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Myofascial techniques: working with musculoskeletal headaches.



These include cryogenic headache (from eating ice cream), hair wash headache (due to the heavy weight of long wet hair after washing), coital cephalalgia (the "morning after" headache), ictal headache (accompanying seizures), thunderclap headache (sudden severe onset), and many more. How would you begin to formulate a coherent approach to dealing with headaches when there are so many kinds and causes?

Fortunately, we can understand headaches by breaking them down into general types. Headaches are conventionally classified as either primary (not caused by another condition) or secondary (you guessed it, caused by another condition). Examples of secondary headaches include those resulting from head injuries, from metabolic and medical conditions, and so on. Although manual approaches can help in many cases, these and other secondary headaches usually merit an initial referral to a physician. This is generally a good practice with any persistent or recurring headache.

Primary headaches are further sub-classified as arising from either:

1. Musculoskeletal origins (such as tension head aches and others related to myofascial or articular restriction).

2. Vascular factors (such as migraines and cluster headaches).

3. Comingled causes (those arising from a combination of both musculoskeletal and vascular sources).

This article will help you distinguish between these types of headaches and gives you some simple but highly effective tools for working with headaches that are of musculoskeletal nature--the kind you will most often see in your practice. Techniques shown are from's Advanced Myofascial Techniques series.

Let's begin by further clarifying the difference between musculoskeletal and vascular headaches (Table 1). Although comingled headaches, which result from both factors, are common, this musculoskeletal/vascular distinction is important because the pain from vascular headaches (the case of many migraines) can be worsened by the same techniques that relieve musculoskeletal headache pain.

Comparison of musculoskeletal and vascular headaches. Comingled headaches, since they arise from both musculoskeletal and vascular causes, can have characteristics of both types.

Musculoskeletal headaches are the most common, though not necessarily the most severe. Tension or musculoskeletal headache pain is usually more widespread, encompassing both sides of the head and exhibiting more generalized pain described as pressure, fullness, or ache--as opposed to the one-sided, throbbing, stabbing sensation of many migraines and other vascular-related headaches. Furthermore, tension headaches are less likely to have a regular pattern of occurrence and are rarely accompanied by nausea or sensitivity to light and sound.

This following techniques address musculoskeletal and many comingled headaches--the majority of the headaches that you are likely to encounter in your office.


The superficial fascia of the scalp (Images 1 and 2) is directly continuous with the superficial fascial membranes of the back of the neck, and by extension, the superficial fascia of the rest of the body. Its position on the crown of the head gives it the unique role of connecting the front of the body to the back, and the left side to the right. As such, it is a mediator and transmitter of fascial stresses and compensations elsewhere in the body. Also known as the subcutaneous fibro-adipose layer, the superficial layer lies between the outer layers of skin and the underlying galea aponeurotica or epicranium.

Although the deeper galea aponeurotica is also mainly membranous, it contains the occipitofrontalis muscles. Because this layer is continuous laterally with the temporal fascia overlying the temporalis muscle, it is particularly sensitive to jaw tension. Below the galea is the pericranium on the bones of the skull themselves.


Image 2 shows a stepped dissection of the cranial fascial layers, including the visible layers of the arachnoid mater just superficial to the brain; the dura mater; the bony cranium; pericranium; galea aponeurotica (with the muscle fibers of frontalis and occipitalis visible anteriorly and posteriorly); and the superficial fascia of the scalp presented continuous with the skin.

Besides transmitting strain and referred pain from the rest of the body's fascias, cranial layers play a direct role in headaches associated with face, neck, and eye strain, as well as mental exertion or stress. Addressing these layers can be especially effective for clients who spend a lot of time at the computer (in our modern society, just about everyone).

The adaptability and pliability of the cranial fascial layers is essential to free motion of the underlying sutures and cranial bones. Sutures are a prime location for adhesions and restrictions can play a role in both musculoskeletal and vascular headaches. Ensuring differentiation and freedom of cranial fascial layers is a logical first step in working with headaches. Here's how.


To release the cranial fascias, use your fingertips to move the various layers against each other and against the skull (Image 3). We're not scrubbing the surface of the scalp or shampooing the hair; we're sliding, shearing, and freeing these layers from each other. Imagine loosening the rind of a cantaloupe around the flesh of the melon: use firm, deep transverse pressure to assess and release adhesions, pulls, and thickenings. Use a decisive but sensitive touch; be patient and thorough.

Be willing to spend at least several minutes with this technique, working the various layers over the entire head. Check in with your client regarding pressure and sensitivity. Many clients will experience this work as "pure heaven," while others will report significant sensitivity, especially in areas that feel knotty or adhered to the underlying layers. With these clients, adjust your touch and work slowly, while continuing to gently hook into the tissue and slide fascial layers.

Holding your client's head, notice her breath. Can you feel the subtle movement of breath continue into her head? Many people with headaches tend to have shallow breath, restricting the airflow and feeling of expansion transmitted into the neck and head. Verbally cue your client to breath into your hands. A great image is that of a whale or dolphin. Ask your client to breathe out of the

top of her head, or even out of her ears. Get creative. Use imagery and somatic language (Table 2) to help your client find ways to relax the mandible, maxilla, pallet, eyes and cranium. Incorporating experiential cues can go a long way toward reeducating long-held movement patterns, which contribute to chronic tension.


"Relax your brain. Just let your brain rest in the back of your skull."

"See if you can release pressure by breathing out of your ears." Or: "... out of the top of your head."

"What if you allowed your jaw and pallet to rest ..."

"Let your eyes have weight. Just let their weight rest against the back of your head."

Rather than reaching out to see things with your eyes, could you allow the images to come to you?

Additionally, the ears can be useful tools in your quest to release the layers of the cranium. With your client's head turned to one side, use your thumb and forefinger of one hand to gently pull on your client's exposed earlobe. Maintain a pull while using the fingers of the opposite hand to release tension away from the ear. Release tension in all directions around the ear, paying close attention to fascial relationships involving the jaw, mastoid process, and the area surrounding transverse process of C1. Releasing the superficial layers around C1 in this manner is very effective at this layer, and will also prepare your client for deeper work described in the nuchal ligament technique towards the end of this article.

Once the outer layers have been released, continue the technique while cuing facial movements. Because the galea aponeurotica contains the muscle fibers of frontalis (Image 4) and occipitalis, engaging active and exaggerated eye, brow, and face movements deepens and extends the fascial release.


When cueing clients to make facial movements, be sure to maintain a steady tactile connection with the tissue. It can be easy to get distracted and lose connection or sink to a deeper level. Additionally, clients are often self-conscious, so be willing to make any face or sounds right along with them! Images 5&6 demonstrate the use of facial expression (and practitioner participation) while addressing the frontalis scalp fascias. Ask for active movements using descriptive language, such as "lift your eyebrows into my fingers," "squeeze your eyes together, wrinkling your whole face," or "snarl and bare your teeth." This technique is also effective for areas around the temporalis. In this case, cuing your client to open and elongate the jaw can induce greater release. Each client is different, so be creative. Feel for your client's unique tension patterns and explore corresponding movements that create the greatest release.




The central nuchal ligament and the suboccipital and greater occipital nerves pass through the suboccipital muscles and play a role in posterior cranium tension headaches. Addressing the suboccipital muscles is a well-known way to relieve tension headaches. The Nuchal Window Technique is a variation on this approach.

With your client supine, place your fingertips along either side of the nuchal ligament, with your middle fingers just under the occipital ridge at the superior end of the nuchal ligament (Images 8 and 9). Allow the weight of the client's head and neck to rest into your hands as you curl your fingertips into the midline of the neck.

With firm but patient pressure, encourage the musculature and soft tissue on either side of the ligament to release laterally. Our intention is to "open the window" of the suboccipital space in order to provide more room for the small muscles as well as the important cervical nerves that pass between them (Image 7), often a source of posterior head pain. (You can view a video clip of this technique among excerpts from's workshops on YouTube.)

This is a great time to use movement cues. Encourage your client to imagine her brains resting back into the table or cue her to allow her head melt into your hands. Check once again to see if you can feel the movement of the breath transmitting through her neck and head.

Although very effective for tension headaches, working the suboccipital region has sometimes been observed to worsen vascular headaches, perhaps because it may increase cranial circulation. Review the distinctions outlined in Table 1; if you suspect vascular elements, use suboccipital work carefully, watching how your client responds.

Musculoskeletal headaches are seldom related to just the cranial fascia or suboccipital muscles: jaw, neck, eye, and shoulder tension will also contribute to many headache patterns, so think broadly. Although headaches have many causes, the two techniques described here are simple but extremely effective hands-on work that will provide relief and help prevent recurrence when there is musculoskeletal involvement.



Til Luchau, Larry Koliha, and Bethany Ward are instructors at the Rolf Institute[R] of Structural Integration and faculty members of, which offers continuing education seminars internationally. Bethany Ward and Larry Koliha will be teaching classes throughout Australia (Oct.-Nov. 2011), with return visits in 2012. Techniques in this article are from's Advanced Myofascial Techniques workshops. For upcoming classes and dates, go to
TYPICAL PAIN 1-sided Bilateral

COMMON PAIN Throbbing or Pressure or
DESCRIPTORS stabbing aching

RESPONSE TO Usually worsened Usually no

EPIPHENOMENA Consistently Not commonly
 accompanied by either associated with
 nausea, light/sound nausea, light/
 sensitivity, or aura sound sensitivity,
 (visual disturbances) or aura (unless

REOCCURRENCE Recurrent, with Variably
 pain-free intervals intermittent, or

HANDS-ON GOAL Reduce cranial persistent Reduce
 compression myofascial tension
COPYRIGHT 2011 Australian Traditional-Medicine Society
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Author:Luchau, Til; Ward, Bethany; Koliha, Larry
Publication:Journal of the Australian Traditional-Medicine Society
Date:Jun 1, 2011
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