan
Both are considered safe, highly effective, and should be initiated as early in the attack as possible (May et al., European Journal of Neurology, 2023).
For prevention, verapamil remains the first-line oral preventive agent. Galcanezumab (a CGRP monoclonal antibody) was the first specific preventive treatment approved by the FDA for episodic cluster headache, marking a significant step in targeted management.
Cluster headache requires specialist input — typically a neurologist or headache specialist. This is not a condition managed with manual therapy or exercise alone, though lifestyle factors like avoiding alcohol during cluster periods are relevant.
Emerging Research
CGRP targeting continues to show promise across episodic cluster headache, and neurostimulation — including sphenopalatine ganglion stimulation and occipital nerve stimulation — is an area of active investigation for refractory cases (The Lancet Neurology, 2024).
5. Red Flags — When a Headache Is a Medical Emergency
This section is not to alarm you. The vast majority of headaches are primary headaches — benign, manageable, and not a sign of anything sinister. But a small percentage of headaches signal something serious, and missing them has consequences.
Every patient I see with a headache is screened for red flags before treatment. Here's what we're looking for.
The SNOOP4 Criteria
Clinicians use the SNOOP4 mnemonic as a framework for identifying secondary headaches that need urgent investigation (Wijeratne et al., 2023):
S: Systemic symptoms or signs — fever, weight loss, night sweats; or systemic illness (cancer, HIV, immunosuppression)
N: Neurological symptoms — confusion, weakness, numbness, speech difficulty, double vision, seizure, fainting
O: Onset sudden — "thunderclap" headache (see below)
O: Onset over age 50 — new headache in someone over 50 raises concern for more serious conditions
P: Pattern change — a headache that is clearly different from your usual pattern, or progressively worsening over days/weeks
P: Positional component — worse on lying flat or standing
P: Precipitated by Valsalva — brought on by coughing, sneezing, straining or exertion
P: Papilloedema — swelling of the optic disc, a sign of raised intracranial pressure
Thunderclap Headache — Treat as an Emergency
A thunderclap headache is defined as a severe headache reaching peak intensity within 60 seconds. Patients often describe it as "the worst headache of my life," unlike anything they've experienced before.
This pattern must be treated as a medical emergency until proven otherwise.
Other Situations That Need Prompt Medical Assessment
Fever + headache + stiff neck
New headache in someone over 50, especially with jaw pain when chewing, scalp tenderness, or visual disturbance
Headache following head trauma
Progressively worsening headache over days to weeks, especially worse in the morning or lying flat
Who to see first:
Tension-type headache: Chiropractor, physiotherapist, GP (if medication needed)
Cervicogenic headache: Chiropractor, physiotherapist — manual therapy and exercise are primary treatments
Migraine: GP for medication assessment; manual therapy and exercise as adjuncts
Cluster headache: GP → neurologist/headache specialist; not a manual therapy primary condition
Red flags present: Emergency department or GP urgently — not a chiropractic or physio appointment
A Note on Overlap
These headache types don't always arrive cleanly separated. Many people with migraine also have significant neck involvement. Some people have both TTH and CGH. Medication overuse can sit on top of any of the above. A thorough history and examination — including cervical assessment where appropriate — is essential to identifying the dominant driver so treatment can be targeted correctly.
If you've had headaches for years, been told "it's just tension" or "it's just migraines," and haven't had a proper assessment of your neck, it might be worth finding out whether CGH is contributing. It's a condition that responds well to conservative care, and it's commonly missed.
References
Qin L, Song P, Li X, et al. Tension-Type Headache Management: A Systematic Review and Network Meta-analysis of Complementary and Alternative Medicine. Pain Ther. 2024;13(4):691–717. doi:10.1007/s40122-024-00600-x
Repiso-Guardeño A, Moreno-Morales N, Armenta-Pendón MA, et al. Physical Therapy in Tension-Type Headache: A Systematic Review of Randomized Controlled Trials. Int J Environ Res Public Health. 2023;20(5):4466. doi:10.3390/ijerph20054466
Deodato M, Granato A, Del Frate J, et al. The efficacy of physiotherapy approaches in chronic tension-type headache: a systematic review and meta-analysis. J Phys Ther. 2025;39(1):34–48. doi:10.22514/jofph.2025.003
Lu Z, Zou H, Zhao P, Wang J, Wang R. Myofascial Release for the Treatment of Tension-Type, Cervicogenic Headache or Migraine: A Systematic Review and Meta-Analysis. Pain Res Manag. 2024:2042069. doi:10.1155/2024/2042069
Trager RJ, Daniels CJ, Hawk C, et al. Chiropractic Management of Adults with Cervicogenic or Tension-Type Headaches: Development of a Clinical Practice Guideline. J Integr Complement Med. 2026. doi:10.1177/27683605251397769
Sico JJ, et al. 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache. Ann Intern Med. 2024. doi:10.7326/ANNALS-24-00551
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Wijeratne T, et al. Red flags including sudden onset, high pain intensity, pattern of change of a preexisting headache, focal neurological signs or seizure, systemic signs and precipitation by physical activity can guide the clinician to suspect a secondary headache. eNeurologicalSci. 2023;32:100473. doi:10.1016/j.ensci.2023.100473
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The information in this blog is for educational purposes and does not constitute medical advice. If you are experiencing new, severe, or unusual headaches, please seek assessment from a qualified healthcare professional. Red flag symptoms should be assessed urgently in an emergency department.
Jess Milsom is a chiropractor and exercise professional based at Surfers Gym, Cromer on Sydney's Northern Beaches. Movement Health & Wellness takes an exercise and rehabilitation-focused approach to chiropractic care.
