Headaches are super irritating. I don’t think anyone would refute that statement. They are also quite complex to treat, because there are so many different triggers, including most of the major lifestyle factors; such as stress levels, sleep pattern, diet, hydration, muscle tension, trigger points in the muscle, posture and work related factors. Finding the exact cause can take time, and relies upon trial and error in some instances. This article focuses on trigger points as one cause of headaches. Trigger points are nodules in the muscle that are incredibly sensitive and can refer pain into different areas of the body. They are an incredibly common cause of headaches.
What is a trigger point?
Trigger points are often described as a hypersensitive nodule in a muscle – usually in the belly of the muscle (the thickest part), which can create localised and referred pain. Referred pain is when the pain is felt in a different location to the source of the problem. There are a whole range of different types of trigger points – including active trigger points that are actively causing pain, and latent trigger points that only cause pain when they are palpated. It is active trigger points that generally result in headaches.
Trigger points feel like a hard ball in the muscle, surrounded on either side by a stringy band. The hard ball is the actual trigger point, and it feels this way because the muscle fibre has remained in a contracted state which stretches and pulls on the fibres on either side of it, creating the stringy bands. Trigger points can very in size from a pinpoint szie that cannot be palpated, to a grape size.
Trigger point referral pattern
As mentioned before, trigger points refer pain. They create a predictable pattern of pain – which is commonly felt some distance from the actual trigger point. For example, trigger points in the upper trapezius, a muscle in the shoulder, can refer pain into the forehead and jaw. This could leave you thinking the issue is in your forehead and jaw, but the actual source of the problem is the shoulder. Similarly rotator cuff muscles of the shoulder can refer pain down the arm, and into the elbow and hand.
Headaches and Trigger Points
There are many different types of headaches, and they are usually identified by their location. Not all headaches are caused by trigger points, but trigger points are definitely one of the biggest sources of headaches. The types of headaches that can be caused by trigger points include tension headaches, cluster headaches, sinus headaches and migraines.
However, while trigger points are often the source of the pain, they are not necessarily the cause of the headaches. Factors such as stress and exercise can create the trigger points that lead to headaches, meaning that treatment of the trigger point can provide symptomatic relief, but the trigger points will recur if the root cause isn’t dealt with. However, in other cases trigger points are the root cause.
Cluster headaches involve pain around the forehead and side of the face. The most common symptom is eye pain, and it tends to affect one side of the head only. Cluster headaches that appear suddenly can be a cause for concern, but in many cases they are the result of trigger points.
A study carried out for the treatment of trigger points for cluster headaches (Calandre et al 2008) found that several trigger points can cause these headaches, including trigger points in the lateral pterygoids (shown left), temporalis (shown below) and the occipitalis (shown left). The study found that trigger points in the lateral pterygoids were the most common cause of cluster headaches.
The lateral pterygoids are muscles on either side of the jaw, and they attach between the jaw and the sphenoid bone of the skull. There are two heads of the muscle, called the superior and inferior heads. The referral pattern of the lateral pterygoids is the side of the head, under the eye and around the front of the ear. This is almost an exact match for the pain felt during a cluster headache.
Occipitalis also has referral of pain around the eye, which is a common aspect of cluster headaches.
Tension headaches are by far the most common type of headache. Symptoms include pain across the forehead, behind the ear and back of the head, as well as down the back of the neck. The pain can occur on just one side but also commonly affects both sides at the same time.
Trigger points in the upper trapezius are the most common type of pain referral into this area. The pain pattern starts at the base of the neck, travels up the back of the neck and hooks around the ear. There are also patches of referred pain in the forehead and also in the base of the jaw. Most people have some trigger points in their upper trapezius, it is the most common place for trigger points, and they also tend to be fairly large in size.
Other contributors to tension headaches include trigger points in temporalis, masseter, sternocleidomastoid and suboccipitals. As you can see there is some overlap with some muscle trigger points being the cause of multiple types of headaches – this can be seen with temporalis, which can cause both cluster and tension headaches.
The sternocleidomastoid is particularly interesting, because the muscle has two heads – called the clavicular and sternal heads. Each head has its own distinct trigger point pattern, which means it can cause slightly different types of pain associated with tension headaches. The clavicular head tends to refer pain into the ear and above the eyebrows, while the sternal head refers pain around the eye, cheek and back of the head. Both of these are shown in the image above.
There are three other muscles in the neck that often get little coverage when it comes to pain conditions – they all have quite similar names which can be quite confusing. The three muscles are splenius capitis, splenius cervicis and semispinalis capitis. The three muscle refer pain into the back, side and top of the head as shown in the image above. They can all contribute to tension headaches.
Migraines are a debilitating type of headache, that involve a throbbing sensation on one half of the head and face, and are accompanied by symptoms such as nausea, light sensitivity and visual auras. They are surprisingly common, with 20% of women suffering from migraines according to the NHS.
In a study by Renner et al 2020, it was found that treating the trapezius muscle trigger points significantly decreased the frequency of migraines. While the study was quite small, it noted that this was a promising result that should be studied in more detail. Due to the widespread effect of migraines, many other muscles can also be involved, including temporalis and sternocleidomastoid.
While migraines can be caused by trigger points, there are also a huge number of factors that can cause them, including alcohol, caffeine, dehydration, stress and lack of sleep. Migraines are very complex and poorly understood, which means it can be incredibly difficult to pinpoint the exact cause, and often there can be multiple causes.
Sinus related headaches and pain can have a variety of causes, one of which is trigger points. There are multiple muscles in the face that can refer pain into the nose, cheeks and forehead; including zygomaticus and orbicularis oculi. These refer pain into the sinus regions, which can mimic sinusitis type pain, as shown in the image below.
Additionally, sternocleidomastoid again comes up as one of the muscles that affects the sinus region, with pain referring around the eye, cheek and nose. The upper trapezius and temporalis can also refer some pain into this area. In fact, the high degree of trigger points that refer into the facial regions can make it incredibly difficult to determine the muscle that is the source of the pain.
Overall, headaches are incredibly common, and quite often they are caused by trigger points in muscles of the head, neck and face referring pain into specific regions. There are many other causes of headaches as well, including stress, poor diet, lack of sleep and dehydration; some of which can result in the formation of trigger points that go on to exacerbate a headache.
This article is NOT medical advice. It is just an outline of trigger points and their referral patterns. Please see a medical practitioner if you are experiencing headaches.
Calandre et al. (2008) “Myofascial trigger points in cluster headache patients: a case series.” Head and Face Medicine BMC. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2631448/ [Accessed 20/6/2022]
“Sternocleidomastoid Syndrome and Trigger Points” Physiopedia. Retrieved from: https://www.physio-pedia.com/Sternocleidomastoid_Syndrome_and_Trigger_Points [Accessed 20/6/2022]
Renner et al. (2020) “Alleviation of migraine symptoms by application of repetitive peripheral magnetic stimulation to myofascial trigger points of neck and shoulder muscles – A randomized trial.” Science Report. Nature. Retrieved from: https://doi.org/10.1038/s41598-020-62701-9 [Accessed 28/6/2022]
“Migraine” NHS Retrieved from: https://www.nhs.uk/conditions/migraine/ [Accessed 29/6/2022]
Thien Phu Do (2018) “Myofascial trigger points in migraine and tension-type headache” The Journal of Headache and Pain. Retrieved from: https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-018-0913-8 [Accessed 29/6/2022]
Types of headaches: https://www.drshehadi.com/4-common-types-of-headaches-symptoms-duration/
Lateral Pterygoid & Occipitalis: edited from http://www.triggerpoints.net/muscle/lateral-pterygoid and http://www.triggerpoints.net/muscle/occipitalis
Orbicularis Oculi & Zygomaticus Major: Edited from http://www.triggerpoints.net/muscle/zygomaticus and https://www.glasgowosteopath.com/complaints/headaches/sinusitis/