First published in Rhode Island Family Medicine Magazine – Written by Dr. Mary Durigan, DPT, Performance Physical Therapy

Tension-type headaches (TTH), varying largely in presentation, are the most common type of headache, and are “considered [to be] a major public health problem by the World Health Organization due to its high prevalence and great socioeconomic impact.”1,2  TTH is frequently intermittent, and treatment is not often sought until symptoms become chronic.1 Typical treatment for TTH has traditionally included OTC analgesics such as Ibuprofen as well as prescription medication such as muscle relaxers or, in more severe/chronic cases, Botox. Although the cause of TTH is often unknown, symptoms may be, in part, due to musculoskeletal imbalances, postural deficits, or bony irregularities, and often respond well to manual therapy and an exercise regimen. With a growing epidemic of opioid addiction and over-prescription of drugs, it may benefit patients to try physical therapy as a conservative method to treating TTH as an alternative or in addition to pharmacotherapy. 

Diagnostic Criteria 

The International Headache Society has established diagnostic criteria for episodic TTH (ETTH), which includes “at least 10 episodes per year on less than 1 day per month on average, each lasting between 30 minutes and 7 days”, and chronic TTH (CTTH) which includes “>180 days/year or >15 days/ month for at least 3 months”. The pain should include at least 2 of the following characteristics: bilateral location, non-pulsating quality, mild to moderate intensity, and not aggravated by routine physical activity.” 1 TTH may be ruled out with symptoms including nausea/vomiting. Photophobia and phonophobia may occur, however, do not present simultaneously during the same episode.2  


Physical therapy treatment for TTH consists of manual therapy, which may include techniques to decrease tension in the suboccipital muscle group; mobilization techniques to promote optimal movement at vertebral joints, therefore reducing overcompensation of adjacent structures; manipulation to the cervical or thoracic spine, shown to improve cervical ROM and decrease pain; and soft tissue massage to the sub-occipital group, and general neck musculature. Therapeutic exercises focus on strengthening the deep neck flexors in order to better support the head as well as scapular and cervical muscle group strengthening for improved posture. Neuromuscular re-education is also utilized for enhanced scapulothoracic movement and improved regional interdependence.  

Education is also a vital aspect of physical therapy intervention, increasing the long-term benefits of physical therapy by encouraging a change in habit or lifestyle. Factors contributing TTH are multifaceted and vary based on the patient, however improving self-awareness of posture and modifiable behaviors which cause TTH may help to avoid recurrence of symptoms.  

Efficacy of PT Intervention. 

Lopez et al. performed a systematic review of the efficacy of manual therapy in the treatment of tension-type headaches which suggests that patients with TTH receiving manual therapy experienced a decrease in frequency and intensity of headaches with an improvement in the quality of life. This systematic review suggests that manual intervention did not decrease analgesic use.2 Although further research is necessary to assess and determine optimal treatment, current research does suggest that physical therapy may be beneficial for many patients with TTH. 

Dr. Molly Durigan, DPT, started with Performance in May of 2016. She has clinical expertise in general and post-surgical orthopedic rehabilitation. She received her Doctorate of Physical Therapy, from Quinnipiac University in 2016. Dr. Durigan received her Bachelor in Health Science Studies degree from Quinnipiac University in 2013.  She volunteers bi-annually with Camp Care, a weekend-long physical therapy camp for children with special needs. Dr. Durigan’s favorite sports are volleyball and taekwondo. Her other passions include bike riding, swimming, playing with dogs, spending time with family and friends. If you would like to contact Dr. Moly Durgan, you can by calling 401.270.8770 or by emailing her at


  1. Chowdhury D. Tension-type headaches. Annals of Indian academy of neurology. 2012, August.doi: 10.4103/0972-2327.100023. 
  2. Lozano López C, Mesa Jiménez J, de la Hoz Aizpurúa JL, Pareja Grande J, Fernández de las Peñas C. Efficacy of manual therapy in the treatment of tension-type headache. A systematic review from 2000 to 2013. Neurology. 2016;31:357–369.