Tension-Type Headache Physio in Port Dickson

Tension-type headache (TTH) gets defined by what it isn't. It isn't migraine (pulsating + unilateral + moderate-to-severe + nausea/photophobia/phonophobia + aggravated by routine activity). It isn't cluster (strictly unilateral orbital/supraorbital + autonomic features — lacrimation, rhinorrhoea, ptosis). It isn't sinister secondary headache (thunderclap, focal neuro deficit, fever + neck stiffness, post-trauma, new daily headache over 50 with scalp tenderness, papilloedema, pregnancy + hypertension + visual change). TTH is bilateral pressing / tightening, mild-to-moderate intensity, not aggravated by walking or stairs, no migraine bundle. What the Port Dickson mix adds is a triage tilt — **retirees on a cervical-OA background** dominate the PD caseload, and upper-cervical (C0–C3) joint stiffness plus sub-occipital myofascial drivers give the symptomatic handle even when imaging shows advanced degenerative change. **Tourism-sector workers** at Teluk Kemang, Admiral Marina Port Dickson, and waterfront F&B present with long-static-posture cervicogenic pattern — forward head + protracted scapula + upper-trap / levator-scapulae overload. **Port Dickson Navy families** bring younger stress-pattern TTH with masseter / temporalis overlay (clenching, bruxism). Assessment uses cranio-cervical flexion test (CCFT) with pressure biofeedback (target 26 → 30 mmHg hold), flexion-rotation test for C1–C2 (≥10° asymmetry = positive), sub-occipital / SCM / temporalis / masseter / upper-trap trigger-point palpation with referral mapping, and VOMS for vestibular-ocular overlay. Hospital Port Dickson handles acute local work-up; Columbia Asia Seremban and **Hospital Tuanku Ja'afar A&E (Accident & Emergency)** handle the red-flag pathway.

A 60-minute first assessment runs through headache history (bilateral pressing vs pulsating, intensity 1–10, duration in hours, frequency, triggers — sleep, posture, stress, caffeine, screen time), a headache diary from the last 2–4 weeks if available, medication-overuse screen (simple analgesics ≥15 days/month or triptans ≥10 days/month flags MOH — medication overuse headache), cervical spine range, cranio-cervical flexion test with pressure biofeedback, flexion-rotation test for C1–C2, trigger-point palpation (sub-occipital → SCM → temporalis → masseter → upper trap → levator scap) with referral mapping to head regions, neurological screen (cranial nerves, upper-limb myotomes / dermatomes / reflexes), VOMS if dizziness or visual provocation, TMJ screen for Navy-family clenchers, and a brief ergonomic / sleep / caffeine review. Treatment in session 1 combines gentle upper-cervical manual therapy (C0–C2 sustained natural apophyseal glides), sub-occipital release, trigger-point pressure release on the most symptomatic points, and CCFT activation work to baseline. Take-home is a 3-point program: CCFT progression (home uses a folded towel instead of pressure biofeedback), chin-tuck against wall × 10 × 3 sets, and a sub-occipital self-release (foam-roller or two tennis balls in a sock). Retirees with cervical OA get modified load dosing; tourism-sector workers get on-shift micro-breaks (30-second chin-tuck every 30 minutes); Navy-family stress-pattern patients get jaw / masseter self-release and a diaphragmatic-breathing reset. Home-visit sessions carry the same structure minus the pressure biofeedback unit.

Episodic TTH (less than 15 headache days/month) responds fastest. **Week 2**: headache diary usually shows fewer peak-intensity days even if frequency hasn't yet dropped; CCFT hold at 26 mmHg for 10 seconds × 10 reps, chin-tuck pain-free through range. **Week 4**: episodic cases often drop by 30–50% in headache-days; CCFT progresses to 28 mmHg; trigger-point density on upper trap / sub-occipital palpation noticeably lower. **Week 8**: most episodic TTH is under self-management with a maintenance program; chronic TTH (≥15 days/month for ≥3 months) is typically at 40–60% reduction. **Week 12**: chronic TTH review — if medication-overuse headache has been managed (rebound protocol, usually with GP / neurology input), if sleep has been addressed, and if the cervicogenic driver has been worked, we expect 50–70% reduction at this point; plateau below that triggers review for secondary drivers (TMJ, cervical-facet arthropathy needing interventional input, ongoing psychosocial load). **Port Dickson retirees** with cervical OA progress a step slower — we expect 6–8 weeks to match what a younger episodic TTH patient hits at 4 weeks, because the OA load adds a joint-irritability ceiling. **Tourism-sector workers** plateau if shift-posture isn't addressed at source — we build a micro-break program into the recovery plan. **Navy-family stress-pattern patients** who manage the masseter / jaw / breathing pattern well can drop faster than the overall average because the driver is more modifiable. Home exercise adherence is the single biggest predictor of the week-8 and week-12 numbers; we track it weekly.

Physiotherapy is the right first stop for TTH and for cervicogenic headache. It is not the right first stop for red-flag headache. **Thunderclap** (reaches peak intensity in under 60 seconds — think subarachnoid haemorrhage) goes directly to **Hospital Tuanku Ja'afar A&E (Accident & Emergency)** — that is the tertiary centre in Seremban, roughly 30 minutes up Jalan Seremban–Port Dickson, with CT and neurosurgical cover. **Fever + neck stiffness + headache** (meningitis pattern) — same pathway, A&E. **Focal neurological deficit** (one-sided weakness, speech change, visual field cut) — A&E for stroke work-up. **Post-trauma headache** (head injury in the last few days, especially with loss of consciousness or worsening symptoms) — A&E. **New daily headache in a patient over 50 with scalp tenderness and jaw claudication** — urgent giant-cell arteritis work-up, A&E or GP with same-day onward referral. **Pregnancy + hypertension + visual change or right-upper-quadrant pain** — pre-eclampsia pathway, straight to obstetric cover. For **acute but non-catastrophic** presentations (severe headache that is behaving atypically but not thunderclap, persistent vomiting, concerning pattern change) **Hospital Port Dickson** and **Columbia Asia Seremban** both provide closer initial assessment — Hospital Port Dickson for a local public pathway, Columbia Asia for private with faster imaging turnaround. If you are already under us and you hit any red-flag pattern, message us on the way and we will help coordinate — but do not delay A&E to see physio first. For everything else — chronic bilateral pressing, tightening, headache that tracks with posture or stress, no migraine bundle, no neurological deficit — physio assessment is the right first step.