July 19, 2021

Neck Pain: The Posture-Headache Double Whammy

Written by: Iris Tabangcora, M.D.

There is not a more unifying factor among people than a bad case of headache. People’s description of their headache (e.g. sharp, boring, etc.) are as variable as their presumed causes (e.g. bad posture, caffeine withdrawal, etc.) Because of its complicated nature, the International Headache Society classifies headache into primary headaches (i.e. headache and its associated features are the disorder itself) and secondary headaches (i.e. headaches caused by exogenous disorders.) The most common type of primary headache is tension-type headache and will be particularly discussed in greater detail in this article.


According to the World Health Organization (WHO), at least 50% of adults have had primary headaches at least once within the last year, making  it one of the most common disorders of the nervous system. 1 As frequent cause of an emergency room (ER) visit, primary headache disorders outrank all other neurologic disorders in terms of causing disability.2 The personal and societal burdens caused by primary headache disorders cannot be overemphasized especially that throughout the world, only a minority are diagnosed and managed correctly.1

Despite being common, there is so much that remains to be known about primary headache disorders. What exactly causes primary headaches? Why do some people have it worse than others? Why do some headaches hardly go away despite maximum pain management? The answers are yet to be known.



The Anatomy and Physiology of Headache


Pain is generally a normal physiologic response of the nervous system to tissue injuries and distention of organs. When either of this happens, pain receptors are stimulated causing them to send pain signals to the brain manifested as headache. Another mechanism is when the pain-producing pathways are damaged or being activated inappropriately.2 However, there is a thin line between a physiologic and a pathologic response.


Specifically, the pain-producing cranial structures include the scalp, dura, and the meningeal arteries. In addition to this, damage to the pain-processing regions of the thalamus and cortex can also cause headache. Lastly, abnormalities involving the pain-modulating system of the hypothalamus and the brainstem are also contributory.


Intrinsic problems in pain modulation and organic lesions affecting these structures can cause headache.



The Headache of Cervical Origin (?)


As mentioned above, tension-type headache is the most common primary headache disorder. Previously called as “cervical headache”, “tension neck syndrome”, and “posture headache”, this type of headache was described to be caused by chronic spasm of neck muscles. Most of the cases are psychogenic as it is more common among women with anxious personalities. On the other hand, it can be due to organic lesions like arthritis and spondylosis. This is also described to be common among children with forward head posture, suggesting a correlation between bad posture and tension headache.3


The pain here is described to be a tight or constricting, band-like discomfort in the head. This pain typically builds slowly and tends to fluctuate in severity. Worse, this can go on for as long as 15 days. Unlike migraine, which is thought to be due to sensory modulation problems, this is not associated with other symptoms like nausea, vomiting, and photophobia.2


Why is then the spasm of neck muscles can contribute to a headache involving the forehead and the surrounding of the eyes?  It has been demonstrated in an experiment that pain originating from the back of the neck are predominantly radiated to the forehead and the surrounding as well as back of the eyes. Aside from this, the posterior neck muscles form neural connections with the eyes and the head which are abundant in pain receptors.3 Indeed, a double whammy of bad posture and bad headache causing debilitating pain, serious financial costs, and damaged quality of life.


However, in the most recent findings, there is no clear evidence for tension as the sole etiology for posture headache.2 Still, since its pathophysiology is incompletely understood, bad posture is still cited as one of its causes.1 After all, several researches have shown that physical therapy for the neck and relaxation techniques have significantly reduced pain among those posture headache sufferers.


For an instance, it was found out that combining cervical spine kinesiotherapy, posture correction exercises, and relaxation techniques have significantly decreased all parameters of pain among university students in Spain with tension headache. 4 Another study found out that cervical deep muscle flexion exercises have mitigated headaches and improved quality of life of posture headache sufferers. 5


Posture or tension-type headache is managed with simple analgesics such as acetaminophen, aspirin,and NSAIDs. Behavioral and non-pharmacologic approach like relaxation techniques have been found to be helpful. For chronic tension-type headache, the only proven treatment is amitriptyline, a tricyclic antidepressant. There is no evidence on the benefit of acupuncture in this type of headache.2



A Call to Action


WHO recognizes posture headache as a public burden and published an atlas on headache disorders and resources available to reduce them. In addition to this, it has partnered with a non-governmental organization to campaign for reducing the burden of headaches.


Said initiatives can be accessed here:

  1. .https://www.who.int/entity/mental_health/management/atlas_headache_disorders/en/index.html
  2. https://www.who.int/entity/mental_health/neurology/headache/en/index.html




  1. World Health Organization. Headache disorders. 2016. (Retrieved 07/01/21 from https://www.who.int/news-room/fact-sheets/detail/headache-disorders).
  2. Jameson, J., Fauci, A, et.al. Harrison’s Principles of Internal Medicine 20th 2018.
  3. Newill, R.G. Headache and giddiness of cervical origin. The Journal of the Royal College of General Practitioners. 1972. (Retrieved 07/01/21 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2156511/?page=1)
  4. Álvarez-Melcón, A.C., Valero-Alcaide, R. Effects of physical therapy and relaxation techniques on the parameters of pain in university students with tension-type headache: A randomised controlled trial. Neurologia (English Edition). 2018. (Retrieved 07/01/2021 from https://pubmed.ncbi.nlm.nih.gov/27491303/)
  5. Choi, W. Effect of 4 Weeks of Cervical Deep Muscle Flexion Exercise on Headache and Sleep Disorder in Patients with Tension Headache and Forward Head Posture. International Journal of Environmental Research and Public Health. March 2021. (Retrieved 07/01/21 from https://pubmed.ncbi.nlm.nih.gov/33806089/)


Article written by Iris Tabangcora, M.D.
Iris is a Philippine-based physician currently training in Emergency Medicine. She has been writing for various health websites for the last 10 years. Also a Nursing degree holder, she has spent her energy in educating nursing students on Research and Pharmacology. Her interests lie in medical education, research, and public health.

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