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Table 1 Migraine and myofascial trigger points

From: Myofascial trigger points in migraine and tension-type headache

First author (year) Blinding Participants Mean age (range) Gender Timing of recordings Methods Muscles Main findings
Calandre (2006) [45] None 8 EMA
55 EMO
35 CMO
32 CTRLs
(18 (56%) of these reported infrequent TTH)
38.5 ± 13.5 (15–75)
41.4 ± 16.8 (21–83)
9 M, 79F
13 M, 19F
Interictally MTrP diagnosis by manual palpation with a pressure by no more than 4 kg.
The number and location of trigger points in each patient were recorded.
Frontal, temporal, and superior trapezius muscles and suboccipital and occipital area • 93.9% migraine patients reported referred pain.
• The number of MTrPs correlated with frequency and duration of migraine attacks.
Fernández-de-Las-Peñas (2006) [46] Examiner blinded to diagnosis 5 EMA
15 EMO
20 CTRLs
33 ± 10 (17–57)
30 ± 8 (19–55)
7 M, 13F
8 M, 12F
Interictally MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89]
FHP was documented in relaxed standing position and relaxed sitting position.
Neck mobility was assessed.
Upper trapezius, sternocleidomastoid, temporalis, and subocciptal muscles • Active MTrPs were only found in the migraine patients.
• Active MTrPs were primarily located ipsilateral to the migraine headaches except for the suboccipital region.
• Migraine patients have a greater FHP and less neck motility in extension and flexion-extension compared to controls.
Ferracini (2017) [47] Examiner blinded to diagnosis 98 EM
45 CM
With or without aura not reported.
37 ± 12 (18–60)
38 ± 12 (18–60)
143F Interictally MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89]
The Migraine Disability Assessment Scale (MIDAS) questionnaire was used.
Temporalis, masseter, suboccipital, sternocleidomastoid, upper trapezius and splenius capitis • No significant difference was in the total number of MTrPs between the two groups.
• Active MTrPs in the temporalis and masseter muscle were most prevalent in both groups.
• The number of MTrPs did not correlate with migraine related disability nor migraine features.
Ferracini (2016) [48] None 50 EM
With or without aura not reported.
34.1 (18–55) 5 M, 45F Interictally: 46%
Ictally: 54%
MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89]
Eight measures of head and neck posture were obtained by radiograph and different angles were defined.
Temporalis, masseter, suboccipital, sternocleidomastoid,, upper trapezius, and splenius capitis • Individuals with migraine showed MTrPs in all the muscles.
• Active MTrPs was positively associated with a reduction in cervical lordosis and head extension of the head on the neck.
• No association between the number of active MTrPs and clinical features of migraine was observed.
Florencio (2017) [49] None 70 EMO 42 ± 12 (39–45) 70F Interictally MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89]
Surface EMG was recorded from superficial flexor and extensor muscles bilaterally as subjects performed a staged task of cranio-cervical flexion. The average Root Mean Square (RMS) was calculated from each 10 s contraction.
Sternocleidomastoid, upper trapezius and splenius capitis • All patients exhibited active MTrPs in their cervical muscles
• Participants with active MTrPs in the included muscles had lower normalized RMS in their superficial neck flexors
• Subjects with active MTrPs in the splenius capitis and upper trapezius had higher normalized RMS values in the splenius capitis.
Gandolfi (2017) [50] Single-blind 22 CM patients receiving onabotulinumtoxinA treatment
Patients were divided into two groups:
12 individuals receiving manipulative treatment
10 individuals receiving electrical stimulation (placebo group)
With or without aura not reported.
45.8 ± 14.1
(18–66)
50.2 ± 6.2
(40–61)
3 M, 19F
2 M, 10F
1 M, 9F
Not reported Patients were randomly assigned to receive either manipulative treatment (treatment aimed at improving mobility and reducing stiffness in the cervicothoracic spine) or transcutaneous electrical nerve stimulation in the upper trapezius.
Treatment consisted of 4 sessions (30 min once a week in 4 weeks)
Patients were asked to keep a headache diary: outcomes were evaluated before treatment, during treatment, and 1 month after the end of treatment.
Cervical active range of motion and trigger point sensitivity were measured pre- and posttreatment. MTrP sensitivity was assessed by measuring PPT using an algometer.
Frontalis, temporalis, occipital, and trapezius • The total consumption of analgesics and NSAIDs was significantly lower in the patients treated with manipulative treatment than in those treated with electrical stimulation.
• The PPTs at the MTrPs in the upper trapezius, occipital and temporal muscles were significantly lower in the patients treated with manipulative treatment than in those treated with electrical stimulation.
• After trial patients who received manipulative treatment had a significantly lower consumption of NSAIDs, analgesics and triptans.
Ghanbari (2015) [51] None 44 migraine patients
Whether patients had chronic or episodic migraine with or without aura was not reported.
37.25
38.63
35.86
Range not reported
20 M, 24F
9 M, 13F
11 M, 11F
Not reported MTrPs were considered to be active if 1) referred pain due to palpation reproduced the subjects’ headache.
2) There was a jump sign that was the characteristic behavioral response to pressure on a trigger point. All subjects included had active trigger points.
Subjects (al were randomly assigned to one of two groups:
1) Medication only
2) Medication + positional release therapy
The treatment phase lasted 2 weeks and medication included NSAIDs, nortriptyline, propranolol and depakine.
Subjects completed a daily headache diary throughout the study and tablet count was recorded.
After a baseline period of 2 weeks the sensitivity of trigger points (using a digital force gauge) and cervical range of motion were assessed.
This was repeated after the treatment phase and as a follow up after 1, 2 and 4 months (counting from start of treatment)
Suboccipital, sternocleidomastoid, upper trapezius, cervical multifidus, rotators and interspinales • Both groups showed significant reduction in headache intensity, frequency, duration and tablet count after 4 months follow up.
• The sensitivity of trigger points was significantly reduced in the medication positional release therapy group, while it remained unchanged in the medicine only group.
Giamberardino (2007) [52] Examiner blinded to diagnosis Primary experiment
78 MO
(7 also diagnosed with TTH)
20 healthy CTRLs
Secondary experiment
12 MO (2 also diagnosed with TTH)
31.4 ± 5.8 (23–46)
33.3 ± 7 (18–46)
29.3 ± 4 (24–35)
32.33 ± 6.44 (24–44)
11 M, 43F
5 M, 19F
5 M, 15F
3 M, 9F
Interictally MTrP diagnosis was performed following the criteria described by Simons et al. [19] A MTrP was considered active if palpation induced both local and referred pain.
Pain threshold was assessed by electrical stimulation.
Subsequent to threshold measurements group 1 also received 0,5 mL bupivacaine (5 mg/mL). The infiltration and pain threshold measurements were repeated on the 3., 10., 30., and 60. day.
PPT in healthy controls was assessed with the same frequency.
Migraines (number and intensity of attacks) were assessed 60 days prior to the study and 60 days after the study started. This was done using a headache diary.
The second study is a 30 days “placebo-like study” where saline was injected near the MTrPs.
PPT, injections and the headache diary were fulfilled similarly to the the prior experiment. (only up till 30 days)
Sternocleidomastoid, semispinalis cervicis, splenius cervicis • Group 1 and 2 pain thresholds were significantly lower than in controls at baseline. In group one pain threshold increased significantly during treatment. In group two there was no significant change. In the control group there was no significant variation.
• In group 1 maximal intensity and number of migraine attacks decreased significantly. In group 2 the change was not significant.
• The mean number of rescue medication taken fell significantly in group 1, but not in group 2.
• The group that participated in the second experiment also had a pain threshold lower than normal.
Landgraf (2017) [53] None 26 adolescent migraine patients (chronic/episodic not reported)
17 MO
5 MA
4 with vestibular migraine
14.5 (6.3–17.8) 13 M, 13F Not specified MTrPs were identified by palpation and the PPT on these points was measured using an algometer.
Manual pressure was applied to the trigger points, and the occurrence and duration of induced headache were recorded.
At a second consultation (4 weeks after the first), manual pressure with the detected pressure threshold was applied to non-trigger points within the same trapezius muscle (control).
Trapezius muscle • Manual pressure to MTrPs in the trapezius muscle led to lasting headache after termination of the manual pressure in 13 (50%) patients (from 5 s to over 30 min).
• No patient experienced headache when manual pressure was applied to non-trigger points at the control visit.
• Headache was induced significantly more often in children ≥12 years and those with internalizing behavioral disorder.
Landgraf (2015) [54] None 3 migraine patients
Whether patients had chronic or episodic migraine with or without aura was not reported.
23.67 (23–24) 1 M, 2F Interictally MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89]
These areas were marked by nitroglycerin capsules on the adjacent skin surface.
High-resolution MR imaging of the posterior cervico-cranial muscles was performed on a 3 T MR scanner with a spine array as well as surface coils. High resolution T2 weighted and T1-weighted sequences as well as short tau inversion recovery (STIR) sequences were acquired in a coronaland axial slice orientation.
Trapezius • MR imaging demonstrated focal, partly T2 hyper intense signal alterations within the trapezius muscles in all three study participants. All of the observed signal alterations were in close proximity to the fiducial markers taped on the skin.
Palacios-Ceña (2017) [55] None 95 EM
With or without aura not reported.
40 (37–43) 0 M, 95F Interictally MTrP diagnosis was performed following the criteria described by Simons et al. [19].
PPT was assessed using an algometer.in the following regions:
• Over the temporalis muscle.
• C5/C6 zygapophyseal joint.
• Tibialis anterior muscle (a pain-free distant control site)
Temporalis, masseter, suboccipital, sternocleidomastoid, upper trapezius, and splenius capitis • The higher the intensity of migraine pain, the lower the PPTs over the cervical spine.
• The number of active MTrPs was significantly and negatively associated with PPT in all the points.
Ranoux (2017) [56] None 7 CMA
50 CMO
57 chronic migraine patients (refractory to conventional treatment)
44.3 (17–85) 14 M, 43F Not specified Observational, open label, real-life, cohort study. The patients were injected with OnabotulinumtoxinA using a “follow-the-pain” pattern in MTrPs. Corrugator supercilii, temporalis and trapezius muscles • 65.1% responded to treatment.
• The associated cervical pain and muscle tenderness, present in 33 patients, was reduced by ≥50% in 31 patients (94%).
• Triptan consumption decreased (81%) in responders.
Sollmann (2016) [57] None 6 MO
14 MA
(50% also had some degree of TTH) chronic/episodic not reported
23 ± 1.8 (19–27) 1 M, 19F Interictally rPMS (repetitive peripheral magnetic stimulation) was used to stimulate active MTrPs of the upper trapezius muscles. This was done in 6 stimulation sessions over 2 consecutive weeks.
PPT was assessed using an algometer.
Participants completed a standardized headache questionnaire including occurrence, duration and intensity of headaches. This was repeated over 3 months.
Trapezius and deltoid (as a control) • In 19 subjects MTrP algometry values were significantly higher immediately after magnetic stimulation.
• PPT increased during the trial.
Tali (2014) [58] Examiner blinded to diagnosis during upper cervical fact joint mobility/stiffness
MTrP evaluation not blinded
20 EM
20 CTRLs
Distribution of with/without aura not reported.
24.95 ± 1.79 (20–27)
25.65 ± 1.42 (23–28)
2 M, 18F
3 M, 17F
Interictally MTrP diagnosis
was performed following the criteria described by Simons et al. [19] and Gerwin et al. [89]
Neck range of motion was assessed using a cervical range of motion instrument.
FHP was noted in a seated position.
Upper cervical facet joint mobility/stiffness was evaluated using a motion palpation technique.
Sternocleidomastoid and upper trapezius muscle • Active MTrPs were only found in the migraine group.
• Significant differences were found in neck range of motion measurements and FHP between the migraine and control groups.
  1. C* chronic, E* episodic, MA migraine with aura, MO migraine without aura, CTRLs healthy controls, F female, M male, MTrP myofascial trigger point, EMG electromyography, PPT pressure pain threshold, FHP forward head posture, VAS visual analog scale, NRS numeric rating scale