THEMED ARTICLE y Migraine & Headache Review

For reprint orders, please contact reprints@expert-reviews.com

Muscle trigger point therapy

in tension-type headache
Expert Rev. Neurother. 12(3), 315–322 (2012)
Expert Review of Neurotherapeutics Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14

Cristina Alonso- Recent evidence suggests that active trigger points (TrPs) in neck and shoulder muscles contribute
Blanco1, Ana Isabel to tension-type headache. Active TrPs within the suboccipital, upper trapezius, sternocleidomastoid,
de-la-Llave-Rincón2,3 temporalis, superior oblique and lateral rectus muscles have been associated with chronic and
episodic tension-type headache forms. It seems that the pain profile of this headache may be
and César Fernández-
provoked by referred pain from active TrPs in the posterior cervical, head and shoulder muscles.
de-las-Peñas*2,3 In fact, the presence of active TrPs has been related to a higher degree of sensitization in tension-
1
Department of Nursing, Universidad type headache. Different therapeutic approaches are proposed for proper TrP management.
Rey Juan Carlos, Alcorcón, Madrid,
Preliminary evidence indicates that inactivation of TrPs may be effective for the management
Spain
2
Department of Physical Therapy, of tension-type headache, particularly in a subgroup of patients who may respond positively to
Occupational Therapy, Physical this approach. Different treatment approaches targeted to TrP inactivation are discussed in the
Medicine and Rehabilitation, current paper, focusing on tension-type headache. New studies are needed to further delineate
Universidad Rey Juan Carlos, Alcorcón,
Madrid, Spain
the relationship between muscle TrP inactivation and tension-type headache.
3
Esthesiology Laboratory,
Universidad Rey Juan Carlos, Alcorcón, Keywords : manual therapy • referred pain • tension-type headache • trigger points
For personal use only.

Madrid, Spain
*Author for correspondence:
Tel.: +34 914 888 884
Fax: + 34 914 888 957
cesar.fernandez@urjc.es
Tension-type headache is a pain disorder com-
monly seen in clinical practice by medical doc-
tors and experienced by almost everyone at some
time during their life. It is a condition in which
management is extremely difficult, particu-
larly on its chronic form (chronic tension-type
headache [CTTH]) [1–3] . In fact, this headache
causes substantial levels of disability to the indi-
vidual [4] . Globally, the percentage of individu-
als with headache is 10% for migraine, 38%
for tension-type headache and 3% for chronic
daily headache [5] . There has been an increas-
ing interest in the pathogenesis of CTTH over
the last decade, but despite several advances in
our understanding of the etiology of this condi-
tion, the real pathogenesis is still not completely
understood [6] . It seems that the most prominent
finding in tension-type headache, and particu-
larly in CTTH, is the presence of mechanical
pain hypersensitivity in the muscle tissues, for
instance pericranial tenderness [7–10] . These
studies have reported that this pericranial ten-
derness is uniformly increased throughout the
head and cervical regions and both muscles and
tendons are excessively tender [7–10] . In fact, in
the second edition of the International Headache
Society guidelines, pressure algometry has been
withdrawn from the diagnostic classification,
as pericranial tenderness assessed by manual
palpation is the most clinically useful tool to
distinguish between the different subtypes of
tension-type headache [11] . Nevertheless, most
studies investigating pericranial tenderness in
CTTH had cross-sectional designs, so a cause-
and-effect relationship between tenderness and
CTTH cannot be established. Therefore, we do
not know if this pericranial tenderness is a cause
or consequence of the headache. A 12-year lon-
gitudinal study demonstrated that subjects who
go on to develop CTTH show normal tenderness
scores at baseline; that is, before the beginning of
the symptoms [12] . This study demonstrates, for
the first time in a longitudinal study, that peri­
cranial tenderness seems to be the consequence,
and not a risk factor, of headache [12] . This man-
uscript reviews current advances in the role of
muscle tissues in the pathogenesis of tension-type
headache, particularly the role of muscle trigger
points (TrPs) [13] and their treatment.
Muscle TrPs in tension-type headache
Tension-type headache is a headache in which
there is clear scientific evidence to support an
etiologic role for TrPs [14] . This headache is
characterized by pressing or tightening pain,
pressure/band-like tightness and increased
tenderness on palpation of neck and shoulder
musculature [11] , resembling clinical descriptions
of referred pain elicited by TrPs [15] . A TrP is
defined as a hyperirritable and hypersensitive

www.expert-reviews.com 10.1586/ERN.11.138 © 2012 Expert Reviews Ltd ISSN 1473-7175 315

 Review Alonso-Blanco, de-la-Llave-Rincón & Fernández-de-las-Peñas

the combination of a sensitive spot within

Trigger points (referred pain to the head) a palpable taut band of a skeletal muscle,
and recognition of the pain elicited by
pressure applied to the spot by the patient
Release of nociceptive substances
[17] . Finally, it is important to note that
Peripheral sensitization the distinction between active and latent
Aδ and C fibers Aβ fibers TrPs has been substantiated by biochemi-
cal findings, since higher levels of chemical
Headache
Nociceptive barrage
mediators, such as bradykinin, substance P
or serotonin, have been found in active
TrPs compared with latent TrPs or control
Expert Review of Neurotherapeutics Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14

Sensitization of trigeminal nucleus caudalis neurons

non-TrP points [18,19] . The pathogenesis of
Central sensitization TrPs is not fully understood. Gerwin et al.
Central inhibition
suggested that TrPs can result from mus-
cle overload, which induces an endogenous
Sensory cortex and thalamus sensitization and involuntary shortening of the fibers,
Pericranial tenderness (Impairment of periaqueductal gray substance)
loss of oxygen and nutrient supply, and
consequent increased metabolic demand
Figure 1. Pain model for tension-type headache including peripheral
on local tissues [20] .
sensitization from active trigger points and central sensitization mechanisms. Several clinical studies conducted by dif-
Adapted from [34] . ferent research groups demonstrated the
relevance of active TrPs in tension-type
spot within a taut band of a skeletal muscle that, when prop- headache [21] . In a noncontrolled study, Mercer et al. found active
erly stimulated with palpation or dry needling, responds with a TrPs within the splenius capitis, splenius cervicis, semispinalis
For personal use only.

referred pain distant from the spot [16] . Active TrPs cause clinical cervicis, semispinalis capitis, levator scapulae, upper trapezius or
sensory and motor symptoms, and their local and referred pain are suboccipital muscles in patients with tension-type headache [22] .
responsible for (or at least part of) the patient’s symptoms. Latent Marcus et al. reported that patients with tension-type headache
TrPs are not a source of spontaneous pain, but their stimula- exhibit a greater number of active TrPs than healthy controls;
tion also elicits referred pain and accompanied symptoms. Active however, muscles where TrPs were frequently found were not
TrPs are distinguished from latent TrPs when the pain elicited summarized [23] .
by the TrP reproduces a familiar symptom to the individual. In In a series of blinded controlled studies, we demonstrated that
fact, the most accepted criteria for diagnosis of active TrPs are active TrPs are associated with tension-type headache. According
to these studies, patients with CTTH
exhibited active TrPs within the suboccipi-
tal [24] , upper trapezius [25] , superior oblique
[26] , sternocleidomastoid [27] , temporalis
[28] and lateral rectus [29] muscles as com-
pared with healthy controls who did not
experience active TrPs. TrPs in the extra-
ocular superior oblique (86%), suboccipi-
tal (65%), sternocleidomastoid and upper
trapezius (60–70%) muscles were the most
prevalent. In addition, these studies also
demonstrated that patients with CTTH
with active TrPs in these muscles exhib-
ited more severe headache intensity, longer
headache duration and higher headache
frequency than those patients with CTTH
with latent TrPs in the same muscles [24–28] .
Couppé et al. also found a higher preva-
lence of TrPs in the upper trapezius (85%)
in patients with CTTH [30] . Our group also
Figure 2. Longitudinal strokes applied over muscle trigger points in the found presence of active TrPs in superior
supra-ciliar muscle. oblique [24] , suboccipital [31] , sternocleido-
�������������
Figure reprinted with permission of the David G Simons Academy™, Switzerland © 2005.   mastoid, upper trapezius and temporalis [32]

316 Expert Rev. Neurother. 12(3), (2012)

 Muscle trigger point therapy in tension-type headache Review

muscles in patients with episodic tension-

type headache but to a lesser extent than in
patients with CTTH. In fact, Sohn et al.
have recently confirmed that active TrPs are
more prevalent in CTTH than in episodic
tension-type headache [33] .
Combining clinical and basic sciences,
Fernández-de-las-Peñas et al. formulated an
updated pain model for CTTH suggesting
the inclusion of peripheral sensitization by
active TrPs and central sensitization. In this
Expert Review of Neurotherapeutics Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14

model, active TrPs located in those muscles

innervated by the upper cervical segment
(C1–C3 nerves) and the trigeminal nerve can
be responsible for peripheral nociception pro-
ducing a continuous afferent barrage into the
trigeminal nucleus caudalis, which sensitizes
the CNS in patients with CTTH  (Figure 1)
[34] . According to Fernández-de-las-Peñas
et al., local muscle tenderness is the conse-
quence, whereas TrPs (referred pain) would Figure 3. Pincer compression applied over muscle trigger points in the
sternocleidomastoid muscle.
be one of the main causes (but not the sole Figure reprinted with permission of the David G Simons Academy™, Switzerland © 2005.
cause) of headache [35] . Nevertheless, this
pain model needs future studies for further commonly used [38] . In clinical practice, different intervention
For personal use only.

confirmation and verification. modalities targeted at inactivating TrPs have been proposed:
dry needling therapies [39] , ultrasound [40,41] , laser therapy [42] ,
Trigger point manual therapy for tension-type electrotherapy [43] and manual therapies [16] . Again, manual
headache therapies are the basic TrP treatment option [44] . In fact, sev-
Based on available data, it seems that the ongoing nociceptive input eral manual therapies are suggested in the literature: TrP com-
from muscle TrPs can perpetuate or promote central sensitiza- pression, spray and stretch, postisometric relaxation techniques,
tion in tension-type headache. If the peripheral nociceptive input neuro­muscular approaches, strain and counter strain, and others
is identified and subsequently eliminated, it is likely that central [45] . In a systematic review, Vernon and Schneider summarized
sensitivity can also be at least reduced. Since
a TrP represents an ongoing peripheral noci-
ceptive input [18] , inactivation of active TrPs
would therefore result in clinical improve-
ment [36] . In clinical practice, it is com-
monly seen that the degree of chronicity is
related to the number of treatments required
to inactivate TrPs [37] .������������������������
In patients with a lon-
ger pain history, where an increased central
sensitization is observed, one of the available
clinical treatments to normalize this central
sensitization is to repeat the treatment as
often as necessary to decrease the symptoms
of the patient. The clinician should elimi-
nate the active TrPs that are contributing
to this process. Since a close association
between TrPs and tension-type headache
exists, a therapeutic approach based on TrP
management in this headache should be
explored in future studies.
Different nonpharmacological interven- Figure 4. Longitudinal stretching strokes applied over muscle trigger points in
tions are proposed for the management of the levator scapulae muscle.
CTTH, but manual therapies are the most Figure reprinted with permission of the David G Simons Academy™, Switzerland © 2005.

www.expert-reviews.com 317
 Review Alonso-Blanco, de-la-Llave-Rincón & Fernández-de-las-Peñas

most studies investigated single modalities,

whereas multimodal approaches are usually
practiced by clinicians.
Recent studies reported that manual
therapies, including soft tissue techniques
targeted at inactivating TrPs, are effective
in reducing headache frequency, intensity
and duration in CTTH [47–49] . A case
series including nine girls (aged 13 years)
with tension-type headache suggested that
TrPs can play an additional role in a sub-
Expert Review of Neurotherapeutics Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14

group of children with this headache [50] .

These girls received TrP treatment twice
per week. After 6.5  sessions, the head-
ache frequency was reduced by 67.7%, the
intensity by 74.3% and the mean dura-
tion by 77% [50] . In these studies, manual
therapies were applied to inactive TrPs.
Nevertheless, clinicians have experienced
that some patients respond quicker than
others. In the last decade, there has been
an increasing interest in identifying clini-
cal features of patients with chronic pain,
in this case CTTH, who will likely benefit
For personal use only.

from specific treatment (i.e., clinical pre-

diction rules). In fact, Fernández-de-las-
Peñas et al. conducted two clinical predic-
tion rules to identify women with CTTH
who will experience a quick improvement
in headache intensity, frequency or dura-
tion after inactivation of TrPs. A pre­
liminary clinical prediction rule identified
four variables for quick short-term benefit
(headache duration <8.5 h/day, frequency
<5.5 days/week, bodily pain <47 [score out
of 100], vitality <47.5 [score out of 100])
and two variables for 1-month benefit (fre-
quency <5.5 days/week, and bodily pain
<47 [score out of 100]) [51] . In this study, if
a patient presents with all variables (+ like­
lihood ratio: 5.9), the probability of expe-
riencing immediate successful treatment
Figure 5. Longitudinal stretching strokes applied over active trigger points in
the upper trapezius muscle in sitting. improved by 87.4%. Nevertheless, this
Figure reprinted with permission of the David G Simons Academy™, Switzerland © 2005. study included a small sample size (n = 35),
and individuals only received TrP therapy
moderate-to-strong evidence supporting the use of static pressure focused on head, neck and shoulder muscles (temporalis, sub­
for immediate pain relief of muscle TrP and limited evidence occipital, upper trapezius, sternocleidomastoid, splenius capitis
for long-term pain relief [46] . Different mechanisms, for instance and semispinalis capitis; Figures 2 & 3 ) [51] .
equalization of the length of the muscle sarcomeres, reactive In a second study, women with CTTH received a multi­modal
hyperemia in the TrP, spinal reflex, mobilization and stretching physical therapy session including joint mobilization to the cervi-
to the TrP taut band, and temporary elongation of the connective cal and thoracic spine and TrP therapy soft tissue stroke, pressure
tissue, had been proposed for explaining therapeutic effects of release or muscle energies (Figures  4  &  5) [52] . In this study, the
manual therapies; however, more research is needed to confirm following eight variables were identified: age <44.5 years, left
these hypotheses. In addition, it is difficult to draw firm con- sternocleidomastoid TrPs, suboccipital TrPs, left superior oblique
clusions from current evidence related to TrP inactivation since TrPs, cervical rotation to the left >69°, total tenderness score

318 Expert Rev. Neurother. 12(3), (2012)

 Muscle trigger point therapy in tension-type headache Review

<20.5, Neck Disability Index <18.5 and

referred pain area of right upper trapezius
TrPs >42.23 (arbritary units) [52] . If five of
the eight variables (+ likelihood ratio: 7.1)
were present, the chance of experiencing
an immediate successful treatment was
86.3%. These studies indicate that some
patients with CTTH may benefit from TrP
treatment; however, further studies validat-
ing current data are now needed. Another
therapeutic option for TrP inactivation is
Expert Review of Neurotherapeutics Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14

the introduction of a needling, either dry

needling or injection, into the TrP [39] . TrP
injections are administered with a hypo-
dermic syringe, whereas dry needling is
administered with a solid filament needle
(Figure 6) . It has previously been suggested
that dry needling can cause more post-
needling soreness than TrP injection [53] ;
however, Ga et al. compared TrP injections
with dry needling using a solidfilament Figure 6. Dry needling of upper trapezius muscle trigger points.
Figure reprinted with permission of the David G Simons Academy™, Switzerland © 2005.
needle and found no significant difference
between the two approaches in postnee-
dling soreness and that dry needling provided longer-lasting pain looking at different dosing paradigms and different injection pro-
For personal use only.

relief [54] . The Cochrane Review found that dry needling was a tocols, so the final answer as to the effective dose and injection site
potentially useful adjunct in the treatment of chronic lower back is yet to come. It is the authors’ opinion that botulinum toxin A
pain [55] ; however, no previous study has investigated the effective- should be injected in muscles where TrPs refer to pain to the head.
ness of TrP dry needling in tension-type headache. In such a way, future trials looking at the effect of botulinum
The injection of botulinum toxin has been used in the treat- toxin A on headaches should identify TrPs in the head, neck and
ment of headaches since the report by Binder et al. [56] ; how- shoulders that reproduce the patient’s headache, and direct injec-
ever, its use remains controversial. Botulinum toxin acts through tion of botulinum toxin A to those TrPs.
inhibiting muscle contraction by preventing vesicles in the pre­ Finally, clinicians should be aware that a TrP role in CTTH
synaptic nerve terminal from docking or attaching to the cell does not negate the relevance of other musculoskeletal promoting
membrane, preventing the release of acetylcholine, and it also has factors, such as forward head posture [62] , muscle atrophy [63] and
an antinociceptive effect (reduction of neuropeptide release) [57] . altered muscle recruitment [64] , and also psychological factors [65] .
The effectiveness of botulinum toxin A in CTTH is limited as For instance, pain-related fear, a feature seen in some individuals
contradictory findings have been found. Schmitt et al. injected with CTTH [66] , may induce muscle disuse and subsequent atro-
20 units of botulinum toxin A into the frontal and temporal mus- phy of the deep cervical extensor muscles [63] . This muscle atrophy
cles and found no statistically significant differences between promotes an increased muscle coactivation of the super­ficial cervi-
treatment and placebo groups in pain intensity, the number of cal muscles [64] . Ultimately, this muscle coactivation can overload
pain-free days and the consumption of analgesics [58] . Similar the musculature, and therefore activate TrPs. Therefore, proper
results were reported by Schulte-Mattler et al. [59] . Silberstein et al. treatment of TrPs also includes the proper management of the
injected 0, 50, 100 and 150 units of botulinum toxin A in five specific promoting factors for each patient.
sites, or 86–100 units injected subcutaneously in three sites, and
also showed no differences in the number of headache-free days Conclusion
in CTTH subjects [60] . However, even though efficacy was not In the past few years, it has been demonstrated that active TrPs
demonstrated for the primary end point, more subjects in three in neck–shoulder muscles contribute to tension-type headache.
botulinum toxin groups had a ≥50% reduction in headache days Active TrPs within the suboccipital, upper trapezius, sterno­
than those given placebo [60] . A recent study found that patients cleidomastoid, temporalis, superior oblique and lacteral rectus
with CTTH who received botulinum toxin A injection over active muscles are associated with CTTH. Based on available data,
TrPs experienced greater reductions in headache frequency in the it seems that the pain profile of tension-type headache may be
short term [61] . It seems that different doses and injection sites can provoked by referred pain from TrPs in the posterior cervical,
induce different effects. One might expect that there would be head and shoulder muscles. In addition, preliminary evidence
failure to affect the frequency or intensity of headache at some indicates that the management of active TrPs may be effec-
doses and with fixed-site protocols. Studies are still in progress, tive for tension-type headache, particularly in a subgroup of

www.expert-reviews.com 319
 Review Alonso-Blanco, de-la-Llave-Rincón & Fernández-de-las-Peñas

patients. Further studies are now needed to further delineate
the relationship between muscle TrPs and headaches.
Expert commentary
Current evidence demonstrate the relevance of referred pain
elicited by TrPs in the development of tension-type headache.
Several studies, conducted by our research group, have changed
the understanding of tension-type headache based on tenderness
from muscle tissues. There are substantial differences between
tenderness (tender point) and trigger points, which have been
summarized in several reviews [14,21] . In the current manuscript
Expert Review of Neurotherapeutics Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14
It should be noted that different therapeutic strategies could be
applied for patients with these headache disorders. In fact, current
evidence confirms that multimodal physical therapy is the most
appropriate intervention for these patients [47–49] .
Five-year view
There is scientific evidence showing the relevance of TrPs in sev-
eral headaches, particularly tension-type headache. In the authors’
opinion, future research should focus on implementing these data
in clinical practice. The first step is to validate current clinical
prediction rules [51,52] in order to determine whether a subgroup of

we have summarized most of the updated evidence related to
the presence of TrPs in tension-type headache and their treat-
ment by both manual and needling approaches. It should be
noted that TrPs are not only found in tension-type headache, but
also in migraine [67,68] and in patients with cluster headache [69] .
Different mechanisms have been proposed for the presence of
TrPs and different headaches. For instance, as we have discussed
in the current paper, tension-type headache can be explained,
at least in part, by referred pain elicited by active TrPs [34] . In
patients with migraine, TrPs may irritate the CNS, thereby
activating the trigeminal nerve nucleus caudalis and hence the
trigemino-vascular system, precipitating, but not causing, the
migraine.
For personal use only.
patients with tension-type headache can potentially benefit from
physical therapy interventions. In addition, another important
step would be the development of randomized controlled trials
including TrP therapy into a multidisciplinary management of
headache patients. Similarly, future studies should investigate
the effects of injection of botulinum toxin A into active TrPs in
headaches. It is our opinion that although several advances in our
understanding of tension-type headache have been achieved in
recent years, much more clinical research is needed.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with

In the authors’ experience, patients with tension-type or the subject matter or materials discussed in the manuscript. This includes
migraine headaches can benefit their clinical improvement with employment, consultancies, honoraria, stock ownership or options, expert
appropriate physical management of TrPs. In the current article, testimony, grants or patents received or pending, or royalties.
we have shown some manual therapies applied in our studies [51,52] . No writing assistance was utilized in the production of this manuscript.

Key issues
• Referred pain from trigger points in the head, neck and shoulder muscles reproduces head pain features of tension-type headache.
• Patients with chronic and episodic tension-type headache exhibit active trigger points.
• Suboccipital, upper trapezius, temporalis and sternocleidomastoid muscles are most commonly affected by trigger points in
tension-type headache.
• Referred pain from extra-ocular muscle trigger points also reproduces the headache pain pattern in tension-type headache.
• Patients with active trigger points exhibit more severe headache clinical parameters than those with latent trigger points in head and
neck muscles.
• Tension-type headache can be explained, at least to some extent, by referred pain from trigger points in head, neck and shoulder
muscles.
• Different therapeutic approaches can be used for the management of trigger points in patients with tension-type headache.
• It seems that a subgroup of patients with tension-type headache responds positively to physical therapy.

3 Bendtsen L, Jensen R. Epidemiology of 5 Jensen R, Stovner LJ. Epidemiology and

References
Papers of special note have been highlighted as:
• of interest
•• of considerable interest
1 Andlin-Sobocki P, Jonsson B, Wittchen
HU, Olesen J. Cost of disorders of the
brain in Europe. Eur. J. Neurol.
12(Suppl. 1), 1–27 (2005).
4 Stovner L, Hagen K, Jensen R et al.
2 Bendtsen L, Jensen R. Tension-type
headache: the most common, but also the
most neglected headache disorder. Curr.
Opin. Neurol. 19, 305–309 (2006).
tension-type headache, migraine and
cervicogenic headache. In: Tension Type and
Cervicogenic Headache: Patho-Physiology,
Diagnosis and Treatment. Fernández-de-las-
Peñas C, Arendt-Nielsen L, Gerwin R
(Eds). Jones and Bartlett Publishers,
Baltimore, MD, USA, 7–13 (2010).
The global burden of headache: a
documentation of headache prevalence and
disability worldwide. Cephalalgia 27,
193–210 (2007).
co-morbidity of headache. Lancet Neurol.
7, 54–361 (2008).
6 Fumal A, Schoenen J. Tension-type
headache: current research and clinical
management. Lancet Neurol. 7, 70–83
(2008).
• A detailed review of the clinical
management of tension-type headache.
7 Langemark M, Olesen J. Pericranial
tenderness in tension headache. A blind
controlled study. Cephalalgia 7, 249–255
(1987).

320 Expert Rev. Neurother. 12(3), (2012)


8 Jensen R, Rasmussen BK, Pederken B,
Olesen J. Muscle tenderness and pressure
pain threshold in headache: a study
population. Pain 52, 193–199 (1993).
9 Jensen R, Olesen J. Initiating mechanism
of experimentally induced tension-type
headache. Cephalalgia 16, 175–182 (1996).
10 Jensen R, Bendtsen L, Olesen J. Muscular
factors are of importance in tension-type
headache. Headache 38, 10–17 (1998).
11 Headache Classification Subcommittee of
Expert Review of Neurotherapeutics Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14
the International Headache Society.
The international classification of headache
disorders: 2nd edition Cephalalgia
24(Suppl. 1), 9–160 (2004).
12 Buchgreitz L, Lyngberg AC, Bendtsen L,
Jensen R. Increased pain sensitivity is not a
risk factor but a consequence of frequent
headache: a population-based follow-up
study. Pain 137, 623–630 (2008).
• A longitudinal study showing that
increased pain sensitivity is the
consequence and not the cause of
headache.
13 Fernández-de-las-Peñas C, Simons D,
For personal use only.
Cuadrado ML, Pareja J. The role of
myofascial trigger points in musculoskeletal
pain syndromes of the head and neck. Curr.
Pain Headache Rep. 11, 365–372 (2007).
14 Fernández-de-las-Peñas C, Schoenen J.
Chronic tension-type headache: what’s new?
Curr. Opin. Neurol. 22, 254–261 (2009).
•• One of the most up-to-date reviews on
chronic tension-type headache.
15 Gerwin R. Headache. In: Clinical Mastery
in The Treatment of Myofascial Pain.
Ferguson L, Gerwin R (Eds). Lippincott
Williams and Wilkins, Philadelphia, PA,
USA, 1–24 (2005).
16 Simons D, Travell J, Simons L. Travell and
Simons’ Myofascial Pain and Dysfunction:
The Trigger Point Manual: Volume 1
(2nd Edition). Williams and Wilkins,
Baltimore, MD, USA (1999).
• The most comprehensive textbook on
trigger points.
17 Gerwin RD, Shannon S, Hong CZ,
Hubbard D, Gevirtz R. Inter-rater
reliability in myofascial trigger point
examination. Pain 69, 65–73 (1997).
18 Shah JP, Phillips TM, Danoff JV, Gerber
L. An in vivo microanalytical technique for
measuring the local biochemical milieu of
human skeletal muscle. J. Appl. Physiol. 99,
1977–1984 (2005).
19 Shah JP, Gilliams EA. Uncovering the
biochemical milieu of myofascial trigger
points using in vivo microdialysis: an
www.expert-reviews.com
application of muscle pain concepts to
myofascial pain syndrome. J. Bodyw. Mov.
Ther. 12, 371–384 (2008).
20 Gerwin RD, Dommerholt D, Shah JP.
An expansion of Simons’ integrated
hypothesis of trigger point formation. Curr.
Pain Headache Rep. 8, 468–475 (2004).
21 Fernández-de-las-Peñas C, Simons DG,
Gerwin R, Cuadrado ML, Pareja JA.
Muscle trigger points in tension-type
headache. In: Tension Type and Cervicogenic
Headache: Patho-Physiology, Diagnosis and
Treatment. Fernández-de-las-Peñas C,
Arendt-Nielsen L, Gerwin RD (Eds). Jones
and Bartlett Publishers, Baltimore, MD,
USA, 61–76 (2010).
22 Mercer S, Marcus DA, Nash J. Cervical
musculoskeletal disorders in migraine and
tension-type headache. Presented at: 68th
Annual Meeting of the American Physical
Therapy Association. Cincinnati, OH, USA,
4–6 April 1993.
23 Marcus DA, Scharff L, Mercer S,
Turk DC. Musculoskeletal abnormalities in
chronic headache: a controlled comparison
of headache diagnostic groups. Headache
39, 21–27 (1999).
24 Fernández-de-las-Peñas C, Alonso-Blanco
C, Cuadrado ML, Gerwin RD, Pareja JA.
Trigger points in the suboccipital muscles
and forward head posture in tension-type
headache. Headache 46, 454–460 (2006).
25 Fernández-de-las-Peñas C, Ge H,
Arendt-Nielsen L, Cuadrado ML, Pareja
JA. Referred pain from trapezius muscle
trigger point shares similar characteristics
with chronic tension-type headache. Eur.
J. Pain 11, 475–482 (2007).
26 Fernández-de-las-Peñas C, Cuadrado ML,
Gerwin RD, Pareja JA. Referred pain from
the trochlear region in tension-type
headache: a myofascial trigger point from
the superior oblique muscle. Headache 45,
731–737 (2005).
27 Fernández-de-las-Peñas C, Alonso-Blanco
C, Cuadrado ML, Gerwin RD, Pareja JA.
Myofascial trigger points and their
relationship with headache clinical
parameters in chronic tension-type
headache. Headache 46, 1264–1272 (2006).
28 Fernández-de-las-Peñas C, Ge H,
Arendt-Nielsen L, Cuadrado ML, Pareja
JA. The local and referred pain from
myofascial trigger points in the temporalis
muscle contributes to pain profile in
chronic tension-type headache. Clin.
J. Pain 23, 786–792 (2007).
29 Fernández-de-las-Peñas C, Cuadrado ML,
Gerwin RD, Pareja JA. Referred pain from
the lateral rectus muscle in subjects with
Review
chronic tension-type headache. Pain Med.
10, 43–48 (2009).
30 Couppé C, Torelli P, Fuglsang-Frederiksen
A, Andersen KV, Jensen R. Myofascial
trigger points are very prevalent in patients
with chronic tension-type headache:
a double-blinded controlled study. Clin.
J. Pain 23, 23–27 (2007).
31 Fernández-de-las-Peñas C, Alonso-Blanco
C, Cuadrado ML, Pareja JA. Myofascial
trigger points in the suboccipital muscles in
episodic tension-type headache. Man. Ther.
11, 225–230 (2006).
32 Fernández-de-las-Peñas C, Cuadrado ML,
Pareja JA. Myofascial trigger points, neck
mobility and forward head posture in
episodic tension-type headache. Headache
47, 662–672 (2007).
33 Sohn JH, Choi HC, Lee SM, Jun AY.
Differences in cervical musculoskeletal
impairment between episodic and chronic
tension-type headache. Cephalalgia 30,
1514–1523 (2010).
34 Fernández-de-las-Peñas C, Cuadrado ML,
Arendt-Nielsen L, Simons DG, Pareja JA.
Myofascial trigger points and sensitisation:
an updated pain model for tension-type
headache. Cephalalgia 27, 383–393 (2007).
•• An updated pain model suggesting the
relevance of trigger points in sensitization
mechanisms in tension-type headache.
35 Fernández-de-las-Peñas C, Arendt-Nielsen
L, Simons DG, Cuadrado ML, Pareja JA.
Sensitization in tension-type headache:
a pain model. In: Tension Type and
Cervicogenic Headache: Patho-Physiology,
Diagnosis and Treatment. Fernández-de-las-
Peñas C, Arendt-Nielsen L, Gerwin R
(Eds). Jones and Bartlett Publishers,
Baltimore, MD, USA, 97–106 (2010).
36 Dommerholt J. Persistent myalgia
following whiplash. Curr. Pain Headache
Rep. 9, 326–330 (2005).
37 Hong CZ, Simons DG. Response to
treatment for pectoralis minor: myofascial
pain syndrome after whiplash.
J. Musculoskeletal Pain 1(1), 89–131 (1993).
38 Eisenberg DM, Davis RB, Ettner SL et al.
Trends in alternative medicine use in the
United States, 1990–1997, results of a
follow-up national survey. JAMA 280,
1569–1575 (1998).
39 Dommerholt J, Mayoral-Del-Moral O,
Gröbli C. Trigger point dry needling.
J. Manual Manipulative Ther. 14, E70–E87
(2006).
40 Srbely JZ, Dickey JP. Randomized
controlled study of the anti-nociceptive
effect of ultrasound on trigger point
321
 Review Alonso-Blanco, de-la-Llave-Rincón & Fernández-de-las-Peñas
sensitivity: novel applications in myofascial
therapy? Clin. Rehabil. 21, 411–417 (2007).
41 Srbely JZ, Dickey JP, Lowerison M,
Edwards AM, Nolet PS, Wong LL.
Stimulation of myofascial trigger points with
ultrasound induces segmental anti-
nociceptive effects: a randomized controlled
study. Pain 139, 260–266 (2008).
42 Dundar U, Evcik D, Samli F, Pusak H,
Kavuncu V. The effect of gallium arsenide
aluminum laser therapy in the management
of cervical myofascial pain syndrome: a
Expert Review of Neurotherapeutics Downloaded from informahealthcare.com by Penn State Berks Campus on 11/05/14
double blind, placebo-controlled study. Clin.
Rheumatol. 26, 930–934 (2007).
43 Tanrikut A, Ozaras N, Ali-Kaptan H et al.
High voltage galvanic stimulation in
myofascial pain syndrome. J. Musculoskeletal
Pain 11, 11–15 (2003).
44 Dommerholt J, Bron C, Franssen JLM.
Myofascial trigger points: an evidence
informed review. Journal of Manual &
Manipulative Therapy 14, 203–221 (2006).
45 Fernández-de-las-Peñas C, Ge HY,
Dommerholt J. Manual treatment of
myofascial trigger points. In: Neck and Arm
Pain Syndromes: Evidence-Informed
For personal use only.
Screening, Diagnosis and Conservative
Management. Fernández-de-las-Peñas C,
Cleland J, Huijbregts P (Eds). Churchill
Livingstone-Elsevier, London, UK (2011).
46 Vernon H, Schneider M. Chiropractic
management of myofascial trigger points
and myofascial pain syndrome: a systematic
review of the literature. J. Manipul. Physiol.
Ther. 32, 14–24 (2009).
47 Torelli P, Jensen R, Olesen J. Physiotherapy
for tension-type headache: a controlled
study. Cephalalgia 24, 29–36 (2004).
48 van Ettekoven H, Lucas C. Efficacy of
physiotherapy including a cranio-cervical
training programme for tension-type
headache: a randomized clinical trial.
Cephalalgia 26, 983–991 (2006).
49 Söderberg E, Carlsson J, Stener-Victorin E.
Chronic tension-type headache treated with
acupuncture, physical training and
relaxation training: between group
differences. Cephalalgia 26, 1320–1329
(2006).
50 von Stülpnagel C, Reilich P, Straube A.
Myofascial trigger points in children with
tension-type headache: a new diagnostic and
therapeutic option. J. Child Neurol. 24,
406–409 (2009).
• A case series showing the importance of
inactivating trigger points in children.
51 Fernández-de-las-Peñas C, Cleland JA,
Cuadrado ML, Pareja JA. Predictor variables
for identifying patients with chronic
322
tension-type headache who are likely to
achieve short-term success with muscle
trigger point therapy. Cephalalgia 28,
264–275 (2008).
• The first preliminary clinical prediction
rule for tension-type headache based on
trigger point physical therapy.
52 Fernández-de-las-Peñas C, Cleland JA,
Palomeque-del-Cerro L, Caminero AB,
Guillem-Mesado A, Jiménez-García R.
Development of a clinical prediction rule for
identifying women with tension-type
headache who are likely to achieve
short-term success with joint mobilization
and muscle trigger point therapy. Headache
51, 246–261 (201).
•• A clinical prediction rule for tension-type
headache and physical therapy.
53 Kamanli A, Kaya A, Ardicoglu O,
Ozgocmen S, Zengin FO, Bayik Y.
Comparison of lidocaine injection,
botulinum toxin injection, and dry needling
to trigger points in myofascial pain
syndrome. Rheumatol. Int. 25, 604–611
(2005).
54 Ga H, Koh HJ, Choi JH, Kim CH.
Intramuscular and nerve root stimulation vs
lidocaine injection to trigger points in
myofascial pain syndrome. J. Rehabil. Med.
39, 374–378 (2007).
55 Furlan A, Tulder M, Cherkin D et al.
Acupuncture and dry-needling for lower
back pain: an updated systematic review
within the framework of the Cochrane
collaboration. Spine 30, 944–963 (2005).
56 Binder W, Brin MF, Blitzer A, Schoenrock
LD, Pogoda JM. Botulinum toxin type-A
(BTX-A) for migraine: an open label
assessment. Otolaryngol. Head Neck Surg.
123, 669–676 (2000).
57 Gerwin RD. Botulinum toxin A in the
treatment of headaches. In: Tension Type and
Cervicogenic Headache: Pathophysiology,
Diagnosis and Treatment. Fernández-de-las-
Peñas C, Arendt-Nielsen L, Gerwin RD
(Eds). Jones and Bartlett Publishers, Boston,
MA, USA, 431–446 (2009).
58 Schmitt WJ, Slowey E, Fravi N, Weber S,
Burgunder JM. Effect of botulinum toxin A
injections in the treatment of chronic
tension-type headache: a double-blind,
placebo-controlled trial. Headache 41,
658–664 (2001).
59 Schulte-Mattler WJ, Krack P, BoNTTH
Study Group. Treatment of chronic
tension-type headache with botulinum
toxin A: a randomized, double-blind,
placebo-controlled multicenter study. Pain
109, 110–114 (2004).
60 Silberstein SD, Göbel H, Jensen R et al.
Botulinum toxin type A in the prophylactic
treatment of chronic tension-type headache:
a multicentre, double-blind, randomized,
placebo-controlled, parallel group study.
Cephalalgia 26, 790–800 (2006).
61 Harden RN, Cottrill J, Gagnon CM et al.
Botulinum toxin A in the treatment of
chronic tension-type headache with cervical
myofascial trigger points: a randomized,
double-blind, placebo-controlled pilot study.
Headache 49, 732–743 (2009).
• An important clinical study suggesting
the importance of injection of botulinum
toxin into trigger points in tension-type
headache.
62 Fernández-de-las-Peñas C, Alonso-Blanco
C, Cuadrado ML, Pareja JA. Forward head
posture and neck mobility in chronic
tension-type headache: a blinded, controlled
study. Cephalalgia 26, 314–319 (2006).
63 Fernández-de-las-Peñas C, Bueno A,
Ferrando J, Elliott JM, Cuadrado ML,
Pareja J. Magnetic resonance imaging of the
morphometry of cervical extensor muscles in
chronic tension-type headache. Cephalalgia
27, 355–362 (2007).
64 Fernández-de-las-Peñas C, Falla D,
Arendt-Nielsen L, Farina D. Cervical muscle
coactivation in isometric contractions is
enhanced in chronic tension-type headache.
Cephalalgia 28, 744–751 (2008)
65 Peñacoba-Puente C, Fernández-de-las-Peñas
C, González-Gutiérrez JL, Miangolarra-
Page JC, Pareja JA. Mediating or moderating
effect of anxiety and depression in headache
clinical parameters and quality of life in
chronic tension-type headache. Eur. J. Pain
12, 886–894 (2008).
66 Norton PJ, Asmundson G. Anxiety
sensitivity, fear, and avoidance behaviour in
headache pain. Pain 111, 218–223 (2004).
67 Fernández-de-las-Peñas C, Cuadrado ML,
Pareja JA. Myofascial trigger points, neck
mobility and forward head posture in
unilateral migraine. Cephalalgia 26,
1061–1070 (2006).
68 Calandre EP, Hidalgo J, García-Leiva JM,
Rico-Villademoros F. Trigger point
evaluation in migraine patients: an
indication of peripheral sensitization linked
to migraine predisposition? Eur. J. Neurol.
13, 244–249 (2006).
69 Calandre EP, Hidalgo J, Garcia-Leiva JM,
Rico-Villademoros F, Delgado-Rodriguez A.
Myofascial trigger points in cluster headache
patients: a case series. Head Face Med. 4, 32
(2008).
Expert Rev. Neurother. 12(3), (2012)