be one of two situations: either the spinal cord and brainstem become desensitized to continued afferent signals from trigger points resulting in hyperexcitability or there is a problem with how the brain processes pain. If a central mechanism is the cause of a tension-type headache, the massage therapist should emphasize the need for regular sessions to compensate for this dysfunction and eventually return the mechanism to a state of homeostasis (Wikipedia, 2017e). The ICHD-3 beta lays out a specific assessment to use for tension-type headache recognition that also provides feedback as to how sensitive the muscles are and which peripheral mechanisms are involved. The procedure, termed pericranial tenderness assessment , involves applying pressure in a circular motion to the following muscles: ● Frontalis (forehead). ● Temporalis. ● Masseter. ● Pterygoid (palpated through the cheek under the zygomatic arch). ● Sternocleidomastoid (near the insertion point at the mastoid process). Upon palpation, the patient gives a tenderness score between 0 and 3 for each muscle. The numbers are then tallied up to produce an overall score. A mid to low score indicates a chronic tension-type is likely the result of peripheral pain mechanisms (International Headache Society, 2016). Indicated muscles As noted previously, the major muscles contributing to tension headache pain are the frontalis, temporalis, masseter, sternocleidomastoid, splenius capitis, and upper trapezius. A quick anatomy review followed by common trigger points and patterns will show the role these muscles play in contributing to tension headache symptoms. The frontalis muscle is on the forehead and is the main muscle involved in raising the eyebrows. It inserts into the fascia directly above the eyebrows. This muscle also wrinkles the forehead, a common sight of tension headache sufferers. An interesting detail is that the frontalis muscle is connected to the occipitalis by a thick band of connective tissue – called the galea aponeurotica – that spans the scalp. Situated at the back of the head, the occipitalis assists the frontalis with raising the eyebrows and wrinkling the forehead (Biel, 2001; Stone & Stone, 2003). Thus it is important to address the occipital area when treating a patient suffering from tension headaches even if the pain is felt strictly in the forehead. These muscles are innervated by cranial nerve VII, the facial nerve. Because of its location and function, the trigger point for the frontalis muscle is found directly above the eyebrow with its pain pattern also in that region (DeLaune, 2008). ● Splenius capitis. ● Upper trapezius. The next muscle that stereotypically indicates a tension headache is the temporalis. This large thick muscle lies directly over the temporal bone above the ear. It then passes under the zygomatic arch to attach to the jaw and functions to close, or elevate, the jaw. Another function of the temporalis muscle is clenching the teeth, which is why people with temporomandibular joint (TMJ) dysfunction often present with tension-type headaches (Biel, 2001; Stone & Stone, 2003). Innervated by the mandibular division of the trigeminal nerve, four trigger points are found in the temporalis. These refer pain to the eyebrows, teeth, temples, and the area above the ears (DeLaune, 2008). The strongest muscle in the body is the masseter, more commonly known as the “belly of the cheeks.” This muscle, used for chewing, is also innervated by the mandibular branch of the trigeminal nerve and, like the temporalis, is implicated in clenching the teeth. There are actually two divisions to the masseter: the superficial belly and the deep belly. The deep belly is reached only from inside the cheek, so it is the superficial belly
that is easily palpated and treatable (Biel, 2001; Stone & Stone, 2003). Trigger point pain in this muscle is reflected in the teeth, eyebrow, or even ear where it can cause tinnitus, or ringing in the ears (DeLaune, 2008). Perhaps the single most culprit in causing tension headaches – because of its tendency for hypertonicity as well as vast coverage of pain in the head and face from trigger points – is the sternocleidomastoid (SCM). Found on the lateral aspect of the neck, this muscle originates from two separate points. One aspect arises from the sternum and the other from the clavicle. The two muscle bellies then converge to insert on the mastoid process of the temporal bone and the lateral portion of the occiput. The SCM functions unilaterally to rotate the head and to flex the head to the same side (as in bringing the ear to the shoulder). Bilaterally, it flexes the head and assists in deep inhalation (Biel, 2001; Stone & Stone, 2003). Seven trigger points can be found between both bellies of the SCM, generally referring to the forehead, eye area, occipital region, scalp, ear, and cheek (DeLaune, 2008). Although this muscle is more than likely to contain trigger points and require manual therapy, care must be taken to avoid the external jugular vein, which passes over the SCM, yet more important, to refrain from the carotid artery, which lies medial and deep to the SCM (Biel). Much like the SCM, the splenius capitis functions to laterally flex the head and to rotate it to the same side. This muscle originates from the upper back, specifically from vertebrae C7 to T3, and inserts to the mastoid process in addition to the lateral aspect of the occiput in the same region as the SCM (Biel, 2001; Stone & Stone, 2003). Because it originates posteriorly, this muscle is antagonistic to SCM in that it extends the head bilaterally. There is only one mapped trigger point for splenius capitis, which is located at the C2 vertebra and refers pain up to the top of the head (DeLaune, 2008). Even though splenius cervicis is not included in the pericranial tenderness assessment, it is a synergist to the splenius capitis in both its bilateral action of extension and its unilateral action to laterally flex and rotate the head to the same side. The splenius cervicis and the splenius capitis differ in two ways. The first is it inserts into the cervical vertebrae and so does not attach to the head limiting its function to the neck only. The other difference is that the upper fibers (from T3 to C1) lie beneath the splenius capitis and the lower portion (T3 to T6) is deep to the trapezius making it inaccessible for palpation (Biel, 2001). Even so, it is important to note a trigger point found between the C3 and C4 vertebrae because its referred pain pattern is felt mainly behind the eye but also in the temporal region (DeLaune, 2008). Despite not being able to isolate the splenius cervicis for palpation, the massage therapist can still affect the trigger point by knowing that the muscle rests in the lamina groove of both cervical and thoracic vertebrae, C1 to T6. The lamina groove is the space between the spinous process, or bony protrusion most recognized as the spine, and the transverse process, which is a similar bony protrusion on the sides of the vertebrae (Stone & Stone, 2003). The final muscle relevant to tension-type headaches and second most implicated for carrying emotional stress is the upper trapezius. The most superficial of the back musculature, the upper trapezius originates on the medial aspect of the occiput including the external occipital protuberance in addition to the spinous process of C7. The fibers then run downward and laterally to insert to the outer portion of the clavicle. Similar to the SCM and splenius capitis muscles, the upper trapezius laterally flexes the head toward the shoulder of the same side. It also functions to rotate the head but does so to the opposite side. Bilaterally, the upper trapezius extends the head (Biel, 2001; Stone & Stone, 2003). Two trigger points found near the insertion point to the clavicle refer pain up the side of the neck and into the temporal region closer to the eye than to the ear. Considering the splenius capitis is partially covered by the trapezius, sound palpation skills help the massage practitioner
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