Published May 2026. Written by the Upwell Health Collective clinical team. Clinically reviewed May 2026. Next review November 2026. For educational purposes only — please consult a qualified GP, neurologist, or allied health professional for personalised care. If you have any of the red flag symptoms described in this guide, seek medical attention urgently.
Related reading from Upwell Health:
• The Disc Injury Directory 2026
• The Shoulder Pain Master Guide 2026
• Perimenopause & Menopause Thrive Guide 2026
• Combat Sports Chronicle 2026
• Pain Is Not Damage: Hurt vs Harm
If you have headaches or migraines — occasional, recurring, chronic, or anywhere in between — five things to know before anything else:
1/ Headache is the most common pain complaint in the world. Around 48.9% of the global adult population experiences headache in any given year. Migraine alone affects approximately 1 in 7 people. Tension-type headache is even more common. Cervicogenic headache — driven by the neck — accounts for 15-20% of chronic headaches. Most of these are highly treatable.
2/ Not all headaches are the same. The International Classification of Headache Disorders (ICHD-3) recognises over 200 distinct headache types across primary headaches (migraine, tension-type, cluster), secondary headaches (caused by another condition), and the painful cranial neuropathies. Understanding which type you have is the foundation of effective treatment.
3/ Migraine treatment has been transformed in the past 7 years. The CGRP-targeting therapies — monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) and gepants (atogepant, rimegepant, ubrogepant, zavegepant) — represent the first migraine-specific preventive medications ever developed. The 2024 American Headache Society Consensus recommended them as first-line preventives. The 2025 ACP Guideline confirmed them as effective monotherapy options for episodic migraine prevention.
4/ Allied health does substantially more for headaches than most people realise. The 2024 Jung et al network meta-analysis in Physical Therapy confirmed that combined physiotherapy interventions (spinal manipulation, exercise, dry needling, soft tissue work) significantly reduce cervicogenic headache intensity and frequency. The 2025 Ogrezeanu dose-response meta-analysis showed aerobic exercise meaningfully reduces migraine frequency. Manual therapy, exercise, postural retraining, vestibular rehabilitation, and pain neuroscience education all have evidence for specific headache types.
5/ Most chronic headache improves substantially with the right framework. The combination of accurate diagnosis, lifestyle medicine (sleep, exercise, nutrition, stress), evidence-based medical therapies, and targeted allied health care transforms outcomes for the vast majority of chronic headache sufferers — even those who have struggled for years.
This guide is the most comprehensive evidence-based headache and migraine resource we've produced. It integrates research from 2023–2026 across ICHD-3 classification, migraine pharmacology, cervicogenic headache, tension-type headache, cluster headache, post-concussive headache, vestibular migraine, hormonal migraine, and the multidisciplinary care that transforms outcomes. It sits at around 15,000 words.
Before we get to the ICHD-3 framework, let's start somewhere more useful: with you. Where might you fit in this story?
This is the most common pattern. You're likely dealing with episodic tension-type headache, episodic migraine, or both ("mixed" headache is common). The framing trap: dismissing them as "just headaches" and never seeking proper assessment. The win: even a single GP consultation with a headache-aware clinician can transform your trajectory. You probably qualify for evidence-based preventive strategies that you've never been offered.
Post-traumatic headache. Increasingly recognised as a distinct entity. Often involves a cervicogenic component (the neck took a hit too), a vestibular component (the inner ear was shaken), and a sensitisation component (the nervous system is now hyperresponsive). Multidisciplinary care is essential. Standalone medication often fails. The good news: with the right team, most post-traumatic headache resolves substantially within 6-12 months.
Welcome to cervicogenic headache — one of the most under-recognised and most treatable headache types. Triggered by neck movements or sustained postures. Often unilateral. Often associated with neck stiffness, ipsilateral shoulder/arm symptoms, and visible cervical dysfunction on examination. The 2024 Jung network meta-analysis confirms that combined physiotherapy (manual therapy plus targeted exercise) is the strongest evidence-based intervention.
Three possibilities. First, the diagnosis might need refinement — chronic migraine, vestibular migraine, hemiplegic migraine, or even migraine with significant cervicogenic overlay are commonly missed. Second, you may not yet have accessed the modern treatment landscape — CGRP monoclonal antibodies and gepants have transformed outcomes for thousands of "treatment-resistant" patients since 2018. Third, there may be a medication overuse picture compounding things — surprisingly common, often invisible to the person experiencing it.
Menstrual migraine. Affects up to 60% of women with migraine. Driven by oestrogen drop in the late luteal phase. Highly responsive to specific menstrual-cycle-targeted preventive strategies (mini-prophylaxis with NSAIDs or triptans during the perimenstrual window, hormonal manipulation, or CGRP-targeted therapy). Our companion guide Perimenopause & Menopause Thrive Guide 2026 covers the hormonal landscape in depth.
Stop reading and seek medical attention immediately. The SNNOOP10 red flags (covered in detail below) help differentiate primary headache from potentially serious secondary causes. A thunderclap headache, sudden change in headache pattern, headache with neurological deficit, headache with fever and neck stiffness, or headache in the setting of cancer or immunocompromise all warrant urgent assessment.
You're not alone. Chronic headache (15+ headache days per month for 3+ months) affects approximately 4% of the global population. The cumulative life impact — work productivity, relationships, mental health, exercise capacity, sleep, identity — is enormous. But the contemporary evidence base for chronic headache transformation is the strongest it has ever been. Don't accept the verdict that this is just how your life will be.
Headache is one of the most common reasons people see a GP. It's in the top three reasons for emergency department presentations. The Global Burden of Disease Study consistently ranks migraine among the top 10 causes of disability globally. In Australia, headache and migraine cost an estimated $14 billion annually in productivity losses, healthcare costs, and lost workdays.
Despite these numbers, headache remains profoundly under-treated. Surveys consistently show that fewer than half of people with migraine have an accurate diagnosis, and only a minority of those who would benefit from preventive treatment are actually using it. The gap between what's possible and what most people experience is one of the largest in modern healthcare.
• Cultural minimisation. Headache has been treated as a trivial complaint for generations — "just take a Panadol" still dominates Australian health culture.
• Diagnostic complexity. Over 200 distinct headache types in ICHD-3. Many GPs receive only brief headache training.
• Modern therapy access. CGRP-targeted therapies are only PBS-subsidised for chronic migraine patients meeting specific criteria. Many patients with severe episodic migraine pay out-of-pocket or miss out entirely.
• Allied health fragmentation. Few clinics integrate physio, EP, myotherapy, and Pilates around headache care — even though the evidence supports multidisciplinary management.
• Patient resignation. Many people with chronic headache simply stop seeking help after years of frustration.
This guide exists to close that gap. Read it slowly. Bookmark it. Share it.
The International Classification of Headache Disorders, 3rd Edition (ICHD-3) is the global diagnostic gold standard for headache. It categorises headaches into three main groups:
1/ Primary headaches — the headache itself is the disorder. No underlying cause. Includes migraine, tension-type headache, trigeminal autonomic cephalalgias (TACs) like cluster headache, and other primary headache disorders.
2/ Secondary headaches — caused by another underlying condition. Includes post-traumatic headache, headache from infection, headache from a structural cause, medication-overuse headache, cervicogenic headache, and many more.
3/ Painful cranial neuropathies, other facial pains, and other headaches — includes trigeminal neuralgia, occipital neuralgia, persistent idiopathic facial pain, and others.
Accurate diagnosis is the foundation of effective treatment. The same person can have multiple coexisting headache types — most commonly migraine plus tension-type, or migraine plus cervicogenic, or any combination.
Migraine is a chronic neurological disorder characterised by recurrent attacks of moderate-to-severe headache, typically lasting 4–72 hours, often pulsating in quality, often unilateral, often associated with nausea, vomiting, photophobia (light sensitivity), phonophobia (sound sensitivity), and often disabling. Around 20–40% of people with migraine experience aura — transient neurological symptoms (visual changes, sensory changes, language disturbance) that precede or accompany the headache.
Migraine is not just "a headache". It unfolds in phases:
1/ Prodrome (premonitory phase). Hours to days before headache onset. Mood changes, food cravings, fatigue, neck stiffness, yawning, increased urination, light/sound sensitivity. Often missed but increasingly understood as a critical intervention window.
2/ Aura (in those who experience it). 5–60 minutes. Visual disturbances most common — flashing lights, zigzag lines, scotomas. Can include sensory aura (tingling, numbness) or language disturbance. Migraine with aura carries slightly elevated cardiovascular and stroke risk — worth knowing for prevention strategies.
3/ Headache phase. The classic migraine attack — throbbing, unilateral, severe, with associated nausea/vomiting/photophobia/phonophobia. Lasts 4–72 hours untreated.
4/ Postdrome ("migraine hangover"). Hours to days after the headache resolves. Fatigue, cognitive slowing, residual neck or head tenderness, mood changes. Often the most overlooked phase.
Episodic migraine — fewer than 15 headache days per month. The vast majority of migraine.
Chronic migraine — 15 or more headache days per month for at least 3 months, with at least 8 of those days having migrainous features. Affects approximately 1–2% of the population. Often progresses from episodic migraine over years.
• Migraine without aura — the most common form.
• Migraine with aura — about 25–30% of migraine.
• Vestibular migraine — vertigo and balance disturbance as a primary feature. Often without headache. Frequently misdiagnosed as inner ear disorder for years.
• Hemiplegic migraine — rare. Aura includes motor weakness. Familial and sporadic forms exist.
• Retinal migraine — monocular visual disturbance. Rare. Requires careful differentiation from amaurosis fugax.
• Status migrainosus — a migraine attack lasting longer than 72 hours despite treatment. Warrants urgent care.
• Menstrual migraine — closely timed to the menstrual cycle, particularly the late luteal phase.
• Chronic migraine with medication overuse — chronic migraine compounded by overuse of acute analgesics or triptans.
The contemporary model: migraine is a complex neurovascular disorder driven by sensitisation of the trigeminovascular system. The neuropeptide calcitonin gene-related peptide (CGRP) is central — it is released from trigeminal nerve endings, causes vasodilation, drives inflammation, and amplifies pain signaling. The success of CGRP-targeted therapies is the strongest empirical evidence of this mechanism.
Beyond CGRP, the modern picture includes hypothalamic dysfunction (explaining the prodromal phase and many trigger sensitivities), cortical spreading depression (the wave of neuronal activity that produces aura), brainstem nuclei activation, and central sensitisation in chronic migraine.
Triggers are individual. Common ones include:
• Sleep disruption — too little, too much, irregular schedule.
• Hormonal fluctuations — oestrogen drop in late luteal phase, perimenopause.
• Skipped meals / hypoglycaemia.
• Dehydration.
• Stress — particularly the relaxation phase after stress (the "weekend headache").
• Foods — highly individual. Common culprits include red wine, aged cheeses, chocolate, processed meats, MSG, artificial sweeteners. Many "food triggers" are actually craving symptoms of the prodromal phase.
• Caffeine — both excess and withdrawal.
• Weather changes — barometric pressure shifts in particular.
• Bright lights, loud sounds, strong smells.
• Physical exertion in some patients.
• Neck strain and sustained posture.
The current evidence strongly favours not obsessive trigger avoidance. The 2025 evidence-based clinical practice guideline emphasises lifestyle stability (regular sleep, regular meals, hydration, stress management, regular aerobic exercise) over restrictive trigger lists.
The hierarchy:
1/ Simple analgesics. Paracetamol, ibuprofen, aspirin. Often combined with caffeine. Effective for mild-to-moderate attacks. Limit to fewer than 15 days per month to avoid medication-overuse headache.
2/ Triptans. Sumatriptan, rizatriptan, zolmitriptan, eletriptan. Migraine-specific 5-HT1B/1D agonists. The standard prescription medication for moderate-to-severe migraine since the 1990s. Take at the first sign of headache. Limit to fewer than 10 days per month. Cardiovascular contraindications apply.
3/ Gepants (acute use). Ubrogepant (Ubrelvy), rimegepant (Nurtec), zavegepant (Zavzpret). The first new acute migraine drug class in 30 years. No vasoconstriction — safe for patients with cardiovascular disease. Available in Australia for selected patients.
4/ Ditans. Lasmiditan (Reyvow). Another newer acute option. 5-HT1F agonist. No vasoconstriction. Causes drowsiness — patients shouldn't drive for 8+ hours after dose.
5/ Antiemetics. Metoclopramide, prochlorperazine, ondansetron. Address nausea and vomiting that limit oral absorption.
6/ Combination therapy. Paracetamol/aspirin/caffeine combinations. Triptan plus NSAID. Often more effective than monotherapy.
This is where the 2024–2026 evidence base has changed most dramatically.
The 2024 American Headache Society Consensus Statement — published in Headache — recommended CGRP-targeting therapies as first-line preventive treatment for episodic migraine, alongside (and arguably preferred over) the older preventive medications. This was the biggest shift in migraine prevention since topiramate's approval in 2004.
The 2025 American College of Physicians Guideline — published in Annals of Internal Medicine, February 2025 — recommended monotherapy with a CGRP receptor antagonist (atogepant or rimegepant) or a CGRP monoclonal antibody (erenumab, fremanezumab, galcanezumab, eptinezumab) for prevention of episodic migraine.
Preventive options today:
• CGRP monoclonal antibodies — erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), eptinezumab (Vyepti). Monthly or quarterly subcutaneous injections (or IV for eptinezumab). Excellent tolerability. PBS-listed for chronic migraine in Australia with specific eligibility criteria.
• Gepants for prevention — atogepant (Qulipta) and rimegepant (Nurtec, can be used acute or preventive). Daily oral. Effective for both episodic and chronic migraine.
• Beta-blockers — propranolol, metoprolol. Long-standing first-line preventives.
• Topiramate — effective preventive. Cognitive side effects can be limiting.
• Amitriptyline — useful where comorbid sleep or mood issues coexist.
• Sodium valproate — effective but teratogenic. Avoid in women of childbearing age.
• Candesartan — evidence-based but underused option.
• Botulinum toxin (Botox) — PBS-listed for chronic migraine in Australia. Quarterly injection protocol.
• Magnesium, riboflavin, coenzyme Q10 — nutraceuticals with modest evidence. Useful adjuncts.
• Melatonin — emerging evidence for migraine prevention, particularly when sleep is a trigger.
The American Headache Society criteria for considering preventive therapy:
• 4+ migraine days per month with some impairment.
• 6+ headache days per month even without impairment.
• 8+ headache days per month regardless of acute treatment response.
• Failure of, contraindication to, or significant adverse effect from acute medications.
• Patient preference.
• Specific migraine subtypes (hemiplegic, prolonged aura, migrainous infarction).
Most oral preventives take 8–12 weeks of consistent dosing at therapeutic dose to demonstrate benefit. CGRP-targeted therapies often show benefit within 1–3 months — sometimes within weeks for some patients. Botulinum toxin protocols are typically assessed after 2 treatment cycles (6 months).
The most common headache type globally. Often dismissed as "just stress". The contemporary understanding is more nuanced.
• Bilateral, often described as a tight band or vice around the head.
• Mild-to-moderate intensity, rarely severely disabling.
• Pressing or tightening quality (non-pulsating).
• Not aggravated by routine activity (unlike migraine).
• No or minimal nausea, no vomiting, may have mild photophobia OR phonophobia (but not both).
• Duration 30 minutes to 7 days.
• Infrequent episodic — fewer than 1 day per month on average.
• Frequent episodic — 1–14 days per month.
• Chronic tension-type headache (CTTH) — 15+ days per month for 3+ months.
The older theory — muscle tension — has been complemented by a broader understanding involving central sensitisation, descending pain modulation dysfunction, and stress-related changes in pain processing. CTTH in particular often involves significant central sensitisation — the same nervous system process we describe in our Whole Person Pain™ (WPP™) framework.
• Acute — simple analgesics (paracetamol, NSAIDs). Limit frequency to avoid MOH.
• Prevention — amitriptyline is first-line for CTTH. Tricyclics have decades of evidence here.
• Physiotherapy — manual therapy, cervical exercise, postural education. Solid evidence for tension-type headache.
• Myotherapy — hands-on soft tissue work, dry needling, trigger point therapy. Common adjunct.
• Resistance training — emerging evidence base. Neck and shoulder strengthening shows benefit.
• CBT and stress management — strong evidence.
• Lifestyle medicine — sleep, exercise, nutrition, hydration, stress management.
This is one of the most under-recognised yet most treatable headache types. It accounts for 15–20% of chronic headaches. The good news: it responds beautifully to evidence-based physiotherapy.
A secondary headache caused by a disorder of the cervical spine (the neck) and/or its component bony, disc, and/or soft tissue elements. The ICHD-3 criteria require:
• Clinical, laboratory, or imaging evidence of a cervical spine disorder.
• The headache developed in temporal relation to the onset of the cervical disorder.
• Headache improves or resolves with treatment of the cervical disorder.
• The headache features support cervical involvement (reduced cervical range, pain reproduction with neck movement or pressure, etc).
• Typically unilateral, side-locked (always on the same side).
• Starts in the neck or occiput (base of skull) and refers forward to the forehead, eye, or temple.
• Triggered or aggravated by neck movements, sustained postures, or pressure on specific cervical structures.
• Often associated with reduced cervical range of motion.
• Often associated with ipsilateral neck, shoulder, or arm symptoms.
• Can mimic migraine but usually lacks the autonomic features (nausea, photophobia, phonophobia).
The 2024 systematic review and network meta-analysis published in Physical Therapy (Jung A, Carvalho GF, et al, February 2024) examined all RCTs of physiotherapy interventions for cervicogenic headache. Findings:
• Combined interventions — spinal joint manipulation plus dry needling, or muscle energy technique, or soft tissue techniques, or exercises — produced the strongest short-term reductions in cervicogenic headache intensity and frequency.
• Manual therapy combined with exercise — the most consistently effective approach across multiple outcome measures.
• Exercise alone — also effective, comparable to manual therapy alone in many trials.
• Combined manual therapy and exercise outperforms either alone.
The 2025 Xu/Ling Frontiers in Neurology network meta-analysis confirmed these findings, with combined approaches consistently producing the best outcomes.
1/ Thorough assessment — cervical range of motion, manual examination of cervical joints, soft tissue palpation, neurological screen, posture and movement analysis.
2/ Manual therapy — mobilisation or manipulation of restricted cervical segments, soft tissue work to address contributing muscle dysfunction.
3/ Targeted exercise — deep cervical flexor training, scapular stabiliser strengthening, postural endurance work.
4/ Dry needling — where indicated, for myofascial trigger points contributing to symptom production.
5/ Postural and ergonomic modification — desk setup, screen positioning, work habits.
6/ Lifestyle factors — sleep position, stress management, regular movement.
Most patients with cervicogenic headache experience substantial improvement within 6–12 weeks of structured care.
Cluster headache is the most severe primary headache disorder. Survivors describe it as the worst pain a human can experience — it has been called "suicide headache" because of the toll it takes. Despite this severity, it is also one of the most treatable headache disorders with appropriate specialist input.
• Strictly unilateral, severe-to-very-severe pain.
• Located around the eye, temple, or forehead.
• Lasts 15 minutes to 3 hours.
• Associated with ipsilateral autonomic features — red eye, tearing, nasal congestion, sweating, eyelid drooping.
• Restlessness — patients pace rather than lie still (in contrast to migraine).
• Attack frequency: from one every other day to 8 per day.
• Cluster periods of weeks to months, separated by remission periods of months to years (episodic cluster), or persistent (chronic cluster).
This is a specialist neurologist domain. Acute treatments include high-flow oxygen (10–12 L/min via non-rebreather mask for 15 minutes — dramatically effective), subcutaneous sumatriptan, intranasal zolmitriptan. Preventive treatments include verapamil, lithium, prednisolone, galcanezumab (PBS-listed in Australia for episodic cluster), and occipital nerve blocks.
Other trigeminal autonomic cephalalgias include paroxysmal hemicrania (highly responsive to indomethacin), hemicrania continua (also indomethacin-responsive), and SUNCT/SUNA. All warrant specialist neurology assessment.
This is the most missed diagnosis in chronic headache. The 2025 Rocha-Filho review estimated that medication overuse headache (MOH) affects 1–2% of the global population. Among chronic headache patients in tertiary clinics, MOH is the most common secondary headache, accounting for around 7–15% of all presentations.
• Simple analgesics (paracetamol, NSAIDs, aspirin) — used 15+ days per month for 3+ months.
• Triptans, ergots, opioids, or combination analgesics — used 10+ days per month for 3+ months.
• Combination of multiple acute medications — 10+ days per month for 3+ months.
... in a person with pre-existing primary headache disorder, with worsening or chronification of headache pattern.
The medications that should be helping are actually making things worse. The neurochemistry of repeated acute analgesic use sensitises the pain system. The headache becomes more frequent. The person takes more medication. The cycle compounds.
The good news: withdrawing the overused medication restores the original episodic pattern in up to 70% of patients. The bad news: the withdrawal period is unpleasant — typically 2–8 weeks of worsening symptoms before improvement.
Always involves specialist medical input. Options include abrupt withdrawal (sometimes with bridging therapy like a short prednisolone course), gradual withdrawal, or initiation of an effective preventive medication (CGRP monoclonal antibodies in particular have shown effectiveness in MOH without requiring full withdrawal first).
Following concussion, mild traumatic brain injury, whiplash, or significant cervical trauma. Often persists beyond the expected concussion recovery window. We've covered the broader concussion conversation in our Combat Sports Chronicle 2026.
• Headache developing within 7 days of injury (or within 7 days of regaining consciousness).
• Acute post-traumatic headache — resolves within 3 months.
• Persistent post-traumatic headache — lasts beyond 3 months.
• Phenotype: often mixed — some attacks look migrainous, others tension-type or cervicogenic.
• Frequently associated with other post-concussive symptoms — dizziness, brain fog, sleep disturbance, mood changes, vestibular dysfunction.
Multidisciplinary management is essential. Standalone medication often fails. The framework:
• Cervical assessment and treatment — the neck almost always took a hit too. Cervicogenic contribution is the rule, not the exception.
• Vestibular and oculomotor rehabilitation — the inner ear and visual system are commonly affected.
• Graded return to aerobic exercise — sub-symptom-threshold aerobic exercise (the Buffalo Concussion Treadmill Test protocol) accelerates recovery.
• Pharmacotherapy — treat the predominant phenotype (migraine treatment if migrainous, tension-type approach if tension-type pattern).
• Sleep optimisation — critical.
• Psychology — for mood and anxiety which commonly compound symptoms.
• Pain neuroscience education — reduces sensitisation.
Most persistent post-traumatic headache resolves substantially within 6–12 months of structured multidisciplinary care.
One of the most common causes of recurrent vertigo. Frequently misdiagnosed as inner ear disease, BPPV, or anxiety for years before correct diagnosis. Affects approximately 1% of the population.
• Recurrent vertigo or balance disturbance lasting minutes to days.
• Migraine history (currently or previously).
• At least half of vestibular episodes occur with migrainous features (headache, photophobia, phonophobia, aura) OR follow migraine triggers.
• Can occur without headache during vestibular episodes — the source of frequent misdiagnosis.
The same preventive medications that work for typical migraine — propranolol, topiramate, amitriptyline, CGRP-targeted therapies — work for vestibular migraine. Acute treatment with triptans is variably effective for the vestibular symptoms (more effective for headache when present).
Vestibular rehabilitation is a critical adjunct. The 2025 evidence supports vestibular rehabilitation for vestibular migraine — graded exposure to movements that provoke symptoms, gaze stability training, and balance retraining. Available through Upwell's physiotherapists with vestibular training, or referred to vestibular-specific physiotherapists.
Migraine has a strong sex difference — it affects women 3:1 over men in adulthood, largely driven by hormonal influence. Many women experience predictable migraine patterns tied to the menstrual cycle.
• Pure menstrual migraine — attacks only in the perimenstrual window (2 days before to 3 days after menstruation onset).
• Menstrually-related migraine — attacks in the perimenstrual window plus at other times.
• Both driven primarily by the oestrogen drop in the late luteal phase.
• Mini-prophylaxis — NSAIDs (naproxen 500mg twice daily) or longer-acting triptans (frovatriptan, naratriptan) for the 5–7 day perimenstrual window only.
• Hormonal manipulation — continuous oral contraceptive pill, transdermal oestrogen during the late luteal phase to soften the oestrogen drop.
• CGRP-targeted therapies — effective for hormonal migraine as for other migraine subtypes.
• Lifestyle stability — especially through the late luteal phase.
Migraine commonly worsens during perimenopause, then improves substantially in late postmenopause. Our Perimenopause & Menopause Thrive Guide 2026 covers this transition in depth. Key principle: MHT (menopause hormone therapy) often improves perimenopausal migraine, particularly when prescribed transdermal continuous oestrogen plus appropriate progesterone. The hormonal stability of MHT can be transformative for many women's headache patterns.
Most headache is benign. But a small minority of headaches indicate serious underlying pathology. The SNNOOP10 mnemonic (Do et al, Neurology, 2019) is the international gold standard for screening for serious secondary headaches:
S — Systemic symptoms (fever, weight loss).
N — Neoplasm (history of cancer).
N — Neurologic deficit (including decreased consciousness, focal neurological signs).
O — Onset sudden ("thunderclap" headache reaching maximum severity within 1 minute — think subarachnoid haemorrhage until proven otherwise).
O — Older age (new headache onset after age 50 — think giant cell arteritis, malignancy, structural cause).
P — Pattern change (progressive headache, change in characteristics).
P — Positional headache (worse on standing or lying — think CSF disorders).
P — Precipitated by Valsalva (cough, sneeze, exertion — think intracranial mass).
P — Pregnancy or postpartum (specific differential including cerebral venous sinus thrombosis, pre-eclampsia, pituitary apoplexy).
P — Painful eye with autonomic features (think acute angle-closure glaucoma, carotid dissection).
P — Posttraumatic (covered above).
P — Pathology of the immune system (HIV, immunosuppression).
P — Painkiller overuse or new drug at onset (covered above).
If you have any of these red flags with a headache, seek medical attention promptly. "Thunderclap" headache, headache with sudden neurological deficit, or headache with fever and neck stiffness warrant urgent emergency department assessment.
No medication or treatment plan compensates for poor foundations. The evidence base for lifestyle medicine in headache is extensive and growing.
Sleep disruption is one of the strongest predictors of headache frequency. Both insufficient sleep and excessive sleep can trigger migraine. Sleep apnoea is meaningfully associated with chronic morning headache and warrants screening in patients with snoring, daytime sleepiness, or witnessed apnoeas.
Practical principles:
• Consistent sleep and wake times — even on weekends.
• 7–9 hours per night for most adults.
• Cool, dark, quiet bedroom.
• Screen-free wind-down in the final hour.
• Limited alcohol — it fragments sleep.
• Caffeine cutoff by midday.
• Address sleep apnoea if present — CPAP transforms outcomes for many chronic headache patients.
The 2025 evidence is unambiguous. The Ogrezeanu et al dose-response meta-analysis (October 2025, Headache) of aerobic exercise for migraine prevention confirmed meaningful reductions in pain intensity and frequency. The Meydanal et al 2025 pilot study showed combined resistance and aerobic exercise outperformed aerobic alone. The 2023 La Touche evidence-based clinical practice guideline established the framework: moderate-intensity aerobic exercise, 3–5 sessions per week, at least 30 minutes per session, for at least 6–8 weeks produces measurable reductions in migraine frequency and disability.
Practical principles:
• Start where you are. If you haven't been exercising, start with 10–15 minute walks and progress.
• Build to 150–300 minutes of moderate-intensity aerobic activity per week.
• Add resistance training 2–3 sessions per week — emerging evidence base for tension-type and migraine.
• Some patients are exertion-triggered. Start very low intensity and progress gradually. Most exertion-triggered patients can build tolerance with patience.
• Outdoor or gym — doesn't matter. Consistency is the variable.
• Regular meals — avoid skipping.
• Adequate hydration — dehydration is a common trigger.
• Mediterranean dietary pattern — strong evidence base for general health and cardiovascular outcomes, modest evidence for headache reduction.
• Limit alcohol — a major trigger for many people, particularly red wine.
• Personalise trigger foods — the standard "migraine diet" rarely matches individual reality. Track and individualise.
• Magnesium supplementation — 400mg/day has evidence for migraine prevention.
• Riboflavin (B2) — 400mg/day has evidence for migraine prevention.
• Coenzyme Q10 — 100–300mg/day has emerging evidence.
Stress is the most commonly reported headache trigger. The science is clear: chronic stress dysregulates the autonomic nervous system, increases central sensitisation, disrupts sleep, and amplifies pain signaling. Effective interventions include:
• Cognitive behavioural therapy (CBT) — strong evidence base for both migraine and tension-type headache.
• Mindfulness-based stress reduction (MBSR) — growing evidence.
• Biofeedback — particularly effective for tension-type headache.
• Yoga and gentle movement practices — evidence base for migraine and chronic headache.
• Therapy for underlying mood and anxiety disorders — frequently comorbid with chronic headache.
Standard recommendation: 2–2.5L water daily for most adults. Caffeine: tricky. It can abort an acute attack (which is why caffeine appears in many combination analgesics). It can also trigger withdrawal headaches. For most chronic headache patients, consistent moderate caffeine intake (1–2 cups in the morning, none after midday) works better than abstinence or variable use.
At Upwell Health Collective in Camberwell, we work with headache patients across the spectrum — occasional tension-type, severe episodic migraine, chronic migraine, post-traumatic headache, cervicogenic headache, vestibular migraine, and complex mixed presentations. Our integrated allied health team brings physiotherapy, exercise physiology, clinical Pilates, podiatry, and myotherapy together under one roof. We coordinate with GPs, neurologists, headache specialists, psychologists, and dietitians as needed.
Here is what working with our team looks like:
Our physiotherapists are well-trained in the modern headache framework. We assess and treat:
• Cervicogenic headache — the primary domain where evidence supports physiotherapy as first-line treatment. Manual therapy, exercise, dry needling, and postural retraining following the 2024 Jung network meta-analysis framework.
• Tension-type headache — hands-on treatment, postural and ergonomic modification, exercise prescription.
• Post-traumatic headache — cervical assessment, vestibular rehabilitation where indicated, graded exercise progression.
• Vestibular migraine — graded vestibular rehabilitation, balance retraining.
• Migraine-associated neck dysfunction — most migraine patients have measurable cervical contribution. Addressing it improves outcomes.
• Education and the Whole Person Pain™ framework for chronic headache patients with significant central sensitisation.
Our exercise physiologists (AEPs) deliver the evidence-based exercise prescription that transforms outcomes in chronic headache:
• Graded aerobic exercise programs — following the 2025 La Touche/Ogrezeanu evidence base for migraine prevention.
• Resistance training programs — emerging evidence for tension-type and migraine reduction.
• Return-to-exercise after concussion or sustained inactivity.
• Cardiovascular conditioning for general health and headache resilience.
• Chronic disease management plan (CDM) referrals for eligible patients.
Particularly valuable for:
• Deep cervical flexor training (critical for cervicogenic headache).
• Scapular stability and postural endurance.
• Mind-body work for stress-related headache contribution.
• Gentle return-to-movement for chronic headache patients who have stopped exercising.
Particularly valuable for:
• Tension-type headache — cervical, suboccipital, temporal, and masseter muscle tension.
• Acute flare management.
• Dry needling for myofascial trigger points contributing to symptoms.
• Adjunct to active rehabilitation.
For some headache patients, foot biomechanics and gait contribute to neck and postural loading patterns. Particularly relevant for runners and standing workers with chronic headache.
Most importantly, our team works together. Your physio, EP, Pilates instructor, and myotherapist communicate. We share the same clinical philosophy and the same evidence base. We refer to and from your GP, neurologist, headache specialist, psychologist, and other professionals as appropriate. We participate in your care — we don't try to be everything for everyone.
A headache-aware GP. Critical. Many GPs are not up-to-date with the post-2024 evidence base. If your GP is hesitant to discuss CGRP-targeted therapies, modern preventive options, or multidisciplinary care, consider seeking a second opinion.
A neurologist with headache expertise. For complex migraine, treatment-resistant headache, cluster headache, or any presentation where the diagnosis is unclear. The Australian and New Zealand Headache Society maintains a directory of headache-specialist neurologists.
A clinical psychologist. CBT for migraine and tension-type headache has Level 1 evidence. Particularly valuable when chronic headache coexists with anxiety, depression, sleep disturbance, or significant life stress.
A vestibular physiotherapist. For vestibular migraine, post-concussive vertigo, or balance dysfunction requiring specialist assessment.
A sleep specialist. If sleep apnoea, restless legs, or chronic insomnia coexist with headache. CPAP for sleep apnoea is one of the highest-yield interventions in chronic headache.
A dietitian or nutritionist. For systematic trigger identification, anti-inflammatory dietary patterns, or specific nutritional interventions.
Rough heuristic: migraine is typically one-sided, throbbing, moderate-to-severe, associated with nausea/photophobia/phonophobia, and worsened by routine activity. Tension-type is bilateral, pressing/tight, mild-to-moderate, with minimal associated symptoms, and not worsened by activity. Many people have both.
The most common reason: the diagnostic conversation in standard general practice is often rushed. A thorough headache history takes 20–30 minutes. Detailed headache diaries (frequency, duration, intensity, triggers, associated symptoms, medication response) over 4–6 weeks transform diagnostic accuracy. A headache-aware GP or neurologist will use these tools.
In the absence of red flag features (SNNOOP10) and in a person with a stable, longstanding headache pattern, routine MRI is generally not indicated. The incidental finding rate is high and findings rarely change management. If you have any red flag features, sudden change in pattern, new neurological symptoms, or new headache onset after 50, imaging becomes more appropriate.
Yes. Cervicogenic headache is well-established. Even in migraine without cervicogenic origin, cervical dysfunction frequently contributes to severity, frequency, and treatment-resistance. Addressing the cervical contribution improves outcomes across multiple headache types.
Yes. Erenumab, fremanezumab, galcanezumab, and eptinezumab are all available. Erenumab, fremanezumab, and galcanezumab are PBS-subsidised for chronic migraine patients meeting specific criteria. Atogepant and rimegepant are also available. Discuss with a headache-aware GP or neurologist.
Most oral preventives need 8–12 weeks at therapeutic dose to demonstrate benefit. CGRP-targeted therapies often show benefit within 1–3 months. Botulinum toxin protocols are usually assessed after 2 cycles (6 months). Patience is part of the process.
Yes — both directly (through autonomic and pain pathway modulation) and indirectly (through sleep disruption, muscle tension, lifestyle changes, and medication overuse). Stress management is a legitimate clinical intervention, not a soft adjunct.
Many medications are contraindicated in pregnancy. Paracetamol is generally safe. Some triptans have favourable pregnancy data (sumatriptan in particular). CGRP-targeted therapies are not recommended in pregnancy. Lifestyle approaches, physiotherapy, and stress management become more important. Discuss specific medications with a headache-aware obstetric care provider.
Paediatric migraine is well-recognised and increasingly understood. Lifestyle medicine (sleep, hydration, regular meals, stress management, screen limits, regular exercise) is the foundation. Paracetamol and ibuprofen are first-line acute treatments. Triptans have paediatric data (rizatriptan and sumatriptan in adolescents). Preventive medications used in adults are sometimes used in children when needed. See a paediatrician or paediatric neurologist for complex cases.
If you're using paracetamol or NSAIDs 15+ days per month, or triptans/combination analgesics 10+ days per month, you may have medication overuse headache. Don't stop abruptly without medical guidance — the withdrawal period is unpleasant and benefits from a structured approach. Discuss with your GP.
Beyond the heuristic above: migraine is a complex neurological disorder with characteristic neurovascular features, often with hereditary basis, and responds to migraine-specific therapies. Tension-type headache is more about central pain processing and muscle tension. They can coexist — and the same person can have both. Accurate differentiation guides treatment.
Headache is the most common pain experience in humans. The cultural narrative for generations has been to ignore it, push through, take a Panadol, get on with life. For some people that works. For millions of others, it costs them years of quality of life, productivity, relationships, and identity.
The 2024–2026 evidence base has been transformative. CGRP-targeted therapies represent the first migraine-specific medications ever developed. The physiotherapy evidence for cervicogenic headache and post-traumatic headache is the strongest it has ever been. Exercise has been formally established as preventive medicine. Multidisciplinary care produces outcomes that no single intervention can match.
If you have headaches, you have options. If you've been told there's nothing more to be done, that's almost certainly wrong. If you've been pushing through for years, the post-2024 toolkit may transform your life.
Whenever you need allied health support, Upwell Health Collective is here. Our Camberwell team works with headache patients across every stage of their journey. To book an appointment, visit upwellhealth.com.au or call our clinic on 03 9882 6485. We bulk-bill where eligible and work with NDIS, DVA, TAC, and WorkSafe.
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A note from Team Upwell
This guide is the most comprehensive headache and migraine resource we've produced. It integrates research from 2023–2026 across every major headache type, the modern pharmacological landscape, allied health interventions, and the multidisciplinary care that transforms outcomes. We've built it to be useful to patients, family members, GPs, and clinicians — anyone touched by headache.
If you spot something we've got wrong, or if the evidence has updated since publication, please reach out. We update this guide every six months. Our next scheduled review is November 2026.
If you have headaches — there is more help available than you might believe. Find the right team. Get the right diagnosis. Try the modern toolkit. Stay hopeful.
With care,
— Team Upwell, Camberwell