Chronic tension-type headache as a risk factor of myofascial trigger points in upper trapezius muscle fibers in neck pain patients
Pakistan Journal of
Neurological Sciences (PJNS)
fibers in neck pain patients Chronic tension-ty pe headache as a risk factor of myofascial trigger points in upper trapezius muscle
Aisha Amin 0 1
DHQ hospital Gujrawala 0 1
Farah Niaz Awan 0 1
Hafiz Sheraz Arshad 0 1
Ali Hamza Arshad 0 1
Azra Naheed Medical College, Superior University, Lahore
0 Children Hospital & ICH Lahore
1 Azra Naheed Medical College, Superior University , Lahore
2 Women Medical officer, BHU chahal kalan
3 Assistant Professor, Azra Naheed Medical College, Superior University , Lahore
4 Physiotherapist, DHQ hospital Gujrawala
5 Post Graduate residence, Children Hospital & ICH Lahore
Follow this and additional works at: https://ecommons.aku.edu/pjns Part of the Neurology Commons Recommended Citation
Women Medical officer; BHU chahal kalan
Chronic tension-type headache as a risk factor
of myofascial trigger points in upper trapezius muscle
fibers in neck pain patients
Date of submission: April 05, 2017 Date of revision: May 29, 2017 Date of acceptance: June 15, 2017
Background: Chronic tension type headache (CTTH) is one of the very common neurological conditions which
have striking impact on daily functional activities. In tension type headaches the myofascial TrP's are frequently
examined .It is observed that myofascial pain syndrome is frequent determinant of chronic nonspecific neck pain.
OBJECTIVE: To determine tension type headache as a risk factor of myofascial trigger points in upper trapezius
muscle fibers in neck pain patients. MATERIAL AND METHODS: It was a case control study. The study was
conducted from January 2016 to July 2016 and data was collected from four hospitals of Lahore..Convenient
sampling technique was used. Sample size of 130 patients was taken which were equally divided into case and
control group. An international headache criterion was used for diagnosis of tension headache and Travell & Simon
criterion was used for diagnosis of trigger points. RESULTS: Total 130 subjects were recruited in the study. 65
(50%) were having trigger points (case group) and 65 (50%) were without trigger points (Control group).Mean age
of case group was 27.80±9.177 and control group was 30.11±8.839 (P=0.15). In case group, 48 (74%) participant
were having tension type headache whereas 17 (26%) were without headache and out of 65 controls 26 (40%)
were having tension type headache and 39 (60%) were without headache (OR=4.24, 95% CI=2.01-8.91,
CONCLUSION: Tension headache is the factor that could increase the probability of having myofascial trigger
points in upper trapezius muscle fibers in patients of neck pain
KEYWORDS: Myofascial trigger points, upper trapezius, and tension type headache.
Headache is one of the very common neurological
conditions which have striking impact on daily
functional activities. Recurrent headache is a
commonly experienced problem with compelling
effect on public health and it is most common
neurological syndrome presented by patients to
general practitioners and neurologists .According to
World Health Organization ranks of the causes of
disability, the headache problem is included in the
top ten utmost debilitating conditions for both genders
equally . The percentage of adult population in twenty
first century being distressed from headache is 46%.It
has also been found out that in the general population
the migraine contributes 11%,tension headache
contributes 42% and chronic headache contributes
3% of the total of 46% of headache. As result of this
disabling syndrome, psychosocial functioning in
various areas including family time, friends,
relaxation time, peer groups, working potential, and
yielding at work may be undermined . Tension-type
headaches are more common in females than males.
Recurrence of episodic tension headache in men
increases at the age of 39 years after which it
descends, whereas in women the recurrence of
episodic tension headache increases from12 years of
age to 40 years on average and after that it is
relapsed. Concurrently, preponderance of tension
headache is increased in both genders until the age
thirty nine after which it is declined .
It is observed that frequent determinant of chronic
non specific neck pain is myofascial pain syndrome
.Active trigger points are prevailing in patients who
are exposed to non specific chronic neck pain .
Scientific researchers have supported the fact that in
musculoskeletal disorders involving head and neck,
there is a role of trigger points . In tension headaches
the myofascial TrP's are frequently examined .
Myofascial TrPsare defined as the stretched band of a
skeletal muscle. These are the hyperirritable spots
that evoke referred isolated pain, when manual
examination is performed on them ''' . Latest studies
have proposed that trigger points (TrPs) contribute
to tension headache when these points are active in
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S 2 1
neck and shoulder muscles .
In the economy of any country the health sector has an
i m p o r t a n t r o l e t o p l a y . F r e q u e n c y o f
headache in Pakistan is about 92.4% .In Pakistan
there is a significant prevalence of clinical cases of
migraine and tension headaches. .The International
Headache Society have investigated and also
assorted the headache disorders in Pakistan
according to its criteria. Majority of the patients of the
productive age, about 80% who were referred for
treatment were women aged between 15 and 49
years. Probably the headache is the most common
disorder observed by health care experts in clinical
practice centers, in most common presenting forms as
cervicogenic headache, migraine and tension type
headaches which are linked with high noticeable
strain of social and economic expenses .
Pakistan is just few steps away from being labeled as a
'psychological pressure cooker' due to increased
poverty, terrorism, high criminal activities and social
stresses as well as fragile security. Psychiatrists of
Pakistan believe that majority of people are suffering
from condition called post-traumatic stress disorder
and no steps are being taken to deal with them. World
Health Organization has estimated that in Pakistan
there are only 320 psychiatrists available for 176
million psychiatric patients. .
Posttraumatic stress disorder (PTSD) is often
comorbid with chronic tension-type headache Health
care professionals have observed that the importance
of brain health has not been accentuated and there is
no policy in developing countries like Pakistan for the
prohibition and control of neurological diseases .
Stress is the major cause of tension headache and it is
very common in our country due to many reasons . No
previous research work regarding headache disorders
and its consequences has been conducted in Pakistan
. Although the researches related to tension type
headache and myofascial trigger points formation has
been conducted in western societies. But no such
attempt has been conducted to validate this fact
regarding TrP's and headache disorders in Pakistan.
Therefore this study will help to fill the knowledge gap
OBJECTIVE OF STUDY:
The objective of this study is determine tension
headache as a risk factor of myofascial trigger points in
upper trapezius muscle fibers in neck pain patients.
Tension headache criteria by “The International
Classication of Headache Disorders in 2nd edition”
was employed for diagnosis of chronic tension-type
headache and Travell and Simons diagnostic criteria
was used for palpation of myofascial trigger points by
manual examination method ''' .
MATERIAL & METHODS
Case Control Study
Data was collected from following hospitals of
Ch.MuhammadAkram teaching and
research hospital, Raiwind road, Lahore
Social security hospital, Manga road,
Rasheed hospital, DHA, Lahore
Mid city hospital, Jail road, Lahore
This study was conducted from January 2016
to July 2016
The sample size 130 was taken by using
G*power software using following parameters.
Anticipated odds ratio=2.3
Power of study = 80%
Level of significance = 0.05
130 subjects were equally divided into cases
20-50 years of age
Both genders were equally inclusive
Neck pain patients
Patients with trigger points in upper trapezius muscle
20-50 years of age
Neck pain patients
Patients without trigger points in upper trapezius
Other primary headaches
All types of secondary headaches.
Headache due to medications overuse
Diagnosed neurological disease
DATA COLLECTION PROCEDURE:
Case control study was conducted in four hospitals of
Lahore. An informed consent was taken from patients
by telling the aims and objectives of this study. The
were selected through convenient sampling
technique. Patients of both genders with neck pain
were included. Then manual examination was
performed to assess the myofascial trigger points in
trapezius upper fibers and tension headache was
confirmed by the international tension headache
SPSS version 20 software was used for collected data
analysis. Frequencies and percentages were
calculated for categorical variables while means and
standard deviations are calculated for continuous
variables. Odd ratio was calculated to find the
probability of having trigger points in upper trapezius in
patients with tension headache
An informed consent was taken from patients as well
as hospital administration. Personal information of the
respondents remained confidential and was entirely
for research purpose.This study didn't cause any
physical, social or psychological harm to patients. All
medical ethics were considered
of total 65 cases, 23 (35%) were males and 42 (75%)
were females whereas out of 65 controls 28 (43%)
were males and 37 (57%) were female (p=0.37). In
case group, 48 (74%) participant were having tension
type headache whereas 17 (26%) were without
headache and out of 65 controls 26 (40%) were having
tension type headache and 39 (60%) were without
headache (OR=4.24, 95% CI=2.01-8.91, p<0.001).
The study provided the evidence that myofascial
trigger points in neck muscles are common in subjects
found with tension headache and not in controls.
These findings are similar as reported by Ferna´
ndezde-las-Pen˜ as et al for the sub-occipital muscles.
Although there is clear evidence of close connection
between trigger points in specific neck and head
muscles and tension headache , the extent of data
does not state the relationship of cause and effect
between trigger points and tension type headache.
This is well known fact that central sensitization is also
one of the cause of headache pain from TrPs . Some
studies reported the correlation between the area of
the referred pain and the intensity of muscle pain in
patients facing sensitization of specific central
pathways . It has been reported that pain referred in
areas of deep somatic, secondary hyper-algesia,
resembles the characteristic pain seen in secondary
hyper-algesic areas at the following skin . In this way,
referred muscle pain can also relate with the
mechanism of tenderness and secondary
hyperalgesia observed in patients with tension headache
Since active trigger points may be found in many
chronic conditions that cause sensitization of central
pathways, the question arises: are trigger points the
result of central sensitization? If this central
sensitization were producing active trigger points, they
would not be likely in patients experiencing episodic
tension type headache (ETTH), in which the
mechanism of central sensitization has not been
established . As there is lesser level of central
senzitisation in ETTH, because of the repeated nature
of the condition, we could expect lesser active and
more latent in episodic tension type than in CTTH. It
has been demonstrated that active trigger points in the
upper trapezius, sub-occipital, sternocleidomastoid
and temporalis muscles are also present in episodic
tension type headache , to a similar degree as in CTTH
. However, active trigger points were not associated
with headache clinical characteristics in episodic
tension type headache, endorsing the hypothesis that
there was no temporal accumulation of peripheral
nociceptive signals in patients with episodic tension
type headache, due the episodic nature of the
condition. These findings depict that active trigger
points are not the consequences of central
sensitization, as they are also present in ETTH.
T h e s o c i o - d e m o g r a p h i c c h a r a c t e r i s t i c s o f
observations are summarized in Table-I .Total 130
subjects were recruited in the study. 65 (50%) were
having trigger points (case group) and 65 (50%) were
without trigger points (Control group).Mean age of
case group was 27.80±9.177 and control group was
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Conflict of interest: Author declares no conflict of interest.
Funding disclosure: Nil
Conception and design: Aisha Amin
Collection and assembly of data: Aisha Amin & Farah Niaz
Analysis and interpretation of the data: Ali Hamza Arshad
Drafting of the article: Hafiz Sheraz Arshad
Critical revision of the article for important intellectual content: Umer Maqsood
Statistical expertise: Hafiz Sheraz Arshad
Final approval and guarantor of the article: Umer Maqsood
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