Trigger Points and Migraines
As a person with chronic headaches, I have learned that there are many pieces of the pain puzzle which the average person is unfamiliar with.
Even someone who suffers from frequent headaches may be in the dark about such key elements. Among these are "trigger points."
What Are Trigger Points?
Trigger points are commonly referred to as "muscle knots.”
Everybody experiences these painful knots from time to time. They are a common result of overexertion during hard labor or exercise.
For most people, trigger points go away over a certain period of time as muscle tissue recovers.
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Once the trigger points are gone, they usually do not flare up again on their own very often, and may not even flare up again the next time the same muscles are strained.
But in other people, trigger points are a chronic issue.
They may recur frequently, and may be triggered by seemingly small actions or physiological changes.
They may also not go away on their own without intervention.
Such intervention may need to be practiced diligently over a period of days or even weeks or months in order to get the trigger points to deactivate.
If your trigger points have become a chronic problem, a doctor may diagnose you with what is called "myofascial pain syndrome," sometimes abbreviated “MPS.”
MPS comes with additional issues.
Not only are you stuck with painful trigger points that are resistant to softening, but you often have complex “satellite systems” of trigger points.
Because certain trigger points activate others, you might have to deactivate them repeatedly and in the right order in order to make them go away.
This can feel a bit like solving a puzzle, one where you are punished each time you get it wrong.
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But arguably the worst thing about myofascial pain syndrome is that trigger points tend to refer pain to different parts of your body.
Quite a few trigger points which are located in the back, shoulders and neck refer pain directly to the head and face.
And that is what brings this discussion back to headaches.
As I mentioned before, a lot of people who have headaches do not seem to be aware of the connection with trigger points.
Indeed, trigger points do not seem to receive a lot of attention from the medical community.
In fact, if you do some research, you will discover that there is even still debate as to whether or not trigger points "exist."
As a person who has myofascial pain syndrome, I can certainly tell you that this seems patently absurd to me.
Trigger points most certainly exist, although their true nature seems to be somewhat mysterious.
Exactly what role do they play in different types of headaches?
I will attempt to explain or my own experience shortly.
This study recognizes their involvement in “both migraine and tension-type headache, but the role they play in the pathophysiology of each disorder and to which degree is unclarified. In the future, ultrasound elastography may be an acceptable diagnostic test."
What Do Trigger Points Feel Like?
Not sure whether you have trigger points or not? That is understandable.
Exact descriptions of trigger points can vary quite a bit.
They are often called muscle knots because they can feel like a knot of hardened muscle tissue.
Often, however, this is not a complete description of them.
In their presence, muscles can actually form taut, tightened bands.
As an example, with active trigger points in my neck and shoulder, my shoulder itself no longer has a nice gentle downward arc which flattens out. Instead, the muscle stands out stiffly, creating more of a straight line angling down from my neck to my arm.
If you have these taut bands in your muscles, your muscles can end up shortening and losing flexibility.
Additionally, you may also experience a loss of strength.
This seems to be because the muscle knots themselves are “stuck” contractions—the types which form when you are performing work, only they do not cease.
That means that some of the fibers are constantly diverted toward doing this nonexistent work, and their strength is not available for other tasks.
Plus, if you attempt to move your muscles and use them in a natural fashion, the trigger points will often react, resulting in pronounced pain.
I have described what you will feel through your skin using your fingers, but I have not yet describe the sensation in the muscles themselves or the sensation of the referred pain.
If you press down on the trigger point, it will feel tender to the touch in most cases.
You may also feel pain in the parts of your body to which the trigger point refers.
The entire taut band of muscle may also be sore. This should not be surprising since it may have trigger points active along its length, and it has been working hard.
Indeed, the muscles in question may feel as if you have been exercising them continuously all day long.
Sadly, you do not get any productive gains from this.
As for the referred pain itself, the sensations can vary a great deal depending on the referring trigger points, the destination sites, and other aspects of your physiology.
Myofascial pain can be dull or sharp. It can be mild or severe. It can be highly localized or dispersed.
Even though many people have never heard of myofascial pain syndrome, it is among the most common reasons why patients check themselves into pain clinics for help.
Sadly, I have lost the source on a particular statistic that I recall reading, but I remembered that something upwards of 80% of all pain clinic visits involve trigger points in some form or fashion.
Types of Trigger Point Headaches
Let's get more specific now about how trigger points can be involved with headaches.
The American Migraine Foundation writes, " Trigger points within muscles of the head, neck, and shoulders can cause headache by themselves, and this type of condition is often called myofascial pain. In addition, trigger points can be present in patients with migraine, tension-type, post-traumatic, and other headache disorders, and can be worsening or perpetuating factors for the underlying headache condition.”
My chiropractor has told me that muscle knots located near the shoulder blades seem to be a very common trigger for migraines.
It is also important to note that migraines may cause neck tension, and not simply result from it. You can read about this in detail in my article, "New Research Shows Migraines Can Spawn Muscle Tension."
This means that whether or not a trigger point is the cause of your migraine, simply having a migraine can potentially lead to the formation of active trigger points. These in turn may continue to fuel your migraines.
2. Cervicogenic Headaches
Another headache condition which causes symptoms that are almost indistinguishable from those of migraines is cervicogenic headache.
This type of headache stems in full or in part from structural problems with the neck.
When your spine is not properly aligned, gravity and your bones do not properly do their part to support your head and neck.
As a result, your muscles and ligaments may need to work overtime. On top of that, they may be strained in unnatural positions because of the alignment issues.
So it should come as no surprise that those with cervicogenic issues may readily develop trigger points and myofascial pain syndrome.
As with migraines, this can turn into a self-perpetuating cycle.
Problems with alignment lead to issues with soft tissues. Soft tissue problems in turn further pull the spine out of alignment, worsening the structural problems in the neck.
As someone who has these problems, I can tell you that they can be extremely painful and tiresomely persistent.
3. Tension-Type Headaches
A third type of headache in which trigger points can be involved is a tension-type headache.
This is the type of headache which most people describe as a "dull" pain. Rather than being side-locked like a migraine for cervicogenic headache tends to be, a tension headache is most commonly referred to as being sort of like a "band" constricting around one's skull.
Because trigger points can make entire bands of muscle taut, they can not only refer pain, resulting in migraines and cervicogenic headaches, but they also can produce more generalized tension headaches as well.
Identifying Your Trigger Points
Regardless of the types of headaches you may experience, one of the most empowering and informative things you can do is learn how to identify your specific trigger points.
Before finding the specific trigger points which are referring your pain, your symptoms may seem incredibly mysterious.
It can be somewhat satisfying to track down the root of a sensation. Once you find the referring trigger point, you also may be able to treat it.
To figure out which trigger points are causing your pain, I recommend this website: TriggerPoints.net.
You can look up specific muscles, body parts or symptoms, and you will be presented with a series of diagrams which may help you track down the trigger points involved with your pain.
There are other resources for this online, but this is the most complete one I have found so far. I have also found it to be very accurate.
You will find the majority of trigger points associated with headaches or migraines on this page.
The little X’s you see in the diagrams represent the locations of the trigger points.
The red in the diagrams represents where pain may be felt from those associated trigger points.
So let's take a couple of examples.
If you have pain on the side of your face next to your eye, try feeling along the side of your scalp.
If you have pain there as well—which may be less pronounced— you might notice that the trapezius diagram shows approximately that pain pattern:
This is often described as a distinct "question mark” shape running up the side of the neck and arcing around to the side of the face.
You can see that the referring trigger points are actually clear down near the collarbone on the side of the neck, and are located in your trapezius.
This, in my experience, is one of the most stubborn sets of trigger points.
To add to your fun, there are other trigger points located in the trapezius as well which are also likely to be active.
Take a look at the diagram below:
Here, you can see a couple of trigger points which are located close to the shoulder blades. Note that both trigger points exists on both sides. They have simply drawn one per side to keep the illustration simple.
Even though the pain radiation patterns you see here are confined to the back, these trigger points can ultimately refer pain to the head.
This should not be a surprise, considering that you already saw that other points on the trapezius do refer to the head.
Remember, trigger points create taut bands. This is why the development of one active trigger point can lead to another.
According to my chiropractor, these trigger points by the shoulder blades are frequently present in patients who complain of migraines.
I suspect that a surprising number of "migraine" complaints probably come from patients with cervicogenic headache, but I have no doubt that at least some of them do have genuine migraines as well.
Suffice to say that regardless, these particular trigger points can be extremely problematic in those with severe head pain.
To complete our examination of the trapezius, take a look at one last diagram.
Here, you see a couple of unusual trigger points which cause pain not only in the shoulder, but also a ways down the arm.
I noticed that when I have these trigger points active, I have an almost compulsive need to clutch and claw at my arm.
My brain is under the misapprehension that this is the source of the pain, and that if I could just knead it out, the shoulder, neck and head pain will cease.
Of course, I have it backwards. It is the trapezius which is the source.
So if you ever find yourself clutching compulsively at your arm while you have a headache, that probably means that it is actually your trapezius which is causing both symptoms.
Another particularly nasty referral pattern is the SCM:
These trigger points run up the front and side of your neck.
I have noticed that it is very rare for just one or two of them to be active. They almost always all activate together. This makes sense, since the SCM turns into a tight band.
As you can see, collectively, the SCM trigger points are able to produce pain across large swaths of the head and face.
You may feel pain at the side and back of the skull, inside the ear, and next to your eye, as you do with trapezius trigger points. The pain may arc over your brow and down. Since trigger points in your brow can activate pain in your nose, you also may feel pain there as well. Pain in the forehead and cheeks may also occur.
The SCM is the source of a lot of “migraine” type pain. These headaches are sometimes mistaken for sinusitis as well.
Like the trapezius, the SCM can be extremely challenging to deactivate. It is easily reactivated when the trapezius or muscles in the back of the neck become tight.
The next time you have head or face pain, I highly recommend going over all the relevant charts on this site, not just the ones I have showed you. You will probably find them very revealing.
When Trigger Points Become Chronic: Myofascial Pain Syndrome
I mentioned previously that trigger points can be an acute or chronic issue.
When you have chronic activated trigger points, the condition is referred to as myofascial pain syndrome, and it is actually surprisingly common.
According to this pain clinic, "… a latest survey reveals it as the root cause behind 93 percent of regional pain in joints and muscles."
As the pain clinic also points out, a variety of different causes can be responsible for the development of myofascial pain syndrome.
If in usual stresses placed upon muscles, this can spur the development of this disorder.
This could happen, for example, because your spine is misaligned, or your jaw is out of place (both of which apply in my case).
Nutritional absorption issues or anemia can also lead to the development of MPS.
Repetitive stress injuries and postural problems can cause myofascial pain syndrome to develop.
Health conditions which involve hormones or neurotransmitter levels could lead to MPS.
Simply being female also could be a risk factor for myofascial pain (and quite a few other pain conditions which disproportionately affect women).
If you are lucky, your myofascial pain could be alleviated completely if the underlying cause is able to be removed, and the MPS has not become fully ingrained by your body.
But in many cases, such a fix is impossible. For example, my jaw is permanently misaligned because my upper palate developed incorrectly. This pulls my spine out of alignment.
There are experimental treatments, but only a few, and I would be quite an early test subject.
There is also no guarantee that this would put an end to my MPS. By now, I've had it for quite a long time, and some of its momentum is probably its own.
So while improvements might be possible through such an invasive measure, there probably is not a cure for me.
But this does not mean that one must be entirely at the mercy of myofascial pain. Because you can identify the trigger points, you can attempt to get them to release.
Mine usually activate cyclically in relation to my menstrual cycle, suggesting a component involving hormones, neurotransmitters, or a combination.
I will provide you with some methods you can use to try and deactivate your trigger points momentarily.
But first, I want to talk about another health condition which is quite similar to myofascial pain, called fibromyalgia.
Is It Myofascial Pain or Fibromyalgia?
Myofascial pain and fibromyalgia are so similar that differential diagnosis can be a challenge, and many people even assume that they are the one and the same.
The fact that both conditions are still poorly understood from a research standpoint only makes this harder.
Patients with fibromyalgia often have many of the same active trigger points as patients of myofascial pain syndrome.
But whereas myofascial pain is a localized disorder, fibromyalgia tends to be widespread throughout the body.
If you have myofascial pain syndrome…
- Your trigger points are localized. For example, they might be located in your neck, shoulders and back, but you probably do not have them in your arms or legs.
- Myofascial pain syndrome is characterized by myofascial trigger points which radiate referred pain.
- If the underlying cause of myofascial pain can be eliminated, it does not always have to be a lifelong problem. Even if it is, it may be significantly reduced.
- Myofascial pain syndrome may not directly cause other symptoms in the same fashion as fibromyalgia, but many of those same symptoms may be associated with it. The pain can certainly lead to fatigue as well as cognitive and emotional issues. Structural issues in the neck can also produce digestive discomfort, dizziness, light sensitivity, and a range of other issues (another reason why cervicogenic headaches and migraines are hard to tell apart).
If you have fibromyalgia …
- Your pain is less likely to be localized to one region of your body, and more likely to be spread diffusely throughout your body.
- There are "pain points” of a sort with fibromyalgia, but they do not behave exactly like myofascial trigger points. Usually, they are referred to as "tender points."
- Fibromyalgia is usually a lifelong condition once you have it.
- Along with pain, fibromyalgia produces symptoms such as fatigue, cognitive issues, and even digestive problems in many patients. Note that headaches may be present with fibromyalgia as well.
Either of these conditions can be debilitating on their own. Unfortunately, some patients with one do go on to develop the other as well.
How closely related are fibromyalgia and MPS in terms of mechanics?
Alas, it is hard to say. I have certainly looked into the matter, and have even tried experimenting with fibromyalgia treatments for my myofascial pain.
There are some common factors implicated between the two. For example, serotonin appears to play a role in both.
The problem is that the role of serotonin in the two disorders is itself quite confusing.
I have read, for instance, that in fibromyalgia, abnormal serotonin levels are common finding, but they may be high or low.
Increased levels of serotonin have been measured in myofascial trigger points. Nonetheless, there have been cases of improvements in patients with myofascial pain in response to some of the same medications used in fibromyalgia.
There simply is not enough data right now to say anything definitive.
In any case, it is important to consider the differential diagnosis with regards to your own pain condition.
Trigger Point Release Techniques
Now that you have a broader understanding of myofascial pain and trigger points, let's talk about what you can actually do about them.
Sometimes, trigger points release pretty easily. Other times, it may take weeks or months of effort to get them to release.
Here are some possible approaches to consider.
- Chiropractic adjustments. Even though chiropractors work with bone, alignment issues are common among many patients with myofascial pain. When the bones line up more correctly, stress is relieved on soft tissues. This makes it far more likely that trigger points will release.
- Massage therapy. A skilled massage therapist can sometimes work knots out of muscle tissue. In my experience, getting chiropractic adjustments and massage therapy on a regular basis can greatly help maintain long-term improvements in myofascial pain.
- Acupuncture. There is research suggesting that acupuncture may be an effective treatment for myofascial pain.
- Dry needling. On a related note, dry needling may be effective as well. Dry needling and acupuncture are frequently confused, but they are actually different techniques. Acupuncture is an Eastern technique based on energy concepts. Dry needling is a Western technique designed to physically break up trigger points.
- Spray-and-stretch. This is a technique a physical therapist may perform. It involves the application of a vapocoolant spray, followed by stretching. The goal of the stretching is to assist muscles in returning to their previous length after they have been shortened. It may also help to restore flexibility and range of motion.
- There are also treatments like trigger point injections, nerve blocks, and so forth you can consider.
- Apply heat. One way to soften muscle tissue is through the application of heat. Hot packets and heating pads can be helpful throughout the day. Moist heat, however, is generally the most effective. Hot baths and showers can be useful. If you are in the tub, consider adding some magnesium salts to your water to increase muscle relaxation.
- Apply ice. Nerve pain can sometimes respond to cooling much better than heat. Applying ice also can reduce inflammation during an acute flare (sprains and strains can be very common with myofascial pain, especially with an underlying structural disorder). Cold therapy also has a long history of use in treating migraines specifically.
- Stretch carefully. Just as a physical therapist can help you to stretch, you can also stretch at home. I highly recommend that you apply heat before you stretch to reduce the chances of straining your muscles.
- Correct posture and ergonomics. Whether poor posture is the underlying reason for your myofascial pain or merely a contributing factor, it can be a surprisingly major contributor to continued pain. Do what you can to make every aspect of your life more ergonomic. Also, try not to stay in any one position for an overly long time.
- Avoid straining activities. You should try to move naturally to a fair degree when you have myofascial pain to prevent freezing up. Nonetheless, doing activities which strain your muscles is not going to help your trigger points release. It may make them much worse. As an example, if you have active trigger points in your shoulders or neck, avoid holding heavy objects away from your body.
- Change positions. Sometimes, a change in position can allow an active muscle to relax, decreasing myofascial pain considerably. This can sometimes be as simple as turning over in bed from your left side to your right.
- Replace your pillow. Most people do not have ergonomic pillows. Actually, shopping for an appropriate pillow can be surprisingly challenging. If you sleep on your back, you need support to maintain the curve of your neck. If you sleep on your side, you want to try to keep your spine as straight as possible. You should not lie on your stomach with your face turned to the side. This position is absolutely terrible for you.
- Try TENS. Short for “transcutaneous electrical nerve stimulation,” this small device stimulates your nerves using electronic impulses. These impulses act on opioid receptors. They also can increase endorphin production and provide a competing sensation for pain. If you place them properly around trigger points, you can actually refer the sensations of relief along the same pathways that the pain is traveling through. Technically, a TENS is an analgesic only, not something which can "treat" your condition. When you are in less pain, however, you do tend to relax. This reduction in stress and tension could feasibly help to release trigger points.
- Try EMS. A device which is similar to TENS is EMS, which stands for "electronic muscle stimulation." Rather than stimulating your nerves, however, EMS works directly on muscle tissue, helping to improve circulation (which is very much compromised in trigger points). Research shows that both TENS and EMS may be equally effective as long-term myofascial treatments.
- Take NSAIDs. Over-the-counter anti-inflammatory medications can be extremely helpful in managing myofascial pain and in combating the heightened inflammation which is present in trigger points.
- Address nutritional issues. If you believe that there may be gaps in your nutrition which could be exacerbating your condition, these need to be addressed to make progress. If there is underlying anemia, you will need to treat this with adequate iron. You also need to get plenty of calcium and magnesium. There is uncertainty as to whether choline might help or harm patients with myofascial pain.
- Attempt trigger point release through pressure. Many people recommend releasing trigger points through the application of pressure. Research suggests that moderate pressure, not intense pressure, is most effective. You can look up specific techniques for doing this online. Note that if you have tissue which has been traumatized by an injury (past or present), you probably should not be pressing on it. In my experience, this can make an old injury flare and make an existing one far worse.
- Exercise. Getting exercise on a regular basis can be intimidating with myofascial pain. Try to select workouts which will not aggravate your trigger points, but which will improve overall circulation and health.
- Try gua sha. See this page. This is a Chinese technique for “scraping” muscles. It can impressively boost circulation temporarily in stubborn tissue, helping to flush out toxins. Note that while pictures make it appear painful, it is not, and can result in some immediate pain relief while you're doing it. As with pressing on trigger points, avoid doing this on damaged tissues.
- Apply Lidocaine patches. These patches offer an analgesic effect, and can be worn for up to 12 hours at a time. I personally have not found them to be effective for severe myofascial pain, but they can be quite useful for low amounts of pain.
- Use CBD ointment or Tiger Balm. Other topical treatments which may be helpful for myofascial pain include muscle rub products like Tiger Balm as well as CBD cream. I have not found either to be effective in stopping the referral of pain, but both can provide localized relief for tight muscles.
- Find ways to relax when possible and combat stress. As referenced here, a derangement of the sympathetic nervous system appears to be a culprit in myofascial pain syndrome. This means that any number of stressors (including, ironically, the stress of your pain) can exacerbate your pain. Relaxing in such a state is much easier said than done, but anything you can do (i.e. meditate, get more sleep, play a video game) to reduce your stress on a regular basis needs to be part of your routine.
- Avoid sugars, nicotine, inflammatory substances, and excess caffeine. All of these substances may make trigger points worse. That being said, caffeine can be helpful in reducing the pain of multiple types of headaches. You will need to experiment and figure out to what extent its pros may outweigh its cons or vice versa. If in doubt, "all things in moderation" is a good starting point.
- Address hormonal problems or neurotransmitter imbalances. Both hormones and/or transmitters play an elaborate role in pain disorders. Attempting to diagnose issues with either is incredibly challenging. That being said, if you can make any improvements in either area, it can be a game-changer with myofascial pain (as Vitex has been for me, acting as a progesterone booster and dopamine agonist). Take note that even levels which are "normal" when measured may still not be functional for you as a person with your specific pain disorders.
- Try herbs and essential oils for trigger points. There are a few different herbs and essential oils such as lemon balm, lavender, rosemary, passionflower, valerian, kava kava and skullcap worth trying for myofascial pain.
- Try herbs for head pain. Finally, herbs which are taken specifically for head pain can also be extremely helpful in managing myofascial pain as well as resulting migraines. Consider herbs such as Vitex, feverfew and boswellia.
I greatly recommend reading this article. It is one of the more comprehensive descriptions I have read concerning the molecular nature of trigger points. It also contains detailed discussion for a broad range of potential therapies.
While I have given you a broad spectrum of therapies to try for myofascial pain and related headaches, take note that this is very much a developing area of research.
You should keep up with developments in this field, and consider experimenting with ideas I have not mentioned. Always use caution and seek advice from professionals, but be aware that you may sometimes discover treatments that work before they become recognized for scientific studies.
This was largely the case with me and Vitex. When I first started taking it, there is very little research on it, and I found a forum thread where someone with seemingly sound understanding of nutrition was able to provide an explanation for how it might work to reduce pain.
I started using it, and it provided me with immediate dramatic benefits. I have been using it for years now, and over that time, quite a few studies have been emerging supporting that it does indeed work as that forum user suspected. It has produced improvements similar to those I have experienced in research participants.
Not only that, but it appears there may even be additional long-term health benefits for cancer prevention in those who use Vitex.
Being your own guinea pig is not enjoyable, but it can yield some amazing results if you do your research and proceed with caution.
Remember, you should always inform your healthcare provider if you are trying new herbal supplements.
You also should make sure that there will be no unwelcome interactions with other herbs or medications you may be taking to manage head pain or other conditions.
Conclusion: Trigger Point Release Requires Time and Effort, So Don’t Give Up
Battling myofascial pain is more of a marathon than a sprint for many who suffer from this disorder.
When you have to put in weeks or months of effort to get results from a lot of the methods used to treat myofascial pain, you can find yourself dealing with regular discouragement.
I do not say this in order to discourage you. On the contrary, it is important that you embark with realistic expectations so that you can weather the disappointments and stay the course long enough to see improvements.
While it can be difficult living as someone who is deeply affected by chronic pain, when you do achieve those hard-won moments where you are relatively free from pain, you also have the capacity to more deeply appreciate those blissful moments than someone who is less affected by their pain.
Here are a few tips to give yourself the best chances of success in treating myofascial pain:
- Plan to make this a long-term project.
- Do try multiple methods for managing your pain, and try them simultaneously, not just one after another.
- Take careful notes on what helps and what doesn't.
- Make managing your pain a priority every day.
- Be willing to experiment, but do so with care.
- Research regularly to build on your knowledge.
- Be aware that myofascial trigger points can re-activate. You may need to treat them regularly and take preventative steps to manage them.
- Never forget that pain is a subjective experience. Healthcare professionals can potentially help you, but you know your pain better than anybody else. Demand respect from anyone you work with.
The long and short of it is, "do not give up.” Myofascial pain and the headaches that it causes are incredibly stubborn, but if you are persistent, you should be able to deactivate some or all of your trigger points, soften muscle tissue, and decrease the pain which refers to your head and face.