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Wednesday, March 17, 2010


A new article in the Journal of Musculoskeletal Pain by Michael Sorrell, MD of Tufts University showed excellent results in treating Migraine utilizing trigger point injections and physical therapy with supervised home stretching. The examination of the myofascial trigger points is a step rarely done in working up migraine patients,The majority of patients had received previous diagnosis of migraine and had undergone unsuccessful drug treatment. These patients were unaware that their pain could be referred from muscles until the examination of the muscles revealed the referred pain.

The examination did not include all of the the masticatory muscles but did include masseter and temporalis muscles,the sternocleidomastoid muscle,the trapezius muscle, the corrugater supercilius, the semispinalis, splenius cevicus and capitus muscles, as well as the suboccipitalis and levator scapulae muscles. If muscle palpation examination reproduced the headache the patients were included in the trial.

This study only included patients with chronic migraine and migraine without aura whose pain could be reproduced from muscle examination. A subgroup of 11 patients with Migraine with aura (5 of 11 patients migraine symptoms reproduced on examination) was also included in the study. Those patients did remarkably well with 68% mean improvement in those receiving physical therapy and home stretching compared to 5% improvement in the group not utilizing physical medicine. Over 88% of the study group reported over 50% improvment.

This is an important article primarily because it is from a neurology group treating migraines. It is well known that tension type headaches respond to physical medicine and treatment of myofascial trigger point. Migraines are usually very responsive to physical medicine as well. The field of Neuromuscular Dentistry actively focuses on the elimination trigger through use of TENS, TP injections, Spray and Stretch and other techniques as well. More importantly use of neuromuscular trigger points prevents the formation of new trigger points.

The examination in the above article ignored many of the masticatory muscles known to creat migraine like symptoms.

There is also an important concept of myofascial triggers serving as a trigger for migraines. Removal of these triggers can eliminate future migraines.

I have frequently seen migraine patients achieve complete relief thru a combination of a neuromuscular diagnostic orthotic and physical medicine modalities. I have seen other patient who have greatly reduced frequency of migraine but when a migraine does occur medication is still necessary due to severity. This is common with hormonal headaches and migraines. I will have a patient with severe diaily migraines that are eliminated but the patient qwill still have a tension type headache or migraine at ovulation or prior to Menses.

These are patients who I believe we have relieved the myofascial components of their pain but the hormonal triggers remain. The headaches that are then present are less severe. Other patients may only get the aura when presented with triggers but no pain. I do believe that evaluation and elimination of myofascial triggers is important for all migraine patients but in some patients the myofacial trigger points are a secondary result of the migraine pain rather that a primary cause of migraine. It is still important to eliminate these secondary trigger points so the do not increase and become a primary problem.

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posted by Dr Shapira at 6:10 AM

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