● Sternocleidomastoid (near the insertion point at the mastoid process).
2. Pain that persists anywhere from 30 minutes up to 7 days. 3. Pain that meets at least two out of the four listed characteristics: ○ Located on both sides of the head. ○ Pressing or squeezing. ○ Mild to moderate intensity. ○ Not worsened through physical exertion, such as walking or climbing stairs. 4. Must meet both of the following: ○ Not accompanied by nausea or vomiting. ○ May be accompanied by sensitivity to bright lights or loud sounds, but not both. Sometimes this is confused with a mild migraine with aura. (International Headache Society, 2016; Wikipedia, 2017e). Another headache that mimics tension-type symptoms is medication overuse headache. Classified as a secondary headache, this form of cephalalgia arises from a prolonged use of pain medications. Ironically, the medication is often taken to relieve headache pain, yet over time, the body becomes hypersensitive in response so that the medication no longer has an effect, and a chronic headache remains (Wedro, 2017). If a patient experiences more than 15 days of episodes in a month for at least three consecutive months, it is possible he is suffering from a chronic tension-type headache; the situation should be viewed as a warning sign of a possible hidden disease. Only 1% to 3% of the adult population truly suffers from this form of headache (International Headache Society, 2016; WHO, 2016). The best way to decipher another condition causing chronic tension pain is if the headache occurred in close relation to the diagnosis of a condition known to cause headaches. It is still considered a primary headache regardless of a secondary condition causing the pain. What is important to know with chronic tension-type headaches is that chronic tension cephalalgia is caused within the brain or spinal cord, whereas infrequent tension cephalalgia results from peripheral mechanisms (International Headache Society, 2016). This is significant for the massage practitioner to understand for the patient’s treatment plan. An example of peripheral mechanisms is trigger points in the suboccipitals, upper trapezius, sternocleidomastoid, masseter, or temporalis muscles. These send afferent input, or signals, to the brain where it is processed and then interpreted as pain (DeLaune, 2008; Wikipedia, 2017e). A central mechanism could 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).
● Splenius capitis. ● Upper trapezius.
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). 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
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