Tension Headache Disorder

Most headache pain is the result of muscle tension and active myofascial trigger points (TrPs) in the muscles of the head, neck and upper shoulders. Headaches that are chlamydia treatment caused by TrPs are well defined as to pain pattern and location of the TrP.
There are three areas of the body in which these muscles or groups of muscles are located: the head, neck, and upper shoulders.

Upper Trapezius Headache

The trapezius is the muscle most often beset by myofascial TrPs. The upper trapezius headache is by far the most common form of headache. Active TrPs in the upper fibres of the trapezius muscle (UFT) typically refer pain along the posterolateral aspect of the neck to the mastoid process just behind the ear and on to the temple on the same side as the effected muscle. When severe, the headache will centre on the temple and just behind the back of the eye. Occasionally, pain will also extend to the occiput at the back of the head by the base of the skull and rarely, mild pain is referred to the lower molar teeth. Basically, TrPs in the UFT are the most frequent cause of “tension neckache” and “temporal headache”. (See Figure 1)

Figure 1. Referred pain pattern and location (Xs) of TrPs in UFT muscle.
The upper trapezius is the primary muscle involved in elevating the shoulders, bending the neck and head laterally toward the same side, and aids in extreme rotation of the head to the opposite side. It is involved in supporting weight in the hand with the arm hanging, such as in carrying plastic shopping bags.

Activation of TrPs in the UFT depends in part on many different factors, including such skeletal variations as a short leg, a small hemipelvis, or short upper arms, as well as from the stress of sustained elevation of the shoulders, as when holding a telephone receiver without elbow support, or sitting in a chair with inadequate arm rests, or elevating the shoulders while typing on a computer keyboard. Acute trauma, as in a “whiplash” from the side, and chronic trauma such as compression of the muscle by tight bra straps, or carrying a heavy bag with a shoulder strap, or wearing a misfitting heavy coat, can activate UFT TrPs. The upper trapezius is also a muscle of emotion and is often held slightly elevated and tense during emotional distress.

Sternocleidomastoid Headaches

The sternocleidomastoid muscles (SCM) are primarily involved in rotating the the head to the opposite side and lifting it toward the ceiling. Together, the left and right SCMs flex the head and neck and act as auxillary muscles of inspiration (i.e., breathing in). The SCM is actually split into two divisions— the sternal and the clavicular divisions.

The SCMs frequently contain multiple myofascial trigger points in either their sternal or clavicular divisions, or both. Referred pain from the two divisions present quite different patterns. In each division, TrPs also evoke different autonomic phenomena or proprioceptive disturbances.

Active TrPs in the sternal division may refer pain to the occiput at the back of the head and base of the skull, to the vertex at the top of the head, across the cheek and over the eye, and/or to the throat and sternum. (see Figure 2A) Sternomastoid headaches are usually one-sided, ocurring consistently on the same side as the effected muscle. Autonomic concomitants of TrPs in the sternal division relate to the same-side eye and nose. Eye symptoms include excessive tearing, reddening of the eye, drooping of the upper eyelid and visual disturbances such as blurred vision or dimming of perceived light. Nasal symptoms include cold runny nose or nasal congestion.

Figure 2A. Referred pain patterns and location of TrPs in the sternal divsion of the SCM.Figure 2B. Referred pain patterns and location of TrPs in the clavicular divsion of the SCM.
Active TrPs in the clavicular division may refer pain deep into the ear of the effected side and across the forehead above the eyes. (see Figure 2B) Referred autonomic symptoms may involve localized sweating or blanching of the forehead. Referred proprioceptive symptoms are likely to include postural dizziness, vertigo, and disturbed balance.

SCM TrPs are usually activated by episodes of mechanical overload, for instance, by protracted neck extension in overhead work such as painting ceilings, hanging curtains, writing on a blackboard, or sitting in the front row of a theater with a high stage, etc; by overuse in sports such as wrestling; or by accidental injury such as whiplash in a motor vehicle accident or a fall on the head, etc. Hauling and pulling heavy objects or working with the head constantly turned to one side or tilted to one side can overload the SCMs. Paradoxical breathing, often associated with stress, or a chronic cough can also overload this accessory muscle of respiration.

Masseter Muscles

These jaw muscles are the primary muscles of chewing and are the most commonly involved in TMJ pain. Although active myofascial TrPs in the masseters primarily result in referred pain to the lower jaw, molar teeth, and related gums; they may also refer pain across the temple to the eyebrow area of the head as well as to the ear on the effected side. Headache pain from masseter TrPs is frequently described as “sinusitis”.

TrPs in the masseters are usually caused by problems which disturb the biomechanics of the jaw, producing strain on the muscles. Such factors include: gross trauma from a blow to the jaw; the microtrauma of bruxism (i.e., habitual clenching of the jaw); chronic overload from occlusal imbalance or too much gum chewing; and holding the jaw in other than a rest position for prolonged periods.

Other Muscles

There are nine other muscles that can cause headache pain. These are smaller muscles that develop active myofascial TrPs less often but also refer pain to the head in very specific paterns.

Muscle with TrP
Medial Pterygoid
Lateral Pterygoid
Facial Muscles
Splenius Capitis
Splenius Cervicus
Posterior Cervicus

Where Pain is Felt
side of head, teeth
inside of mouth
jaw, cheek
jaw, neck at base of skull
localized to muscle
forehead, top of head
top of head
shoulder at neck, behind eyes
back of head, temples
temples along side of head

General Comments

Headaches caused by TrPs will vary in intensity and frequency depending on the activity level of the effected muscle. If the muscle, for whatever reason (e.g., stress, physical activity) is overloaded or fatigued, this will increase the intensity and frequency of the headaches. If the opposite happens, headaches will decrease.

Treatment of myofascial headache syndromes should focus on identifying and treating TrPs, not treating the pain itself. Treating TrPs involves releasing them thro-ugh such techniques as ischemic pressure and trigger point massage, vapocoolant spray and stretch techniques, trigger point needling, etc. and subsequent isometric stretch of the muscles involved. Identification and correction of underlying biomechanical or postural problems or stress-related factors that might be precipitating or maintaining TrPs is also very important.

Important Disclaimer

Although the majority of headache problems are myo-fascial in nature, not all headaches are caused by muscle problems or TrPs. Headaches may also be caused by other factors which may require prompt, careful medical evaluation. Sudden, extremely severe headaches with neurological symptoms such as dizziness, vertigo, nausea, slurred or difficult speech, or difficulty in moving should be viewed as emergency situations requiring im-mediate medical evaluation. Copyright Myosymmetries International Inc. May 2000