Headaches Outside the Head
If you have been in practice for more than a day, you have encountered a patient with a complaint of headache. I don't need to regurgitate all the statistics relating to disability, lost time from work, and billions of dollars of healthcare expenses wrought every year blamed on headache. But the topic of "headache" itself becomes very broad – there are sinus headaches, tension headaches, food allergy headaches, vascular headaches, etc. It becomes very easy to focus just on the area of complaint and not look for other issues or referred causes. Many times the headache is a referred symptom of a problem somewhere else – often not even in the head. I would like to briefly review some of the more common myofascial causes of headache.
Myofascial trigger points are recognized in many acupuncture styles as "ah-shi" points, and are often related to the treatment style of the "barefoot doctors." Understanding these muscles, their anatomical arrangement, and their pain referral patterns can give great insight into the root cause of many headache complaints.
The Splenius muscles. Splenius Capitis and Splenius Cervicis. These muscles originate at the lower cervical and upper dorsal spinous processes and attach to the upper cervical transverse processes and the mastoid. These muscles are most often irritated with sudden trauma (whiplash) or exposure to cold draft. Trigger point typically occur in the occipital triangle or at the angle of the neck. Trigger points in these muscles will often refer pain to the vertex, the occiput, the orbit, and diffusely through the skull. Spasm in these muscles can also be associated with blurry vision.
The Posterior Cervical muscles. This collection of muscles is primarily responsible for extension and rotation of the head and neck. Primary trigger points for these muscles is in the posterior multifidi, under the occiput, and on the scalp above the occipital attachments. Spasm or trigger points in these tissues will produce pain at the occiput down the neck and across the shoulder, up the back of the scalp, and around the head ("like a headband"), and over the lateral orbit.
The Suboccipital muscles. These essentially form the occipital triangle – from the occiput, the posterior arch of the atlas, the spinous of the axis, and the transverse process of the atlas. Their primary function is to extend, rotate and tilt the head. Spasm/trigger points in these muscles produces a "ghostly" pain across the side of the head from the occiput, over the ear to the behind the eye.
The Levator Scapulae. Travell notes this as one of the most commonly involved shoulder girdle muscles.
Spasm in these muscles is often associated with the complaint of "stiff neck," and will often present with the involved shoulder girdle pulling high. Pain referral is often focused to the angle of the neck, but in my experience will also commonly refer pain to the upper neck and base of the skull.
The Upper Trapezius. Travell notes this muscle is probably the muscle most often beset by myofascial trigger points, but is often overlooked as a source of temporal headaches. Most charts I have seen clearly document the trigger points at the attachment of the trapezius at the clavicle can refer pain up over the SCM, behind the ear, around the lateral scalp, down to the angle of the mandible, at the temple, and into the orbit. Trigger points near the distal attachments into the scapular spine will also produce pain up under the occipital shelf.
The SternoCleidoMastoid muscle. Both divisions of this – the sternal and clavicular – contain trigger points which refer into the head. The superficial branch refers pain to the back of the head, around the orbit, across the cheek, and sometimes the vertex. The deeper (clavicular) division refers pain over the mastoid, in the ear canal, and over the orbit. It should also be noted that trigger points in the clavicular division can also refer pain across the scalp to over the opposite orbit.
As many of the above discussed muscles have attachments at or near the occiput, the OccipitoFrontalis muscle should also be considered. The scalp (galea aponeurotica) is essentially held in place by the Frontalis, the Occipitalis, and the Temporoparietalis. Spasm in the neck musculature can quickly translate through these attachments and create symptoms in other regions of the scalp.
Certainly this is a very brief overview of these muscles and their possible involvement. Each one individually could be an entire topic in itself. The point here is that when confronted with the vague complaint or headache, much more information must be pursued. First, the type of headache – if the patient has a metabolic food allergy, trigger point therapy may provide some transient relief but will not fix the problem. At the same time a complaint of ear pain may be more due to SCM spasm than a supposed inner ear infection. Make sure to fully investigate the case history and have a clear understanding of the symptoms and complaints. Trigger points are arguably one of the most insidious symptom antagonisits, and often times patients don't even make the correlation. I highly recommend the textbooks by Janet Travell as they are an incredible source of anatomical, clinical, and treatment information.
As health care providers, we are obligated to think outside the box, it is good practice technique to rule out other possible conditions. If our patient has a complaint, we should perform a complete history and careful evaluation so that we provide the correct care. Don't get caught in the trap of defaulting to a garbage "dump-all" diagnosis like "headache" – figure out what the problem really is. If you take the time to fully evaluate the patient so that your diagnosis is correct, your treatment will be appropriate, and your patient will thank you for your quality care.
- Travell, J.G. (1992) Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, MD. Williams & Wilkins.
- Laws, S., Franklin, D.J. The Receptor-Tonus Technique (Available from: Holistic Health Enhancement, 1210 n. 24th St., Quincy, IL 62301)