Musculoskeletal Pain and Headache

Is neck or shoulder pain a headache symptom or a headache trigger?

Reviewing musculoskeletal pain and trigger points

Migraine and tension-type headaches are frequently accompanied by neck and muscular pain. This suggests that there is a functional connection between the trigeminal nerve afferents and the cervical nerve root afferents via the trigeminocervical nucleus. Some suggest that neck pain is a consequence of migraine, while others believe that neck pain is either a trigger of, or at least a contributor to, migraine.

Along with pain in the neck, there are some headache sufferers who have more generalised upper body musculoskeletal pain.

The trigeminal nerve sensory nucleus extends into the upper cervical cord. Some suggest that this relationship explains why migraine pain can be localised in the posterior aspects of the skull and the upper cervical segments. Another possibility is that the trigeminocervical nucleus might be activated as a result of muscle injury and irritations, leading to the formation of trigger points. It is also possible that irritation of established trigger points leads to activation and hence headache.

trigeminal nerve sensory nucleus
The location of the trigeminal nerve sensory nucleus may explain the association of migraine pain and neck pain

Myofascial trigger points

Myofascial trigger points are firm and hyperirritable regions of muscle characterized by taut painful bands which, upon palpation, produce pain locally and refer pain distally. Often a twitch of the muscle can also be appreciated. These areas may restrict range of motion or provoke weakness.

trigger point
A trigger point causing both local and referred pain
What causes trigger points?

The exact pathophysiology of a trigger point remains unclear but is often ascribed to trauma and injury and / or repetitive use with microtrauma. Poor posture, sleep disruption, and lack of exercise have all been implicated in the development of a trigger point.

Treating trigger points

Injection into these regions of tautness, and even dry needling of them, can relieve the tenderness associated with these areas. Furthermore, the injection of these regions with lidocaine and / or steroids can relieve migraine pain and decrease headache frequency in migraine sufferers. Similar findings have been made for tension-type headache sufferers.

Trigger points in headache

Pericranial tenderness in migraine patients has been recognized for decades. Trigger points in the sternocleidomastoid muscle have a referral pattern across the midface and periorbital region—areas that are often painful during headaches.

sternocleidomastoid muscle
Potential areas of pain associated with a trigger point in the sternocleidomastoid muscle.

The exact mechanism of how the two are associated is unclear, but it has been suggested that central sensitisation occurs with the trigger point or musculoskeletal system activation.

Trigger points can be detected in patients who are experiencing migraines. The converse is also true: migraine can occur when a trigger point is palpated and activated manually. One example would be a myogenic headache, occurring with any trigger point which refers sensitivity and pain to the head.

We can also see this in patients with bruxism, where the grinding of teeth – especially during sleep – induces regional muscle irritation and can trigger migraines.

In tension-type headaches, we know that trigger points are present and linked physiologically, but patients who have had recurrent tension headaches seem to have more trigger points. This suggests that trigger points may be caused by tension-type headaches.

Cervicogenic headache

Cervicogenic headache refers to a headache that has a cervical origin and is thus a secondary headache form. Cervicogenic headache is so intimately related to musculoskeletal dysfunction that it is necessary to treat the musculoskeletal issues to aid your patients.

Often a patient with a cervicogenic headache has a history of trauma to the head or neck or a whiplash injury. The mechanism is believed to be rotational injury of the brain around the anterior to posterior axis as it floats in the cerebrospinal fluid. In addition to headaches, the injury may also be associated with cognitive changes, dizziness, sleep disturbance, and depression.

The International Classification of Headache Disorders (ICHD) criteria states that the cervicogenic headache must begin within seven days of the injury or trauma. When a new headache first occurs temporally close to an episode of trauma or injury to the head or neck, it is considered a secondary headache caused by the trauma or injury.

Post-traumatic headaches and whiplash-associated headaches can be either acute or chronic. Headaches for less than three months are deemed acute, while headaches that persist for three months or more are termed persistent or chronic.

If a primary headache pre-existed and is worsened by a trauma or injury, then that patient has BOTH a primary headache disorder and one secondary to an injury of the head or neck.

This is an edited excerpt from the Medmastery course Headache Masterclass by Robert Coni, DO, EdS, FAAN. Acknowledgement and attribution to Medmastery for providing course transcripts.


Neurology Library: Secondary headaches

Neurology Library

LITFL author Robert Coni DO EdS

Robert Coni, DO, EdS, FAAN. Vascular neurologist and neurohospitalist and Neurology Subspecialty Coordinator at the Grand Strand Medical Center in South Carolina. Former neuroscience curriculum coordinator at St. Luke’s / Temple Medical School and fellow of the American Academy of Neurology. In my spare time, I like to play guitar and go fly fishing. | Medmastery | Linkedin |

Dr Hannah Bone LITFL Author

BMBS (The University of Nottingham) BMedSci (The University of Nottingham). Emergency Medicine RMO at Sir Charles Gairdner Hospital Perth, WA. Interested in Medical Education and Emergency Medicine. Swimmer and frequent concert attendee.

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