Where Your Headache Sits and What That Tells You
Medically reviewed by Kim Le on
“Where does it hurt?” is the first question, and for headaches it is genuinely informative — just not as informative as the internet tends to suggest.
Location narrows the field. It does not close the case. The honest version is that where a headache sits gives us a shortlist, and the rest of the history decides between the items on it.
Here is what each location usually points toward, and what else has to line up before it means anything.
Top of the head
Pain across the crown, sometimes described as pressure, weight, or a hat that is too tight.
Most commonly this is tension-type headache. It is the most prevalent headache type there is, it tends to be bilateral, and it is typically described as pressing or tightening rather than throbbing. Stress, sustained postures and poor sleep are the usual companions.
Less commonly, crown pain is referred from the upper cervical spine, which is worth considering when it is accompanied by neck stiffness and worsens across a working day.
Back of the head
Pain at the base of the skull, sometimes travelling up over the back of the head or forward toward the temple.
This is the location most often connected to the neck. The upper cervical nerves and the trigeminal nerve — which supplies sensation to the face and much of the head — converge in the brainstem, so irritation from an upper cervical joint or its surrounding muscle can be genuinely felt at the back or side of the head. This is called cervicogenic headache, and it is one of the presentations manual therapy is best suited to.
Occipital neuralgia produces a sharper, more electrical pain in the same region, often with tenderness over a specific point at the base of the skull.
One side, behind or around the eye
Classically migraine, particularly when it is throbbing, moderate to severe, worsened by routine activity, and accompanied by nausea or sensitivity to light and sound.
Strictly one-sided pain centred on the eye, occurring in bouts, with a red or watering eye on the same side, describes cluster headache — much rarer, considerably more severe, and something that should be assessed by a doctor rather than managed with manual therapy.
A band around the forehead and temples
The textbook description of tension-type headache: bilateral, pressing, mild to moderate, and not made worse by walking up stairs.
Sustained jaw clenching is an underappreciated contributor here. The temporalis muscle covers the temple, and people who clench overnight frequently wake with exactly this pattern.
Face and cheeks
Pressure across the cheeks and forehead that worsens when bending forward, with nasal congestion, suggests a sinus cause. Genuine sinus headache is less common than self-diagnosis of it — a good proportion of “sinus headaches” turn out to be migraine, which can produce nasal and facial symptoms of its own.
Jaw and temple pain that changes with chewing points toward the temporomandibular joint.
What matters more than location
Four things, all of which a clinician will ask about:
The pattern over time. Episodic or constant. Same time of day. Weekends or weekdays. Cyclical for people who menstruate.
What brings it on and what settles it. Screen time, specific foods, dehydration, sleep, alcohol, stress, or particular head positions.
What else happens. Nausea, aura, light sensitivity, neck stiffness, watering eye, jaw symptoms.
Whether it has changed. A headache that has been the same for a decade is a different proposition from one whose character changed last month. Change is the single most important feature in the history.
Headaches that need urgent medical assessment, not manual therapy. Attend an emergency department, or call 000, for:
- A sudden, severe headache that reaches maximum intensity within seconds to minutes — “thunderclap” headache
- Headache with fever, neck stiffness and sensitivity to light
- Headache with confusion, drooping face, slurred speech, or weakness down one side
- Headache after a significant head injury, especially with drowsiness or vomiting
- A new headache with visual loss, or with scalp tenderness in someone over 50
See a GP promptly for a headache that is new or different for you, one that is progressively worsening over weeks, one that is consistently worse in the morning or when lying flat, or any new headache pattern if you are pregnant, immunocompromised, or have a history of cancer.
Where manual therapy fits
Honestly: for some headache types, and not others.
Cervicogenic headache — the kind genuinely driven by the upper neck — is the clearest indication. When assessment reproduces the person’s familiar headache by loading specific cervical segments, and treating those segments changes it, the connection is reasonably direct.
Tension-type headache with a clear postural or muscular contribution often responds to a combination of manual therapy and changes to the loading pattern that is provoking it.
Migraine is a neurological condition, and manual therapy does not treat migraine. Some people with migraine also have a neck contribution that is worth addressing, and reducing that can help — but this is an adjunct to medical management, not a substitute for it, and anyone claiming to cure migraine with adjustments is overreaching.
Cluster headache, and any headache with the red flags above, belongs with a doctor.
If your headaches come with neck stiffness, are worse at the end of a desk-based day, and improve when you move, the neck is worth assessing. If they come with nausea and light sensitivity and knock you out for a day, start with your GP.
Common questions
- Can headache location alone diagnose the cause?
- No. Location narrows the list but never settles it. The pattern over time, what triggers it, what relieves it and what else happens alongside it all carry as much weight. Two people with pain in the same spot can have entirely different headache types.
- Why do so many headaches sit at the back of the head?
- The upper three cervical nerve levels share processing pathways with the nerve that supplies sensation to much of the head. Irritation in the upper neck is therefore commonly felt at the back of the skull, and can travel forward toward the temple or eye.
- Is a headache on one side more serious than one on both?
- Not by itself. Migraine is classically one-sided and tension-type headache classically both, but plenty of people do not follow the textbook. A headache that is always on exactly the same side and never swaps is worth mentioning to a doctor.
- How many headaches a month is too many?
- As a rule of thumb, headaches on more than a few days a month, or any headache pattern that needs regular pain medication to function, should be reviewed by a GP — partly to identify the type and partly because frequent painkiller use can itself drive medication-overuse headache.
