Can Back Pain Cause Tension Headaches?
Yes, back pain can cause tension headaches, and this relationship is well-established in clinical practice, with chronic headache occurring more than four times as frequently in individuals with musculoskeletal symptoms compared to those without. 1
The Clinical Connection
Back pain and tension-type headaches share a bidirectional relationship that extends beyond simple coincidence:
Migraine is directly associated with chronic pain conditions including neck and lower back pain, with these associations being more pronounced in people with chronic migraine than episodic migraine. 2
Chronic headache (>14 days/month) occurs 4.6 times more frequently in individuals with musculoskeletal symptoms compared to those without such symptoms, regardless of whether the headache is classified as migraine or non-migraine. 1
Headache commonly begins or markedly exacerbates after the onset of low back pain in chronic pain patients, even in those without any history of head, neck, or upper back injury. 3
Shared Pathophysiology
The mechanism linking back pain to tension headaches involves central nervous system dysfunction rather than isolated spinal pathology:
Both tension-type headache and non-specific low back pain are muscular pain conditions along the spine that share several specific clinical features: female preponderance, spontaneous occurrence or onset after trivial trauma, high risk of chronicity, muscle tenderness with tender points, diffuse EMG hyperactivity, and discoordinated motor control. 4
Central sensitization appears to be a substrate or consequence of this comorbidity, as individuals with chronic headache and back pain demonstrate lower pressure pain thresholds both at cephalic (head) and extracephalic (finger) sites compared to those without back pain. 5
The cervical spine component is particularly relevant, as individuals with neck pain are more likely to suffer from headache compared to those with musculoskeletal symptoms in other restricted areas. 1
Clinical Implications for Assessment
When evaluating patients with both back pain and headaches, consider:
Frequency of headache has higher impact than headache diagnosis on the association with musculoskeletal symptoms, making headache frequency a critical assessment parameter. 1
Cervical musculoskeletal dysfunctions are present in tension-type headache, including concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, and cervical motor control disturbances. 6
The referred pain pattern from upper cervical joints and muscle trigger points can reproduce the headache pattern in tension-type headache. 6
Potential Mechanisms
Three primary mechanisms explain the high prevalence of headache following back pain:
Increased muscle tension throughout the spinal musculature creates a cascade of motor control dysfunction. 3
Psychosocial factors including stress, fear-avoidance behaviors, and catastrophizing amplify pain perception. 3
Analgesic overuse in patients treating chronic back pain can lead to medication overuse headache. 3
Management Approach
Treatment should address both conditions simultaneously:
Nonpharmacologic therapy is first-line, specifically exercise therapy, spinal manipulation of the upper back, and physical therapy focusing on posture correction. 7
Upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling), and exercises targeting the cervical spine are appropriate for managing the tension-type headache component. 6
NSAIDs are the most effective pharmacologic option with moderate-quality evidence for both back pain and headache management. 7
Cognitive-behavioral therapy or mindfulness-based stress reduction should be added if psychological factors like fear-avoidance behaviors or catastrophizing are present. 7
Critical Pitfalls
Avoid prolonged bed rest, as it leads to deconditioning and worse outcomes for both conditions. 7
Do not routinely order imaging without red flags, as MRI abnormalities are common in asymptomatic patients and findings often do not correlate with symptoms. 7
Recognize medication overuse headache risk in patients using frequent analgesics for back pain, as overuse can transform episodic headache into chronic daily headache. 2