Trigger Point Injections as an Adjunct to Chiropractic Care for
Cervicogenic Headaches

Clearly, physicians have many means for addressing myofascial trigger points. Injection with local anesthetic has been described as the most efficient treatment modality to inactivate trigger points and provide prompt relief.¹ Medical authors typically categorize trigger point injection with local anesthetic as a non-pharmocological treatment. Trigger point injection earns this categorization because the anesthetic effects are specific to targeted trigger points, and side effects other than local discomfort are rare. While manual therapies are also effective in the treatment of trigger points, some cases prove difficult to resolve quickly or completely.^2-5 In these cases, I invite physicians to consider trigger point injections as an adjunct in their chiropractic treatment plan.

As you know, a multitude of muscles can refer pain to areas of the head and neck and cause recurring headaches: sternocleidomastoid, occipitalis, muscles of mastication, trapezius, and cervical paraspinal muscles. Patients can experience this referred pain in both the anterior and posterior cranial muscles.^6-8 Trigger points in the head and neck region can also manifest as torticollis, tinnitus, temporo-mandibular joint pain, and eye symptoms.⁹ In addition, trigger points often refer upper limb pain that mimics shoulder bursitis and tendonitis.^10,11

Even in cases where chronic headaches were not originally caused by muscular dysfunction, physicians should continue evaluating for muscular dysfunction including trigger points. The pain of headaches causes tension in cranial and cervical muscles. Over time, tension can result in myofascial dysfunction. In turn, the muscular lesions contribute to the frequency and severity of headaches.

For years, physicians have used trigger point injections to safely and efficiently eliminate the detrimental effects of these lesions. A number of case studies and consensus statements support the use of trigger point injections for the relief of cervicogenic headaches.^1,12-14 When recalcitrant trigger points stand between your patients and their treatment goals, please consider a referral for adjunctive treatments or co-management. Call me, Neal S. Taub, MD, Physiatrist.

References

1. Alvarez D. “Trigger points: Diagnosis and Management.” Am Fam Physician 2002; 65: 653-60.
   
2. Puustjarvi K. Airaksinen O, Pontinen PJ. “The effects of massage in patients with chronic tension headache” Accupunct Electrother Res 1990; 15:159-62.
   
3. Schoensee SK, Jensen G, Nicholson G, et al. “The effect of mobilization on cervical headaches.” J Orthop Sports Phys Ther 1995;21:184-96.
   
4. Carlsson J, Fahlcrantz A, Augustinsson LE. “Muscle tenderness in tension headache treated with acupuncture or physiotherapy.” Cephalalgia. 1990;10:131-141.
   
5. Jay GW, Brunson J, Branson SJ. “The effectiveness of physical therapy in the treatment of chronic daily headaches.” Headache 1989;29:156-62.
   
6. Kidd RF. Nelson R. “Musculoskeletal dysfunction of the neck in migraine and tension headache.” Headache. 1993;33:566-569
   
7. Pfaffenrath V, Dandekar R, Pollmann W. “Cervicogenic headache – the clinical picture, radiological findings and hypotheses on its pathophysiology.” Headache. 1987;27:495-499.
   
8. Solomon S, Lipton RB, Newman LC. “Nuchal features of cluster headache.” Headache. 1990;30:347-349.
   
9. Sola A, Bonica J. “Myofascial pain syndromes.” In: Bonica J, ed. The Management of Pain. 2nd ed. Philadelphia: Lea & Febiger, 1990: 352-67.
   
10. Han S, Harrison P. Myofascial pain syndrome and trigger-point management.” Reg Anesth 1997; 22: 89-101.
    
11. Rachlin E. “History and physical examination for regional myofascial pain syndrome. In: Rachlin ES, ed. Myofascial pain and fibromyalgia: trigger point management. St. Louis: Mosby, 1994: 159-72.
    
12. Bieber B. “The role of trigger point injections in the development of private practice.” Physical Medicine & Rehabilitation Clinics of North America 8(1): 197-205, 1997.
    
13. Dunteman E, Turner S, Swarm R. “Psuedo-spinal headache.” Regional Anesthesia 21(4): 358-360, 1996.
    
14. Dunteman E, Swarm R. “Atypical Facial Neuralgia.” Anesth Analg 80: 188-190, 1995.