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Table 2 Tension-type headache 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
Alonso-Blanco (2011) [62] None 20 CTTH adult patients
20 CTTH adolescent patients
41 (18–47)
8 (6–12)
10 M, 10F
10 M, 10F
Interictally MTrP diagnosis as described by Simons et al. [19] Temporalis, suboccipital, sternocleidomastoid, and upper trapezius • The number of active MTrPs were higher in adults versus children.
• Referred pain elicited from active MTrPs shared similar pain patterns as spontaneous CTTH in both groups. No significant association between the number of active MTrPs and headache parameters.
Couppé (2007) [67] Double-blinded 20 CTTH patients
20 CTRLs
37.5 (33.3–41.6) Not reported Ictally MTrP diagnosis as described by Simons et al. [19]
EMG examination at a MTrP and a control point in the same subject.
Upper trapezius • The number of active MTrPs were higher in patients versus controls
• No difference in electromyographic activity between MTrPs versus control points.
Fernández-de-las-Peñas (2011) [63] Examiner blinded to diagnosis 50 CTTH patients
50 CTRLs
8 (6–12) 14 M, 36F Interictally MTrP diagnosis as described by Simons et al. [19]. Temporalis, superior oblique, masseter, suboccipital, sternocleidomastoid, levator scapulae, and upper trapezius • Active MTrPs were only found in patients.
• In the CTTH patients, the number of active TrPs correlated with the duration of a headache attack.
• The local and referred pains elicited from active MTrPs shared similar pain pattern as spontaneous CTTH.
Fernández-de-las-Peñas (2009) [68] None 40 CTTH 40 (20–57) 40F Interictally
< 4 on a 11 NRS
MTrP diagnosis was performed following the criteria described by Simons et al. [19] and Gerwin et al. [89]
PPT was assessed using an algometer.
Temporalis (9 landmarks total, 3 each respectively in the anterior, medial and posterior part) • The analysis of variance did not detect significant differences in the referred pain pattern between active MTrPs.
• The topographical pressure pain sensitivity maps showed the distinct distribution of the MTrPs indicated by locations with low PPTs.
Fernández-de-las-Peñas (2007) [69] Examiner blinded to diagnosis 15 ETTH
15 CTRLs
39 ± 17 (20–70)
37 ± 12 (21–70)
3 M, 12F
4 M, 11F
Interictally MTrP diagnosis as described by Simons et al. [19] and Gerwin et al. [89]
FHP was noted both seated and standing.
Temporalis, sternocleidomastoid, and upper trapezius • Active MTrPs in the affected muscles were only found within the ETTH group.
• MTrPs were not related to any clinical variable concerning the intensity and the temporal profile of headache.
Fernández-de-las-Peñas (2007) [70] Examiner blinded to diagnosis 20 CTTH
20 CTRLs
36 (18–56)
35 (20–56)
11 M, 9F
13 M, 7F
< 4 cm on a 10 cm VAS MTrP diagnosis as described by Simons et al. [19] and by Gerwin et al. [89]
PPT was assessed using an algometer.
Upper trapezius • CTTH subjects with active MTrPs showed greater headache intensity, and duration than those with latent TrPs.
• Patients with bilateral MTrPs reported a greater headache intensity and duration than those with unilateral TrPs.
• CCTH subjects showed a decreased PPT compared to controls.
Fernández-de-las-Peñas (2007) [66] Examiner blinded to diagnosis 30 CTTH
30 CTRLs
39 ± 16 (18–65)
39 ± 12 (19–65)
9 M, 21F
9 M, 21F
< 4 cm on a 10 cm VAS MTrP diagnosis as described by Simons et al. [19] and by Gerwin et al. [89] Temporalis • Referred pain was evoked in 87 and 54% on the dominant and non-dominant sides in CTTH patients, which was significantly higher than in controls (10% vs. 17%, respectively).
• CTTH patients with active MTrPs in either right or left temporalis muscle showed longer headache duration than those with latent MTrPs.
• CTTH patients showed significantly lower pressure pain threshold when compared with controls.
Fernández-de-las-Peñas (2006) [71] Examiner blinded to diagnosis 10 ETTH
10 CTRLs
35 ± 15 (18–66)
34 ± 13 (18–66)
2 M, 8F
3 M, 7F
Interictally MTrP diagnosis as described by Simons et al. [19] and by Gerwin et al. [89] Suboccipital • In the ETTH group, 60% showed active MTrPs; 40% showed latent trigger points. In the ETTH group, headache intensity, frequency and duration did not differ depending on whether the MTrPs were active or latent.
Fernández-de-las-Peñas (2006) [72] Examiner blinded to diagnosis 25 CTTH
25 CTRLs
40 ± 16 (18–72)
38 ± 9 (18–73)
8 M, 17F
9 M, 16F
< 4 cm on a 10 cm VAS MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89]
FHP was noted both seated and standing.
Temporalis, sternocleidomastoid, and upper trapezius • Active MTrPs were only found in CTTH patients.
• There was significant association between the presence of active MTrPs and headache intensity and duration.
Fernández-de-las-Peñas (2006) [65] Examiner blinded to diagnosis 20 CTTH
20 CTRLs
38 ± 18 (18–70)
35 ± 10 (20–68)
9 M, 11F
12 M, 8F
Pain intensity < 4 on a 10 cm VAS MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89]
FHP was noted both seated and standing.
Suboccipital • Active MTrPs were only found in CTTH patients.
• CTTH patients with active MTrPs reported greater headache intensity and frequency than those with latent.
• A craniovertebral smaller angle was positively correlated with increased headache frequency and negatively correlated with headache duration.
Fernández-de-las-Peñas (2005) [64] Examiner blinded to diagnosis 15 CCTH
15 ETTH
15 CTRLs
37 ± 16
38 ± 14
38 ± 14
Range not reported
5 M, 10F
4 M, 11F
5 M, 10F
CTTH: Pain intensity < 4 cm on a 10 cm VAS
TTH: Interictally
MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89] Superior oblique • 86% CTTH patients and 60% ETTH patients reported referred pain from MTrPs.
• The pain was perceived as a deep ache located at the retro-orbital region – sometimes extending to the supraorbital region or the homo-lateral forehead.
• Pain intensity was greater in CTTH patients than in ETTH patients.
Harden (2009) [73] Double-blinded 23 CTTH with active cervical MTrPs (12 in active group, 11 in placebo group) 49.6 in active group
40.8 in placebo group
Range not reported
7 M, 5F
7 M, 4F
Not reported Patients received i.m. injections of botulinum toxin A or isotonic saline (placebo) in MTrPs. 25 units dose pr. MTrP, but no more than 100 units in total pr. patient (maximum four trigger points treated pr. patient). Sternocleidomastoid, trapezius, and splenius capitis (which overlies involved cervical muscle groups: semispinalis capitis, longissimus capitis, recti capitis posterior and obliquus capitis superior) • Patients in the active group reported greater reductions in headache frequency during the first part of the study, but these effects dissipated by week 12.
Karadas (2013) [74] Double-blinded 48 CTTH with active MTrPs (24 in active group, 24 in placebo group). 40.4 ± 12 in active group
40.7 ± 13.2 in placebo group
Range not reported
4 M, 20F
5 M, 19F
Not reported Patients received i.m. injections with 0.5% lidocaine or 0.9% NaCl (placebo) to the trigger points of the muscles innervated by C1-C3 and the trigeminal nerve, exit point of the fifth cranial nerve and around the superior cervical ganglion. Muscles innervated by C1-C3 and the trigeminal nerve, exit point of the fifth cranial nerve and around the superior cervical ganglion • Patients in the active group reported significantly greater reductions in headache frequency and intensity.
Lattes (2009) [75] None 27 CTTH Approximately 46 (18–80) 7 M, 20F Not reported I.m. injections with gonyautoxin in 10 landmarks considered as MTrPs.
EMG examination before and after injections.
Occipitalis and trapezius • Responders (70%) had an average of 8,1 weeks free of pain following treatment.
• The EMG recorded immediately after injection in all cases showed that the hyperactivity in the trapezius muscle was completely abolished.
Moraska (2017) [76] Single-blind 34 CTTH
28 ETTH
Massage:
13 CTTH
7 ETTH
Placebo:
11 CTTH
10 ETTH
Wait-list
10 CTTH
11ETTH
31.2 ± 11.3
34.4 ± 10.7
33.0 ± 9.0
7 M, 55F
1 M, 19F
2 M, 19F
4 M, 17F
Not reported Individuals with ETTH or CTTH were randomized to receive 12 twice-weekly 45-min massage or sham ultrasound sessions or wait-list control. Massage focused on MTrPs.
PPT was assessed using an algometer.
MTrP diagnosis was performed following the criteria described by Simons et al. [19]
Suboccipital and upper trapezius • PPT increased across the study timeframe in all four muscle sites tested for massage, but not sham ultrasound or wait-list groups.
Moraska (2015) [77] Single-blind 30 CTTH
26 ETTH
32.1 ± 12 in active group
34.7 ± 11 in placebo group
Range not reported
8 M, 48F (2 M, 15F in active group; 2 M, 17F in placebo group; 4 M, 16F in wait-list group) Not reported 56 patients with TTH were randomized to receive 12 massage or placebo (detuned ultrasound) sessions over 6 weeks, or to wait-list.
Massage focused on MTrPs in cervical musculature.
PPT was assessed using an algometer.
MTrP diagnosis was performed following the criteria described by Simons et al. [19]
Suboccipital, sternocleidomastoid, and upper trapezius • Headache frequency fell in both the massage and the placebo group.
• PPT improved in the massage group.
Palacios-Ceña (2016) [78] Examiner blinded to diagnosis 77 CTTH
80 ETTH
46 (42–50)
47 (43–51)
46 M, 111F Interictally MTrP diagnosis was performed following the criteria described by Simons et al. [19]
PPT was assessed over the trigeminal area, extra-trigeminal area and two distant pain free points using an algometer.
Temporalis, masseter, suboccipital, sternocleidomastoid, splenius capitis, and upper trapezius • No difference in number of MTrPs and PPT in the two groups.
• There was a significant negative correlation between the number of trigger points (active or latent) and PPT.
Romero-Morales (2017) [79] None 60 ETTH
60 CTRLs
38,30 ± 10,05
34 ± 8,20
Range not reported
24 M, 32F
27 M, 33F
Not reported MTrP diagnosis was performed following the criteria described by Simons et al. [19]
PPT was assessed using an algometer.
Temporalis and upper trapezius Minimum clinical differences in PPT between TTH and CTRLs were
• Right upper trapezius; 0,85 kg/cm2
• Left upper trapezius; 0;76 kg/cm2
• Right temporalis; 0;16 kg/cm2
• Left temporals; 0,17 kg/cm2
Sohn (2012) [80] Examiner blinded to diagnosis 23 CTTH
36 ETTH
42 CTRLs
53.43 ± 16.97
51.11 ± 14.42
51.69 ± 16.18
Range not reported
2 M, 21F
7 M, 29F
8 M, 34F
Headache intensity < 3 on a 10 cm VAS MTrP diagnosis was performed following the criteria described by Simons et al. [19] and by Gerwin et al. [89]
FHP was used to evaluate posture abnormalities.
Measurement of neck mobility was used to evaluate mechanical abnormalities.
Temporalis, suboccipital, sternocleidomastoid, and upper trapezius • The number of active MTrPs was significantly greater in CTTH subjects than in ETTH subjects.
• The number of active MTrPs were correlated with the frequency and duration of headache.
• No correlations were observed for FHP or neck mobility.
  1. CTTH chronic tension-type headache, ETTH episodic tension-type headache, CTRLs healthy controls, F female, M male, MTrP myofascial trigger point, EMG electromyography, PPT pressure pain threshold, FHP frontal head position, VAS visual analog scale, NRS numeric rating scale