Position Statement

It is the position of the American Massage Therapy Association (AMTA) that massage can be an effective therapy for those who suffer from tension headaches.

Massage for Headaches, Migraines –

Trigger Point and Deep Tissue Massage are the best modalities to help these conditions-

Follow this link for more info on Trigger Point Massage

Massage for headaches and migraines has proven to be an effective measure for reducing both chronic migraines and tension headaches. Massage also eases the muscle tension in the neck, jaw, and shoulders, which can cause headaches in the first place.

Can deep tissue massage help migraines?

Deep tissue massage between migraine attacks seemed to have the most favorable outcomes. (Deep tissue work during a migraine may exacerbate the pain.) ​ Massage relieves muscle tension and spasms in the shoulders, neck, and head.

Another method is:

Acupressure for Pain and Headaches

This information explains how to use acupressure to reduce pain and headaches.

Acupressure is an ancient healing art that’s based on the traditional Chinese medicine practice of acupuncture. With acupressure, the pressure is applied to specific places on your body. These places are called acupoints. Pressing these points can help release muscle tension and promote blood circulation. It can also relieve many common side effects of chemotherapy.

You can do acupressure at home by using your fingers to apply pressure to different acupoints. Watch the video or follow the steps below to learn how to perform acupressure to reduce pain and headaches.

Pressure Point LI-4 (Hegu)

Pressure point LI-4, also called Hegu, is located between the base of your thumb and index finger. Doing acupressure on this point relieves pain and headaches.

1. Using your right thumb and index finger, find the space on your left hand between the base of your left thumb and index finger (see Figure 1).
2. Press down on this point for 5 minutes. Use a circular motion. Be firm, but don’t press so hard that it hurts.
3. Repeat the process on your right hand.

You can perform acupressure several times a day, or as often as needed for your symptoms to go away.

What is a Migraine?

‘Migraine’ comes from the ancient Greek word “hemicrania” which means “half-head”. Approximately 50 million people in the U.S. suffer. The cause of migraines is not known, why some people get them/some do not. People over 45 who develop migraine headaches with an aura have a six-fold increased risk of having a stroke or heart attack. A migraine stroke occurs when the spasm of the artery feeding the visual fields on one side of the brain is very intense. Women are most affected (3:1 vs. men) most commonly with the premenstrual cycle. Approximately 70% of all women who get migraines can predict the onset of a headache around their cycle. Hormonal fluctuations (estrogen) With menopause, fluctuations stop causing a 65-70% less frequency of headaches 30-45-year-olds have more migraines than any other age group. 70-80% of migraine sufferers have a family history of migraines, why is not known. 17% of children are affected by severe and recurrent headaches in the U.S. Migraine medication is not recommended until more data shows that drugs can help. Avoid the triggers.

Research on massage therapy for migraine

There is limited research on massage and migraines. However, a few small studies provide promising information.

One small 2006 study of 47 migraine sufferers randomly assigned participants to receive massage therapy or to a control group. All trial participants completed daily assessments of their sleep activity and migraine attacks. Those who had massages had fewer migraines and slept better during the weeks they had massages and in the three weeks following massages. On average, the massage group had a 34% reduction in migraines during the weeks they received massage therapy and a 30% reduction in the follow-up period, compared to reductions of 7% and 2% in the control group.¹

In a study that retrospectively looked at the triggers and relieving factors among people with migraines versus people with tension headaches, massage was used by significantly more people with migraines as a technique to relieve symptoms.³

Another small randomized study evaluated 26 people with migraines. Half of the participants received massage therapy, focusing on the neck. Those who received massage therapy had significantly less migraine pain compared to the control group. From the first massage to the last, the massage group reported a 71% reduction in pain intensity.

When a migraine hits, all you want to do is to get rid of it—ASAP. The painful throbbing on one or both sides of the head, sensitivity to light, nausea, and vomiting are enough to make you want to curl up into a ball and wish the tension would just go away.

Sara Crystal, MD, a neurologist, headache specialist, and medical advisor says, the most common migraine triggers are stress, changes in a sleep cycle, hormonal imbalances, and caffeine overuse. Eating chocolate, aged cheese, and foods with MSG, nitrates, and additives could also cause a migraine. But people develop migraines for a variety of reasons.

“The causes of migraines are largely genetic. Each person has a personal trigger. That is why there’s no one-size-fits-all treatment for migraines,” she says.

While there isn’t a silver bullet, doctors recommend over-the-counter medications, prescription drugs, or natural remedies for migraine treatment. And one of those natural remedies involves doing a migraine massage with peppermint essential oil. Dr. Crystal says menthol, which is the active ingredient in peppermint essential oil, has been proven to help relieve headaches. In fact, a 2015 study from Frontiers in Neurology suggests that topically applying a menthol-based gel, such as those with peppermint essential oil, could significantly reduce headache intensity. Here’s how to give yourself a migraine massage:

1. Dilute a few drops of the peppermint essential oil into another oil carrier, like coconut oil.
2. Massage the oil into the temples and forehead, working in circular motions with the index and middle fingers.
3. Continue for a minute.

If the massage is too painful, Dr. Crystal recommends adding a few drops of peppermint essential oil on a tissue and breathing deeply into it, or dabbing some of the oil onto a cold compress and applying it to your forehead. Dr. Crystal also likes using a roll-on stick, like Migrastil Migraine Stick or Health From The Sun’s MigraSoothe Roll-On, for easy application.

Did you know that an estimated 45 million Americans suffer from chronic headaches? Chronic headaches are one of the most common complaints made to healthcare practitioners every year. These headache sufferers are looking for some answers and treatment. Headaches are most often treated with over-the-counter or prescription medications. These treatments are highly effective but can be a temporary solution for a chronic problem. Massage therapy has shown to be effective in treating migraines and tension headaches.

Tension Headaches: These types of headaches can be caused by muscle spasms, trigger points, TMJ dysfunction, neck alignment, stress, hormonal/chemical changes, dehydration, and stress/anxiety. Tension headaches can show up as tightness or constricting feeling in the head, as pain in the head or referred pain in the neck, shoulders, and arms, as muscle spasms/pain, as pain in the jaw, or as pain around the temple and behind the eyes. Tension headaches usually do not come with other sensitivities, such as sensitivity to light and sound or nausea.

Migraines: These types of headaches are still somewhat mysterious. They are believed to be caused by neck alignment, chemical/hormonal changes, neurological problems, vascular problems, environmental irritants, food sensitivities, and/or blood sugar regulation. Migraines can be very severe and can last up to several days. These headaches do usually come with some sensitivities, such as sensitivity to light, sound, and nausea/vomiting.

Both tension headaches and migraines have been effectively treated by massage therapy. Not only can massage help relieve headache pain, but it can also help to prevent headaches from occurring. Massage is helpful for many reasons:

• Massage promotes circulation: Massage can increase blood flow in areas that might be ischemic (lacking blood flow) and therefore help relieve pain.
• Massage decreases pain from Trigger Points: Trigger Points are areas of hyper-irritable tissue that are very tender and also can refer pain to other areas of the body. Trigger Point Therapy or Neuromuscular Therapy (NMT) can help decrease the pain and referrals into the neck and head.
• Massage relieves muscle spasms/tension: Massage can help loosen chronically tight muscles and taught bands of tissue. This helps with muscle balance and neck alignment. Also, loosening the muscles that attach to the base of the skull (sub-occipitals) can relieve the tension headaches that travel up the back of the head and into the eye, and the ‘vice-like’ constricting headaches so many people suffer from.
• Massage helps regulate certain hormones: Massage therapy has shown to decrease levels of the stress hormone Cortisol. Massage therapy also increases endorphins and stimulates the Para-Sympathetic Nervous system, therefore promoting relaxation. Because of this hormone effect, massage therapy can improve the quality of your sleep. It is a happy little cycle: decrease stress = better sleep = fewer headaches = decrease stress =……and so on and so forth.
• Migraines: The research is unclear exactly why massage therapy helps those who suffer migraine headaches. However, in multiple studies, massage therapy was shown to decrease the frequency and duration of migraines.

One of the most exciting things about this research is that there is finally a non-pharmacological treatment for headaches. Massage therapy can be a treatment that is safe and effective–not just a cover-up. However, I must say that there are MANY potential causes of headaches, and some are a lot more serious than others. If you do suffer from chronic headaches, you want to check with your doctor first to make sure you do not need additional treatment. Once you get the okay from your doctor, provide as much information about your headaches as you can to your massage therapist, and he or she can help develop a protocol that is right for you.

Massage for Tension Headaches, Migraines, Vertigo, using Trigger Point

Massage for Tension Headaches:

Headaches are one of the conditions that could be suffered by anyone and cause could be serious or not. However, frequent headache is not only annoying but could be a warning of certain conditions that required further checkup. The treatment of headaches is based on the causes and massage is one of the solutions to treat headaches. Before you find out more about the benefits of massage for tension headaches, finding out more about symptoms, causes, and types of headaches may help you understand more about this condition.

Generally, headaches are just conditioned when people feel an uncomfortable throbbing pain in their head or neck area. However, do you really know what the main cause of headaches is? Based on the causes there are two types of headaches:

1. Primary Headache

A primary headache is not dangerous because it occurs not caused by other health or structural problems. Migraine and tension headaches are two examples of primary headaches. The causes of primary headache are such as insomnia, stress, work pressure, dehydration, and other things that are related to a daily problem. Once you could deal with the problem, the pain will be eased up naturally.

1. Secondary Headache

Unlike primary headache, a secondary headache may occur caused by underlying diseases. In other words, the headache may be the symptom of certain dangerous health conditions such as head injury, infection, brain bleed, and even tumor.

As mentioned above, tension headache is included in primary headache and one of the ways you could do to deal with this condition is massaged. Most people may depend on the use of pain killers for their tension headaches but if you know the benefits of massage for tension headaches you don’t need pain killer anymore.

Benefits of Massage for Tension Headaches

One of the benefits of full body massage is to release muscle tension and pain commonly applied through fingers and hands, though there are some techniques that are using the elbow, feet, and specific massage device. In the matter of dealing with tension headaches, studies have found out about some amazing benefits of massage to help to relieve the throbbing pain caused by headaches.

1. Help Maintaining the Level of Relaxation

Massage has been claimed to be an effective solution in maintaining relaxation. Tensed body and muscles may lead to headaches. That’s why taking massage regularly may help to maintain the level of relaxation in your body and as the result, you could prevent tension headaches and migraine attacks. So, instead of taking pain killer is better to spend some time having your body massaged. Further studies also stated the possibility of massage in order to reduce the symptoms of depression.

1. Could Acts as Stress Relief

There are a lot of factors that could cause stress. Workload pressure, personal matters, unsupportive environment are just some examples of conditions that cause stress. However, stress is not only in your head but could be suffered by your body as well. When your body and mind could no longer able to deal with stressful situations, conditions like headaches may occur. Massage will help to release the tension and at the same time healing the headache and relieving the stress.

1. The solution to Tensed Muscles

Most people may not know that headaches could be caused by tensed muscles or muscle spasms as well. When your muscles are tensed, your body will suffer stressful conditions without you realize it. However, when your body is under pressure, a headache is likely to occur. So, instead of taking a pain killer to treat the headache is highly recommended for you to do massage and release the tension in the muscles. When your muscles are relaxed, the headache will leave you naturally.

1. Promotes Better Sleep Pattern

Among the causes of insomnia, stress and tensed muscles are the common causes. Insomnia is one of the conditions that could lead to headaches. If that happens will be difficult for you to concentrate and focus in the morning. There are a lot of health benefits of deep sleep but when you lose the chance to have a good night’s sleep, your mood will be in danger and you may lose your appetite. Massage has been well known to be the best solution that promotes a better sleep pattern. So, if you have insomnia problems, it is probably the main reason why you have frequent headaches. Instead of taking pain killer as a short-term solution, massage is a safer, healthier long-term solution.

1. Increases Serotonin Level

Some studies have stated that massage could help to stimulate the production of certain hormones and one of them is serotonin. Serotonin is responsible for regulating your mood, appetite, and sleep pattern. When serotonin in your body is at a low level, stress is the first symptom that you will face before uncomfortable throbbing in your head well known as headaches.

1. Help in Regulating Mood

As mentioned above, one of the natural ways to regulate your mood is by making sure the serotonin level in your body is at a safe level. Massage is one of the solutions to help in maintaining the serotonin level to help to regulate your mood always in check. The use of aromatherapy could optimize the process because one of the health benefits of lavender oil is to improve mood.

1. Improves Appetite

There are a lot of factors that could cause someone to lose appetite. Losing appetite is mostly temporary but if it is becoming a frequent problem, perhaps you should find the solution right away. When you lose your appetite, your body will lose some essential nutrients for metabolism. Unhealthy metabolism could lead to certain conditions like headaches which is the indication when your body is suffering from certain nutrients deficiencies.

1. Optimizes the Blood Flow

Massage is a technique that has been used to relieve muscle tension and in the process also helping in optimizing the blood flow. When blood cannot flow normally, headache is the symptom that may occur because the head area is not getting enough oxygen because one of the benefits of oxygen is contributing to the optimal function of cognitive and brain function. In other words, when blood is flowing optimally, conditions like headaches could be prevented.

1. Reduces the Medication Usage

The easiest solution to deal with headaches is by taking painkillers. However, medication or drug is not without side effects. That’s why finding a natural alternative solution is highly recommended. As mentioned above, massage could help to prevent headaches and also treating headaches by dealing with the root of the problem. In other words, there is no point anymore for you to take pain killers to treat headaches if you could do massage.

Massage is one of the alternative solutions to help in dealing with headaches. However, there is one important thing you should note when relying on your headache problem using massage technique if the headache continues, becomes worse or turns into frequent headaches, meeting your doctor is highly recommended because there is always possible that the headache is a symptom of underlying conditions which required immediate treatment.

• symptom checker links:

Upper Back, Shoulder, and Arm

Torso

Lower Torso

Leg, Ankle & Foot

Hip,

Thigh & Knee

Head and Neck

Forearm & Hand Pain

https://www.myofascialtherapy.org/symptom-checker

A trigger point is a small knot in your muscle. These muscle knots can cause pain where it originates or further away, in a spot that seems completely unconnected. Trigger points are responsible for a majority of all pain syndromes, especially those caused by myofascial trigger points.

What causes a trigger point?

• Trigger Points

Muscle inflammation can be caused by repetitive strain, lack of muscle activity, or a direct muscle injury. When muscles are stressed or injured, they often form tender“trigger points” that feel like dense tight knots in the muscle tissue.

What does a trigger point feel like?

Trigger points feel like little marbles or knots just under your skin. When pressing on trigger points, many people feel no pain or discomfort. Sometimes, trigger points become very sensitive, and some people feel significant pain in areas where they have trigger points.

Will trigger points ever go away?

And untreated trigger points can last forever. No one really knows why a trigger point would ever go away, or why it would stop once it’s started. Fortunately, they often do go away. … While the injury heals, trigger point pain overstays its welcome.

Does everyone have trigger points?

Trigger points can cause pain directly. Trigger points are a “natural” part of muscle tissue.15 Just as almost everyone gets some pimples, sooner or later almost everyone gets muscle knots — and you get pain with no other explanation or issue. … Trigger points complicate injuries and other painful problems.

Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of stress on muscle fibers and the formation of trigger points. Patients may have regional, persistent pain resulting in a decreased range of motion in the affected muscles. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. Trigger points may also manifest as a tension headache, tinnitus, temporomandibular joint pain, decreased range of motion in the legs, and low back pain. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding typically associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain toward a zone of reference and a local twitch response. Various modalities, such as the Spray and Stretch technique, ultrasonography, manipulative therapy, and injection, are used to inactivate trigger points. The trigger-point injection has been shown to be one of the most effective treatment modalities to inactivate trigger points and provide prompt relief of symptoms.

About 23 million persons, or 10 percent of the U.S. population, have one or more chronic disorders of the musculoskeletal system. Musculoskeletal disorders are the main cause of disability in the working-age population and are among the leading causes of disability in other age groups. Myofascial pain syndrome is a common painful muscle disorder caused by myofascial trigger points.  This must be differentiated from fibromyalgia syndrome, which involves multiple tender spots or tender points.3 These pain syndromes are often concomitant and may interact with one another.

Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. The spots are painful on compression and can produce referred pain, referred tenderness, motor dysfunction, and autonomic phenomena.4

Trigger points are classified as being active or latent, depending on their clinical characteristics. An active trigger point causes pain at rest. It is tender to palpation with a referred pain pattern that is similar to the patient’s pain complaint. This referred pain is felt not at the site of the trigger-point origin, but remote from it. The pain is often described as spreading or radiating. Referred pain is an important characteristic of a trigger point. It differentiates a trigger point from a tender point, which is associated with pain at the site of palpation only.

TABLE 1

Trigger Points vs. Tender Points

TRIGGER POINTS	TENDER POINTS
Local tenderness, taut band, local twitch response, jump sign	Local tenderness
Singular or multiple	Multiple
May occur in any skeletal muscle	Occur in specific locations that are symmetrically located
May cause a specific referred pain pattern

A latent trigger point does not cause spontaneous pain but may restrict movement or cause muscle weakness. The patient presenting with muscle restrictions or weakness may become aware of pain originating from a latent trigger point only when pressure is applied directly over the point.9

Moreover, when firm pressure is applied over the trigger point in a snapping fashion perpendicular to the muscle, a “local twitch response” is often elicited.

Evaluation

Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding most often associated with a trigger point.1 Localization of a trigger point is based on the physician’s sense of feel, assisted by patient expressions of pain and by visual and palpable observations of local twitch response. This palpation will elicit pain over the palpated muscle and/or cause radiation of pain toward the zone of reference in addition to a twitch response. The commonly encountered locations of trigger points and their pain reference zones are consistent.

A local twitch response is defined as a transient visible or palpable contraction or dimpling of the muscle and skin as the tense muscle fibers (taut band) of the trigger point contract when pressure is applied. This response is elicited by a sudden change of pressure on the trigger point by needle penetration into the trigger point or by transverse snapping palpation of the trigger point across the direction of the taut band of muscle fibers. Thus, a classic trigger point is defined as the presence of discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces both referred regional pain (zone of reference) and a local twitch response. Trigger points help define myofascial pain syndromes.

Tender points, by comparison, are associated with pain at the site of palpation only, are not associated with referred pain, and occur in the insertion zone of muscles, not in taut bands in the muscle belly.8 Patients with fibromyalgia have tender points by definition. Concomitantly, patients may also have trigger points with myofascial pain syndrome. Thus, these two pain syndromes may overlap in symptoms and be difficult to differentiate without a thorough examination by a skilled physician.

Myofascial trigger points, also known as trigger points, are described as hyperirritable spots in the skeletal muscle. They are associated with palpable nodules in taut bands of muscle fibers.^[ They are a topic of ongoing controversy, as there is limited data to inform a scientific understanding of the phenomenon. Accordingly, a formal acceptance of myofascial “knots” as an identifiable source of pain is more common among bodyworkers, physical therapists, chiropractors, and osteopathic practitioners. Nonetheless, the concept of trigger points provides a framework that may be used to help address certain musculoskeletal pain.

The trigger point model states that unexplained pain frequently radiates from these points of local tenderness to broader areas, sometimes distant from the trigger point itself. Practitioners claim to have identified reliable referred pain patterns which associate pain in one location with trigger points elsewhere. There is variation in the methodology for the diagnosis of trigger points and a dearth of theory to explain how they arise and why they produce specific patterns of referred pain.^[

Compression of a trigger point may elicit local tenderness, referred pain, or local twitch response. The local twitch response is not the same as a muscle spasm. This is because a muscle spasm refers to the entire muscle contracting whereas the local twitch response also refers to the entire muscle but only involves a small twitch, no contraction.

Among physicians, various specialists might use trigger point therapy. These include physiatrists (physicians specializing in physical medicine and rehabilitation), family medicine, and orthopedics. Osteopathic, as well as chiropractic schools, also include trigger points in their training.^[ Other health professionals, such as athletic trainers, occupational therapists, physiotherapists, acupuncturists, massage therapists and structural integrators are also aware of these ideas and many of them make use of trigger points in their clinical work as well.

Pathophysiology

Activation of trigger points may be caused by a number of factors, including acute or chronic muscle overload, activation by other trigger points (key/satellite, primary/secondary), disease, psychological distress (via systemic inflammation), homeostatic imbalances, direct trauma to the region, collision trauma (such as a car crash which stresses many muscles and causes instant trigger points) radiculopathy, infections and health issues such as smoking.

Trigger points form only in muscles. They form as a local contraction in a small number of muscle fibers in a larger muscle or muscle bundle. These in turn can pull on tendons and ligaments associated with the muscle and can cause pain deep within a joint where there are no muscles. The integrated hypothesis theory states that trigger points form from excessive release of acetylcholine which produces sustained depolarization of muscle fibers. Indeed, the trigger point has an abnormal biochemical composition with elevated concentrations of acetylcholine, noradrenaline and serotonin and a lower pH. These sustained contractions of muscle sarcomeres compress local blood supply restricting the energy needs of the local region. This crisis of energy produces sensitizing substances that interact with some nociceptive (pain) nerves traversing in the local region which in turn can produce localized pain within the muscle at the neuromuscular junction (Travell and Simons 1999). When trigger points are present in muscles there is often pain and weakness in the associated structures. These pain patterns in muscles follow specific nerve pathways and have been readily mapped to allow for the identification of the causative pain factor. Many trigger points have pain patterns that overlap, and some create reciprocal cyclic relationships that need to be treated extensively to remove them.

Diagnosis

Practitioners do not agree on what constitutes a trigger point, but the assessment typically considers symptoms, pain patterns, and manual palpation. Usually, there is a taut band in muscles containing trigger points, and a hard nodule can be felt. Often a twitch response can be felt in the muscle by running your finger perpendicular to the muscle’s direction; this twitch response often activates the “all or nothing” response in a muscle that causes it to contract. Pressing on an affected muscle can often refer to pain. Clusters of trigger points are not uncommon in some of the larger muscles, such as the gluteus group (gluteus maximus, gluteus medius, and gluteus minimus). Often there is a heat differential in the local area of a trigger point.^[c

A 2007 review of diagnostic criteria used in studies of trigger points concluded that” there is as yet a limited consensus on case definition in respect of MTrP pain syndrome. Further research is needed to test the reliability and validity of diagnostic criteria. Until reliable diagnostic criteria have been established, there is a need for greater transparency in research papers on how a case of MTrP pain syndrome is defined, and claims for effective interventions in treating the condition should be viewed with caution.”^[

A 2009 review of nine studies examining the reliability of trigger point diagnosis found that physical examination could not be recommended as reliable for the diagnosis of trigger points.^[

Imaging

A 2008 review in the Archives of Physical Medicine and Rehabilitation of two recent studies concludes they present findings that can reduce some of the controversy surrounding the cause and identification of myofascial trigger points (MTPs).^[ The study by Chen on the use of magnetic resonance elastography (MRE) imaging of the taut band of an MTP in an upper trapezius muscle may present a convincing demonstration of the cause of MTP symptoms. MRE is a modification of existing magnetic resonance imaging equipment to image stress produced by adjacent tissues with different degrees of tension. This report presents an MRE image of the taut band that shows the V-shaped signature of the increased tension compared with surrounding tissues. Results were all consistent with the concept that taut bands are detectable and quantifiable with MRE imaging. The findings in the subjects suggest that the stiffness of the taut bands in patients with myofascial pain maybe 50% greater than that of the surrounding muscle tissue. The findings suggest that MRE can quantitate asymmetries in muscle tone that could previously only be identified subjectively by examination.

In the study by Shah and associates, they have shown the feasibility of continuous, in vivo recovery of small molecules from soft tissue without harmful effects. With this technique, they have been able to investigate the biochemistry of muscle in subjects with myofascial trigger points and to contrast this with that of the noninvolved muscle.^[

Myofascial pain syndrome

The main innovation of Travell’s work was the introduction of the myofascial pain syndrome concept (myofascial referring to the fascia that surrounds and permeates muscle). This is described as a focal hyperirritability in muscle that can strongly modulate central nervous system functions. Travell and followers distinguish this from fibromyalgia, which is characterized by widespread pain and tenderness and is described as a central augmentation of nociception giving rise to deep tissue tenderness that includes muscles. Studies estimate that in 75–95 percent of cases, myofascial pain is a primary cause of regional pain. Myofascial pain is associated with muscle tenderness that arises from trigger points, focal points of tenderness, a few millimeters in diameter, found at multiple sites in a muscle, and the fascia of muscle tissue. Biopsy tests found that trigger points were hyperirritable and electrically active muscle spindles in general muscle tissue.^[

Misdiagnosis of pain

The misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common maladies, but physicians, in weighing all the possible causes for a given condition, rarely consider a myofascial source. The study of trigger points has not historically been part of medical education. Travell and Simons hold that most of the common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain.^[

Treatment

Physical muscle treatment

Therapists may use myotherapy (deep pressure as in Bonnie Prudden‘s approach, massage or tapotement as in Dr. Griner’s approach), mechanical vibration, pulsed ultrasound, electrostimulation,^[ ischemic compression, trigger-point-injection (see below), dry-needling, “spray-and-stretch” using a cooling spray (vapor coolant), low-level laser therapy and stretching techniques that invoke reciprocal inhibition within the musculoskeletal system. Practitioners may use elbows, feet, or various tools to direct pressure directly upon the trigger point, to avoid overuse of their hands.

A successful treatment protocol relies on identifying trigger points, resolving them and, if all trigger points have been deactivated, elongating the structures affected along with their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, active isolated (AIS), muscle energy techniques (MET), and proprioceptive neuromuscular facilitation (PNF) stretching to be effective. Fascia surrounding muscles should also be treated to elongate and resolve strain patterns, otherwise, muscles will simply be returned to positions where trigger points are likely to re-develop.

The results of manual therapy are related to the skill level of the therapist. If trigger points are pressed too short a time, they may activate or remain active; if pressed too long or hard, they may be irritated or the muscle may be bruised, resulting in pain in the area treated. This bruising may last for 1–3 days after treatment, and may feel like, but is not similar to, delayed onset muscle soreness (DOMS)^[c, the pain felt days after overexerting muscles. Pain is also common after a massage if the practitioner uses pressure on unnoticed latent or active trigger points, or is not skilled in myofascial trigger point therapy.

Researchers of evidence-based medicine concluded as of 2001 that evidence for the usefulness of trigger points in the diagnosis of fibromyalgia is thin. More recently, an association has been made between fibromyalgia tender points and active trigger points.

Trigger-point-injection

Injections without anesthetics, or dry needling, and injections including saline, local anesthetics such as procaine hydrochloride (Novocain), or articaine without vasoconstrictors like epinephrine,^[ steroids, and botulinum toxin provide more immediate relief and can be effective when other methods fail. In regards to injections with anesthetics, a low concentration, short-acting local anesthetics such as procaine 0.5% without steroids or epinephrine is recommended. High concentrations of long-acting local anesthetics, as well as epinephrine, can cause muscle necrosis, while the use of steroids can cause tissue damage.

Despite the concerns about long-acting agents,^[ a mixture of lidocaine and marcaine is often used. A mixture of 1 part 2% lidocaine with 3 parts 0.5% bupivacaine (trade name:Marcaine) provides 0.5% lidocaine and 0.375% bupivacaine. This has the advantages of immediate anesthesia with lidocaine during injection to minimize injection pain while providing a longer duration of action with a lowered concentration of bupivacaine.

In 1979, a study by Czech physician Karl Lewit reported that dry needling had the same success rate as anesthetic injections for the treatment of trigger points. He dubbed this the ‘needle effect’.^[

In the 1950s and 1960s, studies relevant to trigger points were done by J. H. Kellgren at University College Hospital, London, in the 1930s and, independently, by Michael Gutstein in Berlin and Michael Kelly in Australia. ^[

Health insurance companies in the US such as Blue Cross, Medica, and HealthPartners began covering trigger point injections in 2005.^[

Risks

Treatment, whether by self or by a professional, has some inherent dangers. It may lead to damage of soft tissue and other organs. The trigger points in the upper quadratus lumborum, for instance, are very close to the kidneys, and poorly administered treatment (particularly injections) may lead to kidney damage. Likewise, treating the masseter muscle may damage the salivary glands superficial to this muscle. Furthermore, some experts believe trigger points may develop as a protective measure against unstable.

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Myofascial Trigger Point Therapy – What Is It?

The word myofascial means muscle tissue (myo) and the connective tissue in and around it (fascia). Myofascial pain often results from a muscle injury or repetitive strain. When stressed or injured, muscles often form trigger points, like contracted knots, that cause pain and tightness.[mī·ōfa′shē·əl]“pertaining to a muscle and its sheath of connective tissue, or fascia.”     Mosby’s Medical Dictionary, 8th edition. © 2009, Elsevier.

Myofascial trigger points are an extremely common cause of pain. Trigger points are painful when pressed on, cause a shortening of the muscle fibers, and have a special property called referred pain. Referred pain means that a trigger point in one muscle can create pain in another area.

For instance, when the muscle at the top of your shoulder (trapezius) has a trigger point it will refer to pain up the side of your neck and head causing a headache. Active myofascial trigger points in the muscles of the shoulder neck and face are a common source of headaches.  In many instances, the headache has the features of a so-called tension headache, but there is increasing acceptance that myofascial trigger points may initiate classical migraine headaches or be part of a mixed tension/migraine headache complex.

Muscles make up between 36-42% of body weight, on average. They are a large percentage of our total weight and have a corresponding impact on our health. When all is in working order, muscles allow us to perform normal activities with ease. When our muscles harbor trigger points, we experience pain, stiffness and tension, physical limitation, and loss of normal function.

Factors commonly cited as predisposing to trigger point formation include but are not limited to de-conditioning, poor posture, repetitive mechanical stress, mechanical imbalance (e.g. leg length inequality), joint disorders, non-restorative sleep, and vitamin deficiencies.

A diagnosis of Myofascial Pain Syndrome or Chronic Myofascial Pain means that the primary source of your symptoms is from these myofascial trigger points. Often, trigger points are present secondary to other sources of pain, such as arthritis or bulging discs. The trigger points may actually be causing the painful symptoms attributed to these conditions. As such, they are often called “the great mimickers”.

Diagnoses include:

• Back pain
• Headaches
• Neck pain
• Rotator cuff (shoulder) pain
• Jaw pain (TMJD)
• Tennis elbow
• Carpal tunnel syndrome
• Hand and arm pain
• Repetitive Strain Injuries
• Pelvic pain
• Hip pain
• “Sciatic” pain (buttock and leg pain)
• Leg and knee pain
• Plantar fascitis (foot) pain
• Tendinitis/tendinopathy
• Bursitis
• Arthritis
• Disc pain (bulge/rupture/herniation) and radiculopathy
• Frozen shoulder
• Fibromyalgia
• and MUCH more

Muscles have been an under-treated cause of pain. In fact, with a specialized area of medicine for almost every area of the body (heart, eyes, lungs, intestines, kidneys, etc), oddly, there is no muscle specialty in medicine. Myofascial pain from trigger points is often overlooked as a possible source of pain by those seeking relief.

“Muscle is an orphan organ. No medical specialty claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain, and medical students and physical therapists rarely receive adequate primary training in how to recognize and treat myofascial trigger points.” — David G.Simons, MD pioneer in myofascial pain and trigger points, and aerospace physician

Unfortunately, common though the condition may be, the diagnoses and treatment of Myofascial Pain have yet to be included in most medical training. The majority of patients seeking relief from pain are still treated with the traditional approach of anti-inflammatory medications, muscle relaxants, anti-depressant medications, and/or strengthening programs. These prove ineffective, if not detrimental, as trigger points do not respond to them and maybe aggravated by further straining (strengthening exercises). Currently, there is no evidence that any form of drug treatment eliminates myofascial trigger points.  NSAIDs and other analgesics usually provide moderate but very temporary symptomatic relief. It is encouraging that myofascial trigger points are becoming more commonly considered when physicians diagnose their patients. Some primary care physicians, regularly administer trigger point injections. Some recognize the presence of trigger points and refer to Myofascial Trigger Point Therapists. Those that do, enjoy an enhanced success rate and grateful patients.

Research on Trigger Points

Patients evaluated in one pain management center were found to have a myofascial component to their pain in 95% of cases (Gerwin RD. A study of 96 subjects examined for both fibromyalgia and myofascial pain. J Musculoskeletal Pain 1995; 3 (suppl. 1):121-5.).  There is increasing awareness that active myofascial trigger points often play a role in the symptoms of patients with tension headaches (Fernandez-de-Las-Penas C, onso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA. Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache. Headache 2006; 46(8):1264-72.), low back pain, neck pain (Fernandez-de-Las-Penas C, onso-Blanco C, Miangolarra JC. Myofascial trigger points in subjects presenting with mechanical neck pain: A blinded, controlled study. Man Ther 2006; ), temporomandibular pain, forearm and hand pain, postural pain (Treaster D, Marras WS, Burr D, Sheedy JE, Hart D. Myofascial trigger point development from visual and postural stressors during computer work. J Electromyogr Kinesiol 2005;), pelvic/urogenital pain syndromes.

How Trigger Points Are Formed

The damage to muscle and connective tissue which results in trigger points can occur in several ways. It can happen as the result of:

• Repetitive overuse injuries (using the same body parts, in the same way, hundreds of times on a daily basis) from activities such as typing/mousing, handheld electronics, gardening, home improvement projects, work environments, etc.
• Sustained loading as with heavy lifting, carrying babies, briefcases, boxes, wearing body armor, or lifting bedridden patients.
• Habitually poor posture due to our sedentary lifestyles, de-conditioning, and poorly designed furniture
• Muscle clenching and tensing due to mental/emotional stress.
• Direct injury such as a blow, strain, break, twist or tear. Think car accidents, sports injuries, falling downstairs, and the like.
• Surprisingly, trigger points can even develop due to inactivities such as prolonged bed rest or sitting.

Many researchers agree that acute trauma or repetitive microtrauma may lead to the development of a trigger point. Lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbances joint problems may all predispose to the development of micro-trauma.

Active Trigger Points Cause Pain

After forming, trigger points have two phases, active and latent. The active, painful phase of the trigger point is the one that produces the unrelenting, debilitating pain symptoms and which motivates people to seek relief. The active trigger point hurts when pressed with a finger and causes pain around it and in other areas. It causes the muscle in which it’s located to be weak and due to the taut bands, to have limited flexibility. The active trigger point referral symptom may feel like a dull ache, deep, pressing pain, burning, or a sensation of numbness and fatigue. It can also cause sweating, tearing of eyes, goosebumps, and dizziness. The affected dense, shortened muscles, laden with taut bands may even compress and entrap nerves, leading to another secondary set of symptoms. If unaddressed or ineffectively treated, eventually, other muscles around the dysfunctional one may be required to “take up the slack”, becoming stressed and developing secondary trigger points. It is not unusual for chronic pain patients to have multiple, overlapping referred pain patterns, making diagnosis and treatment more complex. It is easy to see why this widespread pain is often mistaken for Fibromyalgia – a related but separate diagnosis.

Latent Trigger Points Matter Too

Trigger points can also lie quietly in muscles, sometimes for years. This type of trigger point is called latent. Latent trigger points are very common. Unless you press on the trigger point and feel the tenderness, you probably don’t know they are there. Most people have at least a few. Latent trigger points may persist for years after apparent recovery from injury. Latent trigger points cause:

• Restricted movement
• Distorted muscle movement patterns
• Stiffness and weakness of the affected muscle

They generally do not cause pain unless compressed. Many things can cause a trigger point to become active. An old injury that periodically re-surfaces (that “trick knee” or low back “going out”) may very likely be due to latent trigger points “waking up” and becoming active when aggravated by muscle overload, a cold draft, fatigue, infection, illness, or stress.

How Many Trigger Points Can I Have?

Since a trigger point is an abnormal biochemical and mechanical area in contracted muscle tissue, the number and exact location of each person can vary.  All muscle tissue is potentially prone to developing trigger points. Sometimes people have one trigger point but more often they have many. Prolonged referral of pain and weakness from one trigger point to another area of the body will generally cause other trigger points to develop in that area. These, in turn, if left untreated, can activate and also refer to pain, creating multiple pain patterns. The more areas that have pain and the longer you have had the pain, the more trigger points you are likely to have. It is rare for someone with pain to only have one or two muscles with trigger points.

Establishing if Trigger Points Are Present

A skilled practitioner who has been trained to recognize the symptoms of myofascial pain and palpate muscles for myofascial trigger points can assess whether myofascial trigger points are present. There are no commonly available lab tests or imaging studies that can confirm the diagnosis at this time. Myofascial trigger points can be seen on special MRI scans and special ultrasounds but these are currently only used in research.

“Myofascial pain syndromes are muscle pain syndromes that are classified as musculoskeletal disorders. They have defined pathophysiology that leads to the development of the characteristic taut or hard band in the muscle that is tender and that refers to pain to distant sites. MPS can be regional or generalized. If an MPS becomes chronic, it tends to generalize, but it does not become fibromyalgia. It can be classified both as a primary disorder without other medical illnesses or as a secondary pain syndrome that occurs as a result of another process. MPS may persist long after the initiating event or condition has passed, but it is nonetheless a muscle disease that can be satisfactorily treated.”R

Treating Myofascial Pain with Trigger Point Therapy

Treating each trigger point is relatively simple. Treating the whole myofascial pain syndrome so that pain goes away is a more complicated process.

You cannot strengthen a muscle that has a trigger point, because the muscle is already physiologically contracted. Too many physical therapists see a weakened muscle and immediately attempt to strengthen it without testing for the presence of trigger points. Attempts at strengthening a muscle with trigger points will only cause the trigger points to worsen.

Since a trigger point is the contraction mechanism of the muscle locked into a shortened position, the treatment of the trigger point involves unlocking that contraction mechanism (sarcomere). This can be achieved in several ways. Trigger Point Pressure Release (David Simons, MD, and Janet Travell, MD) involves applying pressure with a finger or other instrument to the trigger point and increasing the pressure as the trigger point “releases” and softens. There are a number of variations on this technique and a skilled practitioner will choose which is right for each patient and muscle treated.

Other techniques often used include Spray and Stretchwhich is a technique that uses a vapor-coolant spray (very cold because it evaporates the second it touches your skin) to distract the muscle into allowing a more complete stretch thereby helping to release the trigger point.

Once trigger points are released the muscle needs to be moved throughout its full range. Simple limbering movements done by the patient at home are important in the retraining of the muscle.

What to Expect from Treatment

Many patients experience relief from pain during the first treatment. For others, several treatments are needed before their pain starts to diminish. It is common for patients to experience some soreness for one to two days after treatment. This usually resolves after the first few treatments. You may experience fatigue as the chronically held musculature is allowed to relax and return to a normal tone, however, some patients experience an increase in energy. As the workload of the musculature shifts and returns to abnormal balance, pain patterns may change. This is a temporary and normal stage of recovery from chronic pain. It is not uncommon for people to experience relief from symptoms they were not seeking treatment for, such as chronic hand and forearm pain clearing up after being treated for a stiff neck. Returning to normal activities without pain is most often accelerated by adherence to the self-care program given to you by your therapist. Minimizing stress, pacing your activities, and avoidance of overexertion (as well as focusing on what you can do instead of your limitations) are of prime importance. Good communication, patience, and a positive attitude are essential.

Your rate of improvement depends on many conditions:

• Type of injury and length of time since it occurred.
• Overall physical health and level of fitness
• Perpetuating factors (many can be eliminated, others can not)
• Underlying skeletal abnormalities
• Nutrition (vitamin and mineral deficiencies, poor diet, etc.)
• Quality of sleep
• Depression or anxiety
• Patient compliance with self-care and eliminating or reducing perpetuating factors.
• Other medical conditions (i.e. allergies, diabetes, thyroid dysfunction, etc.)

Along with hands-on treatment to release myofascial trigger points, your therapist should:

• Take a full medical and pain history
• Evaluate your pain map for referred pain patterns
• Assess the ergonomics of your workstation and other regular activities.
• Assess and make suggestions to improve the quality of your sleep
• Make nutritional recommendations based on lab results from your physician-ordered blood work or refer you to a qualified health care professional to assist you with this.
• Make suggestions on how to choose an appropriate exercise/movement program and help you to incorporate it into your life.
• Help you to learn some self-treatment, self-management, and self-care to assist you to treat your condition and your trigger points. The degree that self-care will help can depend on many factors including how complex the condition is, if perpetuating factors can be eliminated, your dedication to self-care/making changes, and many others.

Trigger Point Images

Further Reading:

https://www.amtamassage.org/publications/massage-therapy-journal/tackling-migraines-head-on/

https://www.amtamassage.org/about/position-statements/massage-effective-for-tension-headaches/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447303/

https://www.massagemag.com/client-migraine-massage-miracle-87863/

https://healthylivinginbodyandmind.com/7-natural-remedies-for-migraine-headaches/

*Disclaimer: This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider.
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