Headaches & Neck Pain


Headaches are the number one health complaint in America as 90% of the population will have a headache this year and 50 million Americans suffer from chronic daily headaches. There are many causes of headaches; therefore it is imperative you have a comprehensive evaluation by a qualified healthcare provider for your headache, especially if it is a first headache or a different type of headache than you have had previously.

Your primary care physician should evaluate you to rule out the more serious and possibly life threatening causes of headaches.

Neck Pain

Diagram - Neck Pain

Neck pain is one of the most frequent causes of visits to health care providers. Most commonly neck pain results from an acute trauma or chronic stress (from posture) placed upon the muscles within the neck. Less frequently neck pain results from impingement of the nerves, which exit out of the spine within the neck.

Anyone experiencing numbness, tingling, nausea, dizziness or changes in vision associated with their neck pain should be thoroughly evaluated to rule out cervical impingement of the nerves or blood vessels within the neck.

The most common cause of neck pain results from weakened muscles and poor posture. A forward head posture results in strain of the posterior muscles of the neck. This is commonly observed while driving, working on a computer, talking on a telephone or sitting at a desk. Having improper pillow support can also be a cause of neck pain.

The pain is felt as a tight aching pain felt in the back of the neck and shoulders. Commonly this pain is felt as facial pain or a headache that comes up the back of the head to in and around the eyes. What is not frequently realized is that many of the muscles of the anterior neck control the jaw and tongue. Pain in these muscles can refer pain into the face and teeth, and can feel like swollen glands or a lump in the throat.

This can give the voice hoarseness and cause difficulty in swallowing. Additionally, the pain nerves that innervate the jaw muscles and TMJ also join with the nerves of the neck in the brain stem. So jaw pain can ramp up the nerves that cause neck pain and vice versa. Additionally, the jaw muscles are used to stabilize the head position, and during jaw movements there are small concurrent movements within the upper cervical vertebra. Therefore dysfunction within the neck structures commonly leads to problems within the jaw.

Most treatments are aimed at encouraging the normal range of motion of the joints and muscles within the neck and decreasing the aggravating factors. Surgery is only indicated where there is clear evidence that a disk or vertebrae is out of place and causing the pain and dysfunction. Even then, just like with jaw disorders, more conservative treatments should be attempted initially.

Tension-type Headache

Up to 90% of headaches are tension-type headaches. These headaches are usually felt as a pressure or aching pain of mild to moderate severity. They can be unilateral or bilateral and often occur in the back of the head, on the sides of the heads, and around the eyes.

These headaches are most frequently are caused by the muscles of the jaw and neck (See Cervicogenic). The Temporalis muscle is frequently involved in headaches along the side of the head (See Myofascial Pain). It is commonly described as a tight band around the head. Muscle tension is commonly caused by trauma, repetitive strain, misaligned jaw or neck joints, poor posture, nerve impingements, and emotional stress.

Poor sleep and diet are also linked to these headaches. As many factors can contribute to Tension-type headaches it is important that not only a thorough evaluation be done, but that contributing factors be identified and addressed. Tension-type headaches may be a trigger for migraine headaches and unlike migraines are usually made better with physical exertion.

Migraine Headaches

Migraines are typically felt as a unilateral throbbing pain of moderate to severe severity that lasts 4-72 hours. They are usually accompanied by nausea, sensitivity to light and sounds. In some cases the headache is preceded by a visual aura, which can appear as flickering objects at the periphery of the visual field. Some may experience a prodrome as an emotional feeling, craving for a food, or a physical sensation prior to the migraine.

Women are 3 times more likely than men to have migraines and migraines can be associated with hormonal fluctuations such as occurs during menstrual periods or starting stopping birth control. Studies have shown that genetics plays the largest factor, as most people with migraines have a relative that also gets them. Migraines occur when the Trigeminal nerve, which innervates the blood vessels and lining of the brain, becomes irritated causing a release of chemicals resulting in the pain and throbbing sensation.

The trigeminal nerve also innervates the TMJ, jaw muscles, teeth, sinuses and joins with the nerves in the upper neck. For this reason jaw and neck problems are often trigger for the migraines.

Although the headache is similar, migraines with aura appear to be brought on by different mechanisms than migraines without aura. Migraines without aura can be brought on by excessive stimulation of the trigeminal nerve as occurs in tension-type headaches, myofascial pain, TMJ disorders, and dental pathology. Reducing the excessive stimulation of the trigeminal nerve can significantly reduce or eliminate migraines without aura. 

That along with identifying and avoiding other migraine triggers (see below) can often significantly reduce or eliminate your migraines. Migraines are often treated with prophylactic medications (taken every day to reduce frequency of migraine). If migraines occur more than once a week they should be treated with a medication taken every day, otherwise they can be treated with abortive medications. 

These medications can have several severe adverse side effects therefore proper diagnosis should start with your family physician or neurologist.  Bruxism (teeth clenching) and TMJ disorders can be potent triggers for migraines as the trigeminal nerve also innervates the jaw and jaw muscles.  Therefore, in some cases migraine frequency can be significantly decreased with treatment of Bruxism and TMJ disorders.  In our office, Botox into the jaw muscles and trigeminal nerve have also been shown to be effective treatment for jaw pain and migraines.

Below are a list of migraine triggers; make note of any triggers that you can identify are related to your migraines and discuss these with Dr. Pehling.

  • Aged Cheese
  • Alcohol (red wine, beer, whiskey, champagne)
  • Caffeine (excess intake or withdrawal)
  • Chocolate
  • Citrus fruits
  • Cured meats
  • Dehydration
  • Depression
  • Diet (skipping meals or fasting)
  • Dried fish
  • Dried fruits
  • Exercise (excessive)
  • Eyestrain or other visual triggers
  • Fatigue (extreme)
  • Food additives (nitrites, nitrates, MSG)
  • Lights (bright or flickering; sunlight)
  • Lunchmeats
  • Menstrual periods
  • Medications
  • MSG
  • Noise (excessive)
  • NutraSweet®
  • Nuts
  • Odors
  • Onions
  • Salty foods
  • Sleep (too much, too little, other changes)
  • Skipped meals
  • Stress
  • Television or movie viewing
  • Weather (changing conditions)
  • Wine (red)
  • Others

Cervicogenic Headaches & Temporal Arteritis

Cervicogenic Headaches

This usually comes from disturbances at the level of C1 and C2. It is commonly felt as a chronic aching pain that can become sharp with head movement or postural strain. Whiplash injuries and poor posture are a common cause of these disorders. Additionally the jaw and upper neck are closely linked structurally, functionally and neurologically. Therefore jaw dysfunction can lead to pain dysfunction within the upper cervical region.

Temporal Arteritis

This occurs through inflammation of the blood vessels within the temple. It is typically felt as an aching to sharp pain and is usually unilateral. If left untreated this problem can lead to loss of vision and is usually treated with steroids.

Other Headaches

1.   Analgesic Rebound Headaches

These headaches occur when over-the-counter medications such as Tylenol, Excedrin, aspirin or prescription ergotamines or triptans are taken more than 2-3 days per week for treatment of headaches. These headaches are described as a daily dull ache that is caused by sensitization of the trigeminal nerve.

2.   Caffeine-Withdrawal Headache

These headaches occur through sensitization of the trigeminal nerve as well and may be described as a mild to moderate aching to throbbing pain. The amount of caffeine necessary to cause a headache depends upon the sensitivity of the individual.

3.   Sinus Headache

Contrary to what is believed, sinus headaches are relatively uncommon. Most headaches experienced around the sinus area are caused by tension or migraine headaches. Sinus headaches do occur during acute infection of the sinus lining. This is indicated by nasal discharge and stuffiness.

4.   Post-Traumatic Headache

These occur when the lining of the brain is disrupted due to impact with the skull. This can occur with a direct head trauma but has also occurred in a whiplash injury. It is often felt as a throbbing pain and can be accompanied by neurological symptoms such as nausea, dizziness, memory difficulties, or concentration problems. These headaches usually just take time to improve.

5.   Cluster Headache

This accounts for less than 1% of headaches. It is 6 times more prevalent in men than women. There is also an increased incidence among smokers and manic-depressives. It is a very intense unilateral pain often described as feeling like a hot-poker being thrust from the back of the head in behind the eye. It is often associated with other symptoms such as nasal drip, redness and tearing of the eye, and sweating on the affected side.

The pain tends to come on quickly in periodic intervals of 4-8 weeks of attacks and remission. Most attacks occur at night and alcohol is the most common trigger for cluster headaches. Besides medications, physical exertion and ice can provide relief for these headaches.