Relationship Between Active Trigger Points and Head/Neck Posture in Patients with Migraine

Relationship of myofascial trigger points with related disability, anxiety, and depression in patients with migraine headaches

BACKGROUND

Migraine affects one in ten individuals worldwide and is the second leading cause of disability. Studies have shown an association between migraine and the musculoskeletal system, and myofascial trigger points (MTrPs) play an essential role. Additionally, those with myofascial pain have been proven to experience higher levels of depression and anxiety. Understanding the association between MTrPs and migraine is crucial for developing targeted treatment strategies. Additionally, recognizing the link between MTrPs and migraine-related depression and anxiety underscores the importance of a holistic approach to migraine management. By addressing both musculoskeletal and neurological factors, healthcare providers can provide more effective and personalized care for migraine patients. This study aims to determine the association between MTrPs with migraine-related disability, anxiety, depression, and migraine characteristics.

METHODS

This cross-sectional study included 68 migraine patients from an outpatient neurology clinic. The number of MTrPs was determined through examination by an experienced neurologist during a migraine-free period using the recommended international criteria. We evaluated anxiety and depression with the Hospital Anxiety and Depression Scale (HADS) and disability with the Migraine Disability Assessment Scale (MIDAS).

RESULTS

We enrolled 68 patients (22 males) with a mean age of 36.23 ± 9.63 years. The mean number of MTrPs was 2.75 ± 2.934. MTrPs were positively correlated with severity (CC: 0.576, P-value < 0.001). There was no association between MTrPs and HADS-D or MIDAS, but migraine patients with abnormal HADS-A scores had more MTrPs than patients with normal HADS-A scores (0.6 ± 0.84 vs 3.56 ± 3.11, P-value:0.013).

CONCLUSIONS

The number of MTrPs is associated with higher anxiety levels and headache intensity. Further research could investigate the impact of MTrP-based therapies on anxiety among individuals suffering from migraines.

The effect of simultaneous administration of occipital nerve block and cervical myofascial trigger point injection (MTrPI) on headache parameters in chronic migraine patients

BACKGROUND AND AIM

Peripheral myofascial mechanisms have been identified as contributors to migraine pathophysiology. The specific comorbid relationship between migraine and cervical trigger points may exacerbate the occurrence and severity of migraine attacks. Trigger point injections (TPIs) are frequently employed to address headaches and alleviate migraine symptoms. The current study explores the impact of concurrent myofascial trigger point injection (MTrPI) and occipital nerve block (greater occipital nerve block [GONB] + lesser occipital nerve block [LONB]) on the severity of headaches and the number of migraine attacks in individuals with chronic migraine (CM) and cervical myofascial trigger points (MTrPs), with a comparison of occipital nerve block alone (GONB + LONB). During trigger point examination and injection, trapezius, levator scapulae, splenius capitis, temporalis, and sternocleidomastoid muscles were targeted. We planned the treatment based on whether they were in the muscle groups we determined, rather than the number of trigger points.

MATERIALS AND METHOD

This study enrolled 62 individuals experiencing CM with bilateral headache and cervical MTrP who sought care at the Algology Unit within the Departments of Neurology and Physical Therapy and Rehabilitation at Siirt Training and Research Hospital between 2020 and 2022. The CM cohort was stratified into two groups: group 1 received trigger point injections (TrPI), while group 2 underwent concurrent bilateral occipital nerve block (GONB + LONB) and TrPI. Both groups underwent three treatment sessions with bupivacaine 0.5% (1 ml = 5 mg) in weeks 1, 2, and 4. Visual analog scale (VAS) was used to measure the patients' pain intensity. The evaluation included the assessment of the monthly migraine frequency and visual analog scale (VAS) p score for pain before treatment (BT) and after treatment (AT), conducted at baseline and during follow-up visits. Analysis of the data was conducted utilizing IBM SPSS Statistics for Windows version 28.0 software.

RESULTS

Among patients diagnosed with CM and MTrPs, 32 individuals (51.6%) underwent GONB and LONB, while 30 patients (48.4%) received simultaneous GONB, LONB, and cervical MTrPI. Within the entire sample, 51 participants (82.3%) were female, and 11 (17.7%) were male, with a mean age of 32.81 ± 10.75 years. With an average age of 32.81 ± 10.75 years, there was no statistically significant variance between the two groups (p = 0.516). Of the total cohort, 45 individuals (72.6%) reported experiencing headaches persisting for 12 months or longer. Among CM patients, 80% had active trigger points, while 20% had latent trigger points. No statistically significant difference was observed between the groups concerning TrPs (p = 0.158), and the distribution of TrPs was homogenous across the two groups. In group 1, the median (min-max) monthly frequency of migraines reduced from 18.5 days (range: 15.0 to 25.0 days) before treatment to 12.0 days (range: 7.0 to 17.0 days) after treatment (p = 0.000). In group 2, the median monthly frequency of migraines reduced from 16.5 days (range: 15.0 to 22.0 days) before treatment to 4.0 days (range: 2.0 to 8.0 days) after treatment (p = 0.000). The median (min-max) VAS score in group 1 was 8.0 (range: 5.0 to 9.0) before treatment, 4.0 (range: 2.0 to 6.0) at week 1, and 5.0 (range: 4.0 to 8.0) at week 4 (p = 0.000). In group 2, the median VAS score was 7.0 (range: 5.0 to 9.0) before treatment, 0.0 (range: 0.0 to 0.3) at week 1, and 2.0 (range: 0.0 to 0.3) at week 4 (p = 0.000). There were significant distinctions between the groups in terms of both the monthly count of migraine days and the severity of headaches (p = 0.000).

CONCLUSION

The combination of repeated MTrPIs and ONB proves more effective than ONB alone in managing patients with CM and cervical MTrP. In patients with CM, performing TrPs examination and adding treatments for this may contribute to the treatment. In cases where patients endure prolonged episodes of headache associated with chronic migraine, the inclusion of trigger point injections alongside peripheral nerve blocks may offer enhanced therapeutic benefits.

High Medial Longitudinal Arch of the Foot and Latent Trigger Points in Lower Limb Muscles

Background: The objective was to evaluate the prevalence of latent trigger points (LTrPs) in lower limb muscles in participants with a high medial longitudinal arch (MLA) of the foot compared to controls. Methods: Participants with a navicular drop test of 4-9 mm were included in the control group; the high MLA group included navicular drop test values of ≤4 mm. The presence of LTrPs was assessed by palpation techniques. The muscles evaluated were medial gastrocnemius (LTrP1), lateral gastrocnemius (LTrP2), soleus (LTrP1), peroneus longus, peroneus brevis, tibialis anterior, extensor digitorum longus, flexor digitorum longus, rectus femoris, vastus medialis (LTrP1 and LTrP2), and the vastus lateralis of the quadriceps (LTrP1 and LTrP2). Results: Thirty-seven participants with high MLA and thirty-seven controls were included in the study. Twenty-nine (78.4%) participants in the high MLA group had at least 1 LTrP, compared to twenty-three (62.2%) in the control group. No statistical difference (p < 0.05) was found in the total number of LTrPs between groups (4.46 ± 3.78 vs. 3.24 ± 3.85). There were more participants (p < 0.05) with LTrPs in the tibialis anterior, extensor digitorum longus, and vastus lateralis (LTrP1 and LTrP2) in the high MLA group than in the control group. Conclusion: Although no differences were found in the number of total LTrPs between groups, the prevalence was statistically significantly higher in the tibialis anterior, extensor digitorum longus, and vastus lateralis of the participants with high MLA of the foot.

Is painful temporomandibular disorder a real headache for many patients?

Temporomandibular disorders (TMDs) and primary headaches are common pain conditions and often co-exist. TMD classification includes the term 'headache secondary to TMD' but this term does not acknowledge the likelihood that primary headache pathophysiology underpins headache causing painful TMD signs and symptoms in many patients. The two disorders have a complex link and we do not fully understand their interrelationship. However, growing evidence shows a significant association between the two disorders. This article reviews the possible connection between temporomandibular disorders and primary headaches, specifically migraine, both anatomically and pathogenetically.

Neck pain repercussions in migraine - The role of physiotherapy

INTRODUCTION

Migraine is a neurological and disabling disease whose peripheral manifestations can be addressed with physiotherapy. These manifestations can include pain and hypersensitivity to muscular and articular palpation in the neck and face region, a higher prevalence of myofascial trigger points, limitation in global cervical motion, especially in the upper segment (C1-C2), and forward head posture with worse muscular performance. Furthermore, patients with migraine can present cervical muscle weakness and greater co-activation of antagonists in maximum and submaximal tasks. In addition to musculoskeletal repercussions, these patients can also present balance impairment and a greater risk of falls, especially when chronicity of migraine frequency is present. The physiotherapist is a relevant player in the interdisciplinary team and can help these patients to control and manage their migraine attacks.

PURPOSE

This position paper discusses the most relevant musculoskeletal repercussions of migraine in the craniocervical area under the perspective of sensitization and disease chronification, besides addressing physiotherapy as an important strategy for evaluating and treating these patients.

IMPLICATIONS

Physiotherapy as a non-pharmacological treatment option in migraine treatment may potentially reduce musculoskeletal impairments related to neck pain in this population. Disseminating knowledge about the different types of headaches and the diagnostic criteria can support physiotherapists who compose a specialized interdisciplinary team. Furthermore, it is important to acquire competencies in neck pain assessment and treatment approaches according to the current evidence.

Cervical musculoskeletal impairments in the 4 phases of the migraine cycle in episodic migraine patients

OBJECTIVE

To assess cervical musculoskeletal impairments during the 4 phases of a migraine cycle in episodic migraine patients, controlling for the presence of concomitant neck pain.

METHODS

Differences in cervical musculoskeletal impairments were assessed during the 4 migraine phases in episodic migraine patients and compared with healthy controls controlling for concomitant neck pain. Cervical musculoskeletal impairments were assessed as follow: cervical active range of motion; flexion rotation test; craniocervical flexion test and calculation of activation pressure score; the total number of myofascial trigger points in head/neck muscles; the number of positivevertebral segments (headache's reproduction) during passive accessory intervertebral movement; pressure pain thresholds over C1, C2, C4, C6 vertebral segments bilaterally, trigeminal area, hand, and leg. Signs of pain sensitization were assessed by evaluating mechanical pain threshold over trigeminal area and hand, pressure pain thresholds, and the wind-up ratio. The Bonferroni-corrected p-value (05/4 = 0.013) was adopted to assess the difference between groups, while a p-value of 0.05 was considered significant for the correlation analysis.

RESULTS

A total of 159 patients and 52 controls were included. Flexion rotation test and craniocervical flexion test were reduced in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). The number of myofascial trigger points and positive vertebral segments was increased in all 4 phases of the migraine cycle versus healthy controls (p < 0.001). Flexion, extension, and total cervical active range of motion and cervical pressure pain thresholds were reduced in episodic migraine in the ictal phase versus controls (p < 0.007) with no other significant differences. Outside the ictal phase, the total cervical active range of motion was positively correlated with trigeminal and leg pressure pain threshold (p < 0.026), the number of active myofascial trigger points and positive positive vertebral segments were positively correlated with higher headache frequency (p=0.045), longer headache duration (p < 0.008), and with headache-related disability (p = 0.031). Cervical pressure pain thresholds were positively correlated with trigeminal, hand, and leg pressure pain threshold (p < 0.001), and trigeminal and leg mechanical pain thresholds (p < 0.005), and negatively correlated with the wind-up ratio (p < 0.004).

CONCLUSION

In all phases of the migraine cycle, independent of the presence of concomitant neck pain, episodic migraine patients showed reduced flexion rotation test and craniocervical flexion test and an increased number of myofascial trigger points and passive accessory vertebral segments. These impairments are correlated with enhanced headache duration, headache-related disability, and signs of widespread pain sensitization. Reduction in active cervical movement and increased mechanical hyperalgesia of the cervical was consistent in ictal episodic migraine patients and the subgroups of episodic migraine patients with more pronounced widespread sensitization.

Neck and back muscle chains hypomobility in women with migraine

OBJECTIVE

To compare the mobility of neck and back flexor and extensor muscle chains in women with migraine, chronic migraine and headache-free.

METHODS

This is a cross-sectional study. The muscle chain test was performed based on the theoretical assumptions of the Busquet method, in women with migraine (MG, n = 24), chronic migraine (CMG, n = 36) and headache-free (CG, n = 27). The evaluation of neck and back mobility was performed by an examiner expert in the Busquet method with the aid of cervical range of motion (CROM®) device (neck muscles) and the Tiltmeter® application (back muscles).

RESULTS

Compared to woman headache-free, women with migraine (MD = -12° [CI95% = -19°, -5°] and chronic migraine (MD = -15° [CI95% = -21°, -8°] present reduced mobility in the neck extensor muscle chain. Also, in the back extensor muscle chain, migraine vs headache-free (MD = -9° [CI95% = -15°, -2°]) and chronic migraine vs headache-free (MD = -10° [CI95% = -16°, -4°]) and in the back flexor muscle chain, migraine vs headache-free (MD = -6° [CI95% = -10°, -0.1°]) and chronic migraine vs headache-free (MD = -7 [CI95% = -11°, -2°]), with an effect sizes varying between 1.19 e 2.38. No difference was found between groups for neck flexor muscle chain.

CONCLUSION

Women with migraine and chronic migraine have hypomobility of the neck and back extensor muscle chains, and of the back flexor chain.

Is it possible to sort the disability of individuals with migraine based on the International Classification of Functioning, Disability and Health? — A Scoping Review

PurposeTo identify the most frequent outcomes related to disability assessed in individuals with migraine and to correlate these findings with the categories of International Classification of Functioning, Disability and Health.Material and methodThis scoping review was developed based on studies with adult population (18-55 years) of both sexes and assessing the disability generated by migraine. We included studies in which patients had a diagnosis of migraine based on International Classification of Headache Disorders.Results52 articles were found with 42 outcomes related to 17 categories of International Classification of Functioning, Disability and Health, including the four main components of the classification, with seven categories in "Body Functions", one in "Body Structures", four in “Activities and Participation” and five in "Environmental Factors".ConclusionThe findings show that disabilities, activity limitation, or participation restriction generated by migraine can be classified by International Classification of Functioning, Disability and Health. The components "body functions", "environmental factors" and "activities and participation" were the most identified in the present study. Thus, this classification is important to classify the disability caused by migraine and to guide a rehabilitation more focused onthe patient's real demands, as well as directing the research involving this population.

Surgeon Strength: Ergonomics and Strength Training in Cardiothoracic Surgery

With the high prevalence of musculoskeletal pain in surgeons and interventionalists, it is critical to analyze the impact of ergonomics on cardiothoracic surgeon health. Here, we review the existing literature and propose recommendations to improve physical preparedness for surgery both in and outside the operating room. For decades, cardiothoracic surgeons have suffered from musculoskeletal pain, most commonly in the neck, and back due to a lack of proper ergonomics during surgery. A lack of dedicated ergonomics curriculum during training may leave surgeons at a high predisposition for work-related musculoskeletal disorders. We searched PubMed, Google Scholar, and other sources for studies relevant to surgical ergonomics and prevalence of musculoskeletal disease among surgeons and interventionalists. Whenever possible, data from quantitative studies, and meta-analyses are presented. We also contacted experts and propose an exercise routine to improve physical preparedness for demands of surgery. To date, many studies have reported astonishingly high rates of work-related pain in surgeons with rates as high as 87% in minimally-invasive surgeons. Several optimizations regarding correct table height, monitor positioning, and loupe angles have been discussed. Lastly, implementation of ergonomics training at some programs have been effective at reducing the rates of musculoskeletal pain among surgeons. Surgical work-related stress injuries are more common than we think. Many factors including smaller incisions and technological advancements have led to this plight. Ultimately, work-related injuries are underreported and understudied and the field of surgical ergonomics remains open for investigative study.

Instrumental assessment of physiotherapy and onabolulinumtoxin-A on cervical and headache parameters in chronic migraine

Introduction

The purpose of the present study is to compare the effect of the physiotherapy to onabolulinumtoxin-A, and their combination, in relation to cervical and headache parameters in patients with chronic migraine.

Methods

This is an observational cohort study conducted by a headache center and a physiotherapy degree course on 30 patients with chronic migraine. The patients were distributed in three groups of treatments for three months: onabolulinumtoxin-A only, physiotherapy only, and onabolulinumtoxin-A plus physiotherapy. The patients were evaluated, before and after each treatment, using the following: the postural assessment software SAPO for the forward head posture; the CROM goniometer for the cervical range of motion; the Migraine Disability Assessment Score for headache parameters.

Results

After 3 months of each treatment, the scores obtained for the headache-related disability and the frequency of migraine decreased significantly for all groups, but the pain intensity scores changed significantly only in the onabolulinumtoxin-A (p = 0.01) and in the onabolulinumtoxin-A plus physiotherapy groups (p = 0.007). On the other hand, the forward head posture was reduced significantly in the physiotherapy (p = 0.002) and in the onabolulinumtoxin-A plus physiotherapy groups (p = 0.003). The cervical range of motion increased significantly in certain directions in the physiotherapy group and in the onabolulinumtoxin-A plus physiotherapy groups.

Conclusions

The physiotherapy improved the cervical parameters. The onabolulinumtoxin-A decreased pain intensity. As a consequence, it can be said that the combined treatment was more useful than a mono-therapy alone. From our results, it can be concluded that onabolulinumtoxin-A plus physiotherapy could be a good option in the management of chronic migraine.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-021-05491-w.

Influence of clinical experience on accuracy and safety of obliquus capitus inferior dry needling in unembalmed cadavers

Background: Suboccipital myofascial trigger points are common in tension-type headaches.Objectives: Compare the influence of clinical experience on the accuracy and safety of dry needle placement on the C2 laminar arch using a cranial-medial and caudal-medial technique to target obliquus capitus inferior in unembalmed cadavers.Methods: Three physical therapists inserted three 50 mm dry needles, per technique, individually toward the C2 laminar arch targeting the obliquus capitus inferior. Ultrasound video of each trial was recorded, and an investigator trained in ultrasound interpretation and blinded to experience level recorded needling accuracy.Results: The novice, experienced and expert clinicians were accurate on 73.8%, 59.5% and 71.4% of caudal-medial trials, and 14.3%, 16.7% and 66.7% of cranial-medial trials, respectively, with each clinician striking the spinal cord at least once. The expert clinician was 10 times more likely to accurately reach the C2 laminar arch using the cranial-medial direction than the experienced and novice clinicians.Conclusion: Increased clinical experience improved accuracy reaching the C2 laminar arch, with all investigators being more accurate with the caudal-medial technique. Greater experience did not eliminate risk as all investigators recorded at least one incident of striking the spinal cord. Fewer spinal cord strikes occurred with the cranial-medial than the caudal-medial technique.

Neck associated factors related to migraine in adolescents with painful temporomandibular disorders

OBJECTIVE

Migraine is a comorbidity of painful temporomandibular disorders (TMDs). Both migraine and painful TMD have associations with neck pain and head posture. The aim of this study was to clarify the role of neck pain and head posture on the association between migraine and painful TMD in adolescents.

MATERIALS AND METHOD

In total 314 adolescents were included: 235 adolescents with only painful TMD (pTMD) and 79 adolescents with painful TMD and migraine (TMDMIG). Adolescents were diagnosed according to the Research Diagnostic Criteria for Temporomandibular Disorders and International Classification of Headache Disorders, 3rd edition. Head postures were identified using lateral cephalograms. Myofascial trigger points (TrPs) were evaluated in the temporalis, masseter, trapezius, sternocleidomastoid, sub-occipitalis, and splenius capitis muscles.

RESULTS

Multivariate logistic regression analysis confirmed the associations among the orofacial pain duration, number of active TrPs in the trapezius muscles, intensity of neck pain, and distance between the occiput and atlas and migraine in adolescents with TMD. The relationships among intensity of neck pain, number of TrPs in the cervical muscles, and head posture were more prominent in the TMDMIG than those in the pTMD.

CONCLUSION

Neck associated factors seemed to have relevance with migraine in adolescents with painful TMD.

Involvement of cervical disability in migraine: a literature review

Background

The trigeminal nerve theory has been proposed as a pathophysiological mechanism of migraine; however, its association with the triggers of migraine remains unclear. Cervical disability such as neck pain and restricted cervical rotation, have been associated with not only cervicogenic headaches but also migraine. The presence of cervical disability could worsen of the migraine, and also the response to pharmacologic treatment may be reduced. The aim in this review is to highlight the involvement of cervical disability in migraine, considering contributing factors.

Findings

In recent years, evidence of neck pain complaints in migraine has been increasing. In addition, there is some recent evidence of cervical musculoskeletal impairments in migraine, as detected by physical assessment. However, the main question of whether neck pain or an associated cervical disability can act as an initial factor leading to migraine attacks still remains. Daily life imposes heavy loads on cervical structures (i.e. muscles, joints and ligaments), for instance, in the forward head position. The repetitive nociceptive stimulation initiating those cervical skeletal muscle positions may amplify the susceptibility to central migraine and contribute to chronicity via the trigeminal cervical complex.

Conclusion

Further studies are needed to explain the association between cervical disability as a source of pain and the development of migraine. However, evidence suggests that cervical disability needs to be considered in the prevention and treatment of migraine.

Instrument-assisted soft tissue mobilisation versus stripping massage for upper trapezius myofascial trigger points

Objective

This study investigated the effects of instrument-assisted soft tissue mobilisation (IASTM) versus stripping massage (SM) on myofascial trigger points in the right upper trapezius.

Method

Forty patients (34 women and 6 men), aged 18–23 years, with active trigger points in the right upper trapezius were divided into two equal groups (A and B). Group A (n = 20) received IASTM using an M2T blade twice a week for four weeks in addition to stretching exercise. Group B (n = 20) received SM twice a week for four weeks in addition to stretching exercise. The visual analogue scale, a pressure algometer, and the Arabic version of the Neck Disability Index were used to evaluate patients' pre- and post-treatment statuses.

Results

Within-group analysis showed significant differences between pre- and post-treatment values of all outcome measures in both groups. In contrast, between-group analysis did not show any significant differences between the two groups in pre- or post-treatment values of any outcome measures.

Conclusion

IASTM and SM are effective methods for improving pain and function in patients with upper trapezius trigger points.

Repetitive Peripheral Magnetic Stimulation (rPMS) in Subjects With Migraine-Setup Presentation and Effects on Skeletal Musculature

Purpose: Repetitive peripheral magnetic stimulation (rPMS) has been successfully applied recently in migraineurs to alleviate migraine symptoms. Symptom relief has been achieved by stimulating myofascial trigger points (mTrPs) of the trapezius muscles, which are considered part of the trigemino-cervical complex (TCC). However, effects on musculature have not been assessed in detail, and the specificity of effects to muscles considered part of the TCC yet has to be elucidated. Against this background, this study presents the setup of rPMS in migraine and evaluates effects on skeletal musculature. Materials and Methods: Thirty-seven adults (mean age: 25.0 ± 4.1 years, 36 females) suffering from migraine and presenting mTrPs according to physical examination underwent rPMS either to mTrPs in the trapezius muscles (considered part of the TCC; n = 19) or deltoid muscles (considered not part of the TCC; n = 18) during six sessions over the course of 2 weeks. Standardized questionnaires were filled in to assess any adverse events and experience with rPMS as well as satisfaction and benefits from stimulation. Algometry was performed to evaluate changes in pressure pain thresholds (PPTs). Results: All stimulation sessions were successfully performed without adverse events, with 84.2% of subjects of the trapezius group and 94.4% of subjects of the deltoid group describing rPMS as comfortable (p = 0.736). Muscular pain or tension improved in 73.7% of subjects of the trapezius group and in 61.1% of subjects of the deltoid group (p = 0.077). PPTs of the trapezius muscles clearly increased from the first to the last stimulation sessions-regardless of the stimulated muscle (rPMS to the trapezius or deltoid muscles). However, depending on the examined muscles the increase of PPTs differed significantly (subjects with stimulation of trapezius muscles: p = 0.021; subjects with stimulation of deltoid muscles: p = 0.080). Conclusion: rPMS is a comfortable method in migraineurs that can improve local muscular pain or tension. Furthermore, it is able to increase directly and indirectly the PPTs of the trapezius muscles (considered part of the TCC) when applied over mTrPs, supporting the role of the TCC in migraineurs.

Influence of Forward Head Posture on Myotonometric Measurements of Superficial Neck Muscle Tone, Elasticity, and Stiffness in Asymptomatic Individuals With Sedentary Jobs

OBJECTIVE

The objective of the study was to assess the influence of forward head posture on the mechanical parameters and pressure pain threshold of superficial neck muscles in clinically nonsymptomatic individuals with sedentary jobs.

METHODS

Twenty-five office workers with forward head posture and 25 office workers with normal head posture were matched for sex, age, body mass index, and the nature and duration of their work and were compared at a single point. The study participants were divided into study groups on the basis of photometric craniovertebral angle measurements. The upper trapezius, sternocleidomastoid, and splenius capitis mechanical properties were assessed in the sitting position. Primary outcome measures were muscle stiffness (N/m), muscle tone (Hz), and muscle elasticity. The secondary variable was perceived pain threshold.

RESULTS

No significant differences between the groups were found for biomechanical properties and perceived pain threshold in the studied muscles.

CONCLUSION

Forward head posture has no impact on muscle stiffness, tone, and elasticity, nor does it increase the pressure sensitivity of superficial neck muscles in healthy, mildly symptomatic office workers. It is most likely that not incorrect posture of the cervical spine, but probably other factors combined with forward head posture, like comorbid acute and chronic cervical pain and musculoskeletal disorders or prolonged sitting, contribute to changes in active myofascial tone and tensegrity as well as increased pressure sensitivity of neck muscles.

Quantitative magnetic resonance imaging of the upper trapezius muscles - assessment of myofascial trigger points in patients with migraine

Background

Research in migraine points towards central-peripheral complexity with a widespread pattern of structures involved. Migraine-associated neck and shoulder muscle pain has clinically been conceptualized as myofascial trigger points (mTrPs). However, concepts remain controversial, and the identification of mTrPs is mostly restricted to manual palpation in clinical routine. This study investigates a more objective, quantitative assessment of mTrPs by means of magnetic resonance imaging (MRI) with T2 mapping.

Methods

Ten subjects (nine females, 25.6 ± 5.2 years) with a diagnosis of migraine according to ICHD-3 underwent bilateral manual palpation of the upper trapezius muscles to localize mTrPs. Capsules were attached to the skin adjacent to the palpated mTrPs for marking. MRI of the neck and shoulder region was performed at 3 T, including a T2-prepared, three-dimensional (3D) turbo spin echo (TSE) sequence. The T2-prepared 3D TSE sequence was used to generate T2 maps, followed by manual placement of regions of interest (ROIs) covering the trapezius muscles of both sides and signal alterations attributable to mTrPs.

Results

The trapezius muscles showed an average T2 value of 27.7 ± 1.4 ms for the right and an average T2 value of 28.7 ± 1.0 ms for the left side (p = 0.1055). Concerning signal alterations in T2 maps attributed to mTrPs, nine values were obtained for the right (32.3 ± 2.5 ms) and left side (33.0 ± 1.5 ms), respectively (p = 0.0781). When comparing the T2 values of the trapezius muscles to the T2 values extracted from the signal alterations attributed to the mTrPs of the ipsilateral side, we observed a statistically significant difference (p = 0.0039). T2 hyperintensities according to visual image inspection were only reported in four subjects for the right and in two subjects for the left side.

Conclusions

Our approach enables the identification of mTrPs and their quantification in terms of T2 mapping even in the absence of qualitative signal alterations. Thus, it (1) might potentially challenge the current gold-standard method of physical examination of mTrPs, (2) could allow for more targeted and objectively verifiable interventions, and (3) could add valuable models to understand better central-peripheral mechanisms in migraine.

Myofascial trigger points in migraine and tension-type headache

BACKGROUND

A myofascial trigger point is defined as a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. It has been suggested that myofascial trigger points take part in chronic pain conditions including primary headache disorders. The aim of this narrative review is to present an overview of the current imaging modalities used for the detection of myofascial trigger points and to review studies of myofascial trigger points in migraine and tension-type headache.

FINDINGS

Different modalities have been used to assess myofascial trigger points including ultrasound, microdialysis, electromyography, infrared thermography, and magnetic resonance imaging. Ultrasound is the most promising of these modalities and may be used to identify MTrPs if specific methods are used, but there is no precise description of a gold standard using these techniques, and they have yet to be evaluated in headache patients. Active myofascial trigger points are prevalent in migraine patients. Manual palpation can trigger migraine attacks. All intervention studies aiming at trigger points are positive, but this needs to be further verified in placebo-controlled environments. These findings may imply a causal bottom-up association, but studies of migraine patients with comorbid fibromyalgia syndrome suggest otherwise. Whether myofascial trigger points contribute to an increased migraine burden in terms of frequency and intensity is unclear. Active myofascial trigger points are prevalent in tension-type headache coherent with the hypothesis that peripheral mechanisms are involved in the pathophysiology of this headache disorder. Active myofascial trigger points in pericranial muscles in tension-type headache patients are correlated with generalized lower pain pressure thresholds indicating they may contribute to a central sensitization. However, the number of active myofascial trigger points is higher in adults compared with adolescents regardless of no significant association with headache parameters. This suggests myofascial trigger points are accumulated over time as a consequence of TTH rather than contributing to the pathophysiology.

CONCLUSIONS

Myofascial trigger points are prevalent in both migraine and tension-type headache, but the role they play in the pathophysiology of each disorder and to which degree is unclarified. In the future, ultrasound elastography may be an acceptable diagnostic test.

Altered muscle activity during rest and during mental or physical activity is not a trait symptom of migraine - a neck muscle EMG study

BACKGROUND

Migraineurs have a high prevalence of neck pain prior to or during headache attacks. Whether neck pain is a symptom of migraine or an indicator for a constant neck muscle dysfunction potentially triggering migraine attacks is a topic of scientific debate. The presence of myofascial trigger points in neck muscles including the trapezius muscle, points towards muscle alterations associated with migraine. We measured electromyography (EMG) of the neck muscles in a large cohort to identify whether neck pain and neckmuscle tension reported by migraine patients can be attributed to increased neck muscle activation during rest, mental stress or physical activity.

METHODS

Surface EMG responses of the trapezius muscle were recorded during a paradigm including rest periods, mental stress and physical activity of 102 participants (31 chronic migraine, 43 episodic migraine, 28 healthy participants).

RESULTS

All groups showed increased trapezius activity during mental stress and physical activity compared to rest. There was no statistically significant difference between migraine patients and healthy controls for any of the 3 conditions except for the initial mental stress situation (F (2,56.022) = 8.302, p = 0.001), where controls increased tension by only 4.75%, episodic migraineurs by 17.39% and chronic migraineurs by 28.61%. Both migraine groups returned to resting EMG levels within the same timeframe as healthy controls.

CONCLUSIONS

Neck pain associated with migraine can therefore not be attributed to increased trapezius activity during rest, mental stress and physical activity or prolonged muscle activity and should not be seen as a constantly underlying trigger but rather as an accompanying symptom of migraine.

Prediction models of health-related quality of life in different neck pain conditions: a cross-sectional study

PURPOSE

The main aim of the study was to predict the health-related quality of life (HRQoL) based on physical, functional, and psychological measures in patients with different types of neck pain (NP).

MATERIALS AND METHODS

This cross-sectional study included 202 patients from a primary health center and the physiotherapy outpatient department of a hospital. Patients were divided into four groups according to their NP characteristics: chronic (CNP), acute whiplash (WHIP), chronic NP associated with temporomandibular dysfunction (NP-TMD), or chronic NP associated with chronic primary headache (NP-PH). The following measures were performed: Short Form-12 Health Survey (SF-12), Neck Disability Index (NDI), visual analog scale (VAS), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BECK), and cervical range of movement (CROM).

RESULTS

The regression models based on the SF-12 total HRQoL for CNP and NP-TMD groups showed that only NDI was a significant predictor of the worst HRQoL (48.9% and 48.4% of the variance, respectively). In the WHIP group, the regression model showed that BECK was the only significant predictor variable for the worst HRQoL (31.7% of the variance). Finally, in the NP-PH group, the regression showed that the BECK, STAI, and VAS model predicted the worst HRQoL (75.1% of the variance).

CONCLUSION

Chronic nonspecific NP and chronic NP associated with temporomandibular dysfunction were the main predictors of neck disability. In addition, depression, anxiety, and pain were the main predictors of WHIP or primary headache associated with CNP.

Stratifying migraine patients based on dynamic pain provocation over the upper cervical spine

Background

Migraine patients usually report a high prevalence of neck pain preceding or during the migraine attack. A recent investigation of musculoskeletal dysfunctions in migraine patients concluded that neck pain is not simply a symptom of the migraine attack but corresponds to identifiable muscle and joint alterations. Particularly pain provocation using palpation of the joints in the upper cervical spine was significantly more prevalent in patients with migraine than in headache-free participants.

Methods

One hundred seventy-nine migraineurs (diagnosed according to IHS classification criteria version III beta) and 73 age- and gender-matched healthy controls were examined by a physiotherapist blinded towards the diagnosis, using a palpation technique over the upper cervical spine. The palpation combined oscillating movements and sustained pressure.

Findings

Using simple palpation of the upper cervical spine, migraine patients can be stratified into three groups: painfree (11%), local pain only (42%), and pain referred to the head during sustained pressure (47%). Combining both test components (palpation and sustained pressure) has a high sensitivity and specificity for migraine.

Conclusions

The response to palpation of the upper cervical spine may indicate migraine subtypes. The presence of musculoskeletal dysfunctions of the upper cervical spine should be identified and treated to avoid ongoing nociceptive input into the trigeminocervical complex.

Trial registration

German Clinical Trial Register DRKS-ID: DRKS00009622.

[Migraine prophylaxis with trigger point therapy and lymphatic drainage : A pilot study]

Migraine is a complex, multifactorial, neurovascular disorder of the brain. Patients frequently have pericranial trigger points, but trigger point (TP) therapy for migraine has not yet been adequately studied. In contrast, lymphatic drainage (LD) has been studied in patients with migraine. The multifactorial origin of migraine suggests using a combination of approaches such as TP therapy and lymphatic drainage. The present study evaluated the effectiveness of TP therapy alone and in combination with LD in preventing migraine during treatment period and over an 8‑week period after completion of treatment. A wait list control group served as a control group. Patients completed a headache calendar. The results of this pilot study suggest a beneficial effect for TP alone and TP combined with LD for migraine prophylaxis for 8 weeks after completion of treatment.