Most people think of migraine as something that happens in the brain.
A neurological event. Something you take a pill for and wait out. And there's truth in that migraine is a neurological condition. But what's often missed is how much of the pain, the tension, the relentless ache, is being driven by muscle.
I see this constantly in clinic. People who've had headaches for years, sometimes decades. They've tried the medications. Some work, some don't. And when I examine the muscles of the face, jaw, skull, and upper neck they're almost always a significant part of the picture. Tight, tender, full of trigger points. And nobody has ever touched them.
This newsletter is about why that matters, what the research says, and what can actually be done about it.
Which pattern do you notice most in your own body?
The muscle connection
Your headache is coming from somewhere
Tension-type headache the most common headache in the world, affecting around half the adult population is closely linked to something called myofascial trigger points. These are tight, irritable knots within a muscle that, when pressed, refer pain to other areas. In the head and neck, they refer pain directly into the skull creating that classic band of pressure, the weight behind the eyes, the ache at the base of the skull.
The muscles most commonly involved are the ones around and above the jaw the temporalis, masseter, and the suboccipital muscles at the back of the head along with the upper trapezius in the neck and shoulders. Research published in BMC Musculoskeletal Disorders in 2025 found that treating trigger points in these muscles, particularly the upper trapezius, both reduced headache pain and improved neck mobility in migraine patients. Seven treatment sessions. Measurable, significant results.
46%Mean global annual prevalence of headache in adults making it one of the most common and costly neurological conditions worldwide.
Migraine is more complex, but the muscle involvement is real there too. Active trigger points in the neck and facial muscles are consistently found in people with both episodic and chronic migraine. They're not the whole story migraine has central neurological drivers but they're part of it, and they're treatable.
Treating the muscles what actually work
The approach I use combines trigger point therapy with specific work on the jaw joint and upper cervical spine. The muscles I focus on are the same ones that keep showing up in the research: temporalis, masseter, digastric, the muscles around the eyes and forehead, and the suboccipital muscles at the base of the skull. Gentle, sustained pressure on the trigger points not aggressive, not painful repeated across sessions.
It's the same principle behind why Botox works for chronic migraine, and understanding that connection is important. Botox for chronic migraine approved for people with 15 or more headache days per month is injected at 31 points across seven muscle areas in the forehead, temples, back of the head, upper neck, and shoulders. Exactly the muscles we're talking about. The injections reduce tension in those muscles, and studies show patients typically see 30–50% fewer headache days after a few treatment cycles.
Botox and manual trigger point therapy target the same muscle groups for the same reason the muscles are generating and amplifying the pain. One uses a needle and a neurotoxin the other uses hands. The logic is identical.
The difference is that manual therapy is accessible, has no side effects, and can be started immediately. For people with less severe or less frequent headaches than the chronic migraine threshold, it's often the most appropriate first step and for those who are already receiving Botox, there's evidence that combining it with physical therapy produces better outcomes than either alone.
Why Botox works and what it tells us
It's worth understanding the mechanism, because it's instructive. Botox onabotulinumtoxinA works in chronic migraine not primarily by relaxing muscle (though it does that) but by blocking the release of pain-signalling substances, particularly calcitonin gene-related peptide (CGRP) and substance P, at the trigeminal nerve. These are the same substances that accumulate in active muscle trigger points tight muscle knots generate them locally, which sensitises the surrounding nerves and amplifies pain signals.
This is why chronic migraine can develop in the first place. Repeated activation of trigger points over months and years keeps feeding the trigeminal pain system, gradually lowering the threshold for a migraine attack. The headaches become more frequent, then nearly daily. The muscles are partly responsible for that progression and treating them, whether with Botox or hands, interrupts it.
31Injection sites used in the standard Botox migraine protocol all in the forehead temples, back of head, upper neck, and shoulders. Every one a muscle.
What this means if you have headaches
If you have recurring headaches tension-type, migraine, or that vague daily ache that doesn't quite fit either category the muscles of your face, jaw, and neck are worth examining. Not because they're always the cause, but because they're so often a significant contributing factor, and because treating them is safe, effective, and frequently overlooked.
In my experience many people with chronic headache have never had their jaw joint checked never had their suboccipital muscles palpated, never had anyone ask whether their neck feels stiff on the same days their head hurts. These things are connected. The research is clear on that. And the treatment whether it's manual trigger point therapy jaw exercises, upper cervical work, or in severe cases Botox works along the same anatomical lines for the same physiological reasons.
The headache that keeps coming back usually has a reason. Finding it just requires looking in the right places.
"There is a certain peace that comes with knowing less and choosing better."
Until the next signal,
Dr Erik Rudberg
Chiropractor
Most people wait for pain. The attentive ones notice the signal.
