MANUAL TREATMENT FOR CERVICOGENIC HEADACHE AND

ACTIVE TRIGGER POINT IN THE STERNOCLEIDOMASTOID

MUSCLE: A PILOT RANDOMIZED CLINICAL TRIAL
Gema Bodes-Pardo, PT, MSc, a Daniel Pecos-Martín, PT, PhD, b Tomás Gallego-Izquierdo, PT, PhD, b
Jaime Salom-Moreno, PT, MSc, c César Fernández-de-las-Peñas, PT, PhD, c and Ricardo Ortega-Santiago, PT, PhD c

ABSTRACT

Objective: The purpose of this preliminary study was to determine feasibility of a clinical trial to measure the effects
of manual therapy on sternocleidomastoid active trigger points (TrPs) in patients with cervicogenic headache (CeH).
Methods: Twenty patients, 7 males and 13 females (mean ± SD age, 39 ± 13 years), with a clinical diagnosis of CeH
and active TrPs in the sternocleidomastoid muscle were randomly divided into 2 groups. One group received TrP
therapy (manual pressure applied to taut bands and passive stretching), and the other group received simulated TrP
therapy (after TrP localization no additional pressure was added, and inclusion of longitudinal stroking but no
additional stretching). The primary outcome was headache intensity (numeric pain scale) based on the headaches
experienced in the preceding week. Secondary outcomes included neck pain intensity, cervical range of motion
(CROM), pressure pain thresholds (PPT) over the upper cervical spine joints and deep cervical flexors motor
performance. Outcomes were captured at baseline and 1 week after the treatment.
Results: Patients receiving TrP therapy showed greater reduction in headache and neck pain intensity than those
receiving the simulation (P b .001). Patients receiving the TrP therapy experienced greater improvements in motor
performance of the deep cervical flexors, active CROM, and PPT (all, P b .001) than those receiving the simulation.
Between-groups effect sizes were large (all, standardized mean difference, N 0.84).
Conclusion: This study provides preliminary evidence that a trial of this nature is feasible. The preliminary findings
show that manual therapy targeted to active TrPs in the sternocleidomastoid muscle may be effective for reducing
headache and neck pain intensity and increasing motor performance of the deep cervical flexors, PPT, and active
CROM in individuals with CeH showing active TrPs in this muscle. Studies including greater sample sizes and
examining long-term effects are needed. (J Manipulative Physiol Ther 2013;36:403-411)
Key Indexing Terms: Cervicogenic Headache; Trigger Points; Neck Muscles; Manual Therapy

ervicogenic headache (CeH) is a secondary head- ache with symptoms and signs of neck involvement, for

C ache, which means “head pain with a cervical

source.” 1-3 It is characterized by unilateral head-
a criteria used to define the headache. Prevalence rates
Clinician, Clínica Fisioterapia Santiago Vila, San Fernando de
Henares, Spain.
b
Professor, Department of Physical Therapy of Universidad de
Alcalá, Alcalá de Henares, Spain.
c
Professor, Department of Physical Therapy, Occupational
Therapy, Physical Medicine and Rehabilitation of Universidad
Rey Juan Carlos, Alcorcón, Spain.
Submit requests for reprints to: César Fernández-de-las-Peñas
PT, PhD, Departamento de Fisioterapia, Facultad de Ciencias de la
Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922
Alcorcón, Madrid, Spain (e-mail: cesar.fernandez@urjc.es).
Paper submitted December 4, 2012; in revised form February
12, 2013; accepted February 19, 2013.
0161-4754/$36.00
Copyright © 2013 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2013.05.022
example, pain by movement, by external pressure over
the upper cervical, and/or sustained awkward head posi-
tions. 2,3 Prevalence rates for CeH varied in the general
population because some studies have not detailed the
within the general population varied from 0.4% to
2.5%, 4,5 with a female preponderance (2:1). 6 However,
Sjaastad and Bakketeig 7 reported a prevalence of 4.1%
with no female preponderance.
Physical therapy is commonly used for the management
of individuals with CeH. 8 Previous systematic reviews
reported preliminary evidence for the application of upper
cervical spine mobilization or mobilization for the man-
agement of CeH. 9-11 A recent systematic review of manual
therapies suggests that spinal manipulative might be an
effective treatment in the management of CeH patients. 12 A
survey study conducted in Australia revealed that upper
cervical spine mobilization or manipulation was the most

403
404 Bodes-Pardo et al
Myofascial Trigger Points in Cervicogenic Headache
used intervention by physical therapists. 13 The physiologic
basis of CeH pain lies in the convergence between trige-
minal afferents and afferents from the upper cervical spinal
nerves in the trigeminocervical nucleus caudalis. 14,15
Nociceptive afferent inputs into trigeminocervical nucleus
may be originated by spondylosis, disk lesions, or facet
arthropathies in the upper cervical spine. 16,17 Therefore,
therapeutic interventions targeted to tissues innervated by
the trigeminocervical nucleus caudalis can be effective for
the management of individuals with CeH.
Cervicogenic headache pain has been mostly related
to joint, disk, and ligament pain from the upper cervical
spine 18; however, clinicians should consider that the upper
cervical spine also receives afferent inputs from muscles.
The role of referred pain to the head elicited by muscle
tissues has received particular interest in recent years. 19,20 It
has been hypothesized that muscle trigger points (TrPs) can
play a relevant role in the genesis of headache. 21 A TrP is
usually defined as a hyperirritable spot within a taut band of
a skeletal muscle that elicits a referred pain upon exami-
nation. 21 From a clinical viewpoint, TrPs can be classified
as active or latent. Active TrPs are those which local and
referred pain reproduces the pain symptoms, for example,
reproduce the headache pattern. 21 Trigger points have been
reported to be present in patients with tension type
headache, 19 migraine, 22 and cluster headache. 23 In addi-
tion, active TrPs have been also related to neck pain, 24,25 a
common symptom experienced by individuals with
CeH. 3,5,8 However, data related to TrPs in CeH are scarce.
An old article reported an association between TrPs and
CeH, although it was a case series. 26 Furthermore, there is 1
case report where the referred pain elicited by sternoclei-
domastoid muscle active TrPs reproduced the headache
pain pattern in CeH. 27 In addition, treatment of this active
TrP was effective for the management of this patient. 27 It is
possible that active TrPs in this muscle can be present in a
subgroup of patients with CeH. No studies to date have
examined the effectiveness of TrP manual therapy over
sternocleidomastoid muscle in patients with CeH exhibiting
active TrPs in this muscle. Before conducting a random-
ized, controlled clinical trial, it is necessary to conduct a
pilot study as a first step to determine the potential effects of
the intervention and, in the case that no significant results
were found, to obtain preliminary data for a potential
sample size calculation (if needed). Therefore, the purpose
of this study was to conduct a pilot randomized clinical trial
to determine if such a study were feasible and to identify the
preliminary effects of TrP manual therapy in individuals
with CeH with sternocleidomastoid muscle active TrPs.
METHODS
Participants
This study was registered in Clinical Trials as
NCT01790074. This study was approved by the Ethical
Journal of Manipulative and Physiological Therapeutics
September 2013
Fig 1. Referred pain from sternocleidomastoid TrPs mimick-
ing CeH. Modified from Simons DG, Travell J, Simons L. Travell
& Simons' Myofascial pain and dysfunction: The trigger
point manual: Volume 1. 2nd edition, Baltimore: Williams &
Wilkins, 1999.
Research Committee of the Hospital Universitario Principe
de Asturias, Spain. All participants provided informed con-
sent before their enrollment in the study.
Consecutive patients diagnosed with CeH by an ex-
perienced neurologist from the Principe de Asturias
Hospital, Madrid, Spain, were screened for eligibility
criteria from October 2010 to December 2011. To be
eligible, they had to present a diagnosis of CeH
according to the criteria of Sjaastad and Fredriksen 5 :
(1) unilateral pain starting in the neck and radiating to
the frontotemporal region, (2) pain aggravated by neck
movement, (3) restricted cervical range of motion
(CROM), (4) joint tenderness in at least one of the
joints of the upper cervical spine (C1-C3), and (5)
headache frequency of at least 1 per week over a period
greater than 3 months. These criteria demonstrated
moderate to good reliability. 28 In addition, participants
had to be between 18 and 60 years of age and to present
active TrPs in the sternocleidomastoid muscle re-
producing their headache pattern.
Trigger point diagnosis was conducted following the
criteria of Simon et al 21 : (1) presence of a palpable taut
band in a skeletal muscle, (2) presence of a hypersen-
sitive spot within the taut band, (3) palpable or visible
local twitch on snapping palpation, and (4) reproduction
of referred pain elicited by palpation of the sensitive spot
(Fig 1). These criteria have obtained a good interex-
aminer reliability (κ values, 0.84-0.88) when applied by an
experienced clinician. 29 However, this reliability is related
to the presence or absence of a TrP and not related to the
distinction between active and latent TrPs. 30 Trigger points
were considered active when the referred pain elicited by
their palpation reproduced the headache pattern and the
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 7
patients recognized the pain as a familiar experience. 21,29
Participants were examined for the presence of active
TrPs in the sternocleidomastoid muscle by a clinician
with more than 5 years of experience in the management
of TrPs.
Patients were excluded if they exhibited other primary
headaches (ie, migraine, tension-type headache), suffer
from bilateral headaches, had received treatment for neck or
head pain in the previous year, presented any contraindi-
cations to manual therapy, or had pending legal action
regarding their neck and head pain.
Outcome Measures
A series of headache-associated measures and physical
tests of the cervical spine were assessed at baseline and 1
week immediately after finish treatment. The primary
outcome measure was a change in headache intensity from
baseline to immediately after treatment. The intensity of
head and neck pain was separately assessed with an 11-
point numerical pain rating scale (NPRS) (0, no current
pain; 10, maximum pain). 31 It was recorded as a mean
based on headaches experienced in the preceding week
and assessed once at baseline and once at the end of
treatment. It has been reported that, for patients with neck
pain, the minimal detectable change and the minimal
clinically important difference (MCID) is 1.3 and 2.1
points, respectively. 32 However, there are no available
data for the minimal detectable change and MCID in
patients with headache.
A clinical questionnaire was also used to register and to
calculate the headache-associated variables: (i) headache
frequency, calculated by dividing the number of days with
headache by the number of the previous month (days/
month) and (ii) headache duration, calculated by dividing
the sum of the total hours of pain by the number of days
with neck and head pain (hours/day).
Secondary outcomes included CROM, pressure pain
sensitivity, and deep cervical flexors motor performance.
Cervical range of motion was measured using a CROM
device (Performance Attainment Associates, St Paul, MN).
Fletcher and Bandy 33 found an intratester reliability
ranging from 0.87 to 0.96 and standard error of measure-
ments between 2.3° and 4.1° in subjects with and without
neck pain. Subjects were asked to move their head as far as
they could without pain in a standardized sequence: flexion,
extension, affected/nonaffected lateral flexion, and affect-
ed/nonaffected rotation. The mean of 3 repetitions was
calculated for each type of movement and used for the
analysis. Pressure pain thresholds (PPTs), that is, the
amount of pressure where a sensation of pressure first
changes to pain, 34 were assessed with an analogical algo-
meter (Pain Diagnosis and Treatment, Inc, Great Neck,
NY). The reliability of algometry has been found high
(intraclass correlation coefficient, 0.91; 95% confidence
Bodes-Pardo et al 405
Myofascial Trigger Points in Cervicogenic Headach
Fig 2. Assessment of the motor performance of the deep cervical
flexor muscles with the craniocervical flexion test.
interval [CI], 0.82-0.97). 35 Pressure pain threshold was
assessed over C0-C1, C1-C2, and C2-C3 zygapophyseal
joints on the symptomatic side. Again, 3 trials for each
location were recorded, and the mean was used in the main
statistical analysis. A 30-second resting period was allowed
between each trial.
Finally, the motor performance of the deep cervical
flexor muscles was tested in all patients by using the
craniocervical flexor test (CCFT). The CCFT was
evaluated with the patient in supine with both hips and
knees in 45° of flexion and craniocervical and cervical
spine in a standard position of the head (patients' forehead
and chin were in a horizontal line). The CCFT was
measured using an air-filled pressure biofeedback unit
(Chattanooga Group, Inc, Hixson, TN), and it was placed
behind the patient's neck and inflated to a baseline of 20
mm Hg 36 (Fig 2). For the staged test, the movement of the
patient is performed gently and slowly as a head nodding
action (“a nod of the head, similar to indicating yes”).
From a baseline of 20 mm Hg, the patient attempt to
visually target pressures of 22, 24, 26, 28, and 30 mm Hg
and to hold the position steady for 10 seconds. 37,38 A 10-
second rest was allowed between trials. 36 If signs of
abnormal patterns or poor activation of the deep cervical
flexors (eg, the pressure deviated below the target pressure
or not held steadily, palpable activity in the superficial
flexors, or neck retraction before the completion of the 10-
second isometric hold) appeared, it was considered as a
failure, and the last successful target pressure was used for
data analysis. The CCFT is an indirect measure of deep
406 Bodes-Pardo et al
Myofascial Trigger Points in Cervicogenic Headache
Fig 3. Manual stretching of the taut band of sternocleidomastoid
TrP.
cervical flexor muscle activation and strength, which has
shown to be reliable. 39
Study Protocol
Participants were randomly assigned into 2 groups by
using a table of random numbers created by the EPIDAT
program: an experimental group who received TrP therapy
and a control group who received a simulated TrP therapy.
Both groups were treated by a clinician with more than 6
years of clinical experience in the management of
musculoskeletal pain disorders. All participants attended a
physical therapy clinic 3 days for a week period. Both
treatments (real TrP therapy and simulated TrP therapy)
were applied over the symptomatic side of the headache.
Patients were unaware of the objective of the study in that
they were aware of the ethical implications without re-
vealing the real intervention was being evaluated. All sub-
jects were informed of the true nature of the study at the end
of the study.
Outcome measures were evaluated at baseline and 1
week immediately after finish the treatment by an assessor
blinded to group assignment.
Trigger Point Therapy
Trigger point therapy is composed of different manual
approaches, for example, compression, stretching, or trans-
verse friction massage. 40 Vernon and Schneider 41 reported
moderate to strong evidence supporting the use of TrP pres-
sure release for immediate pain relief of TrPs. Therefore,
pressure release over the sternocleidomastoid muscle TrP
was applied for this study. For the TrP therapy group,
pressure was progressively applied and increased over the
TrP until the finger encountered an increase in tissue resis-
tance (tissue barrier). This pressure was maintained until the
clinician sensed a relief of the taut band. At that moment, the
pressure was increased again until the next increase in tissue
resistance. The process was repeated for 3 times on each
session. 42 Patients within the experimental group also re-
ceived a stretching intervention of the taut band muscle
Journal of Manipulative and Physiological Therapeutics
September 2013
fibers. This technique has been found to be effective for
lengthening the TrP in the muscle and the associated con-
nective tissue. 40,42 Briefly, both thumbs of the therapist were
placed over the taut band above and below the TrP. The
therapist applied moderate slow pressure over the TrP and
slides the fingers in opposite directions (Fig 3). Trigger point
manual therapy was applied slowly and was performed
without inducing pain to the patients.
Simulated TrP Therapy
The simulated group received a simulation of the same
TrP therapy treatment applied to the active treatment group.
The clinician localized the TrP with the fingers and
maintained the same pressure over the TrP without in-
creasing pressure. Following this, longitudinal strokes
(slider technique) were performed over the TrP taut band,
without applying additional pressure or tension over the
tissues. Only slight pressure was applied to simulate hand
contacts of the active therapy; the intention was not to reach
pressure of a therapeutic level.
Statistical Analysis
Statistical analysis was conducted with the SPSS 18.0
package. Mean, SDs, or 95% CIs were calculated. The
Kolmogorov-Smirnov test showed a normal distribution of
quantitative data (P N .05). Differences within baseline
demographic variables were compared between both
groups using independent Student t tests for continuous
data and χ 2 tests of independence for categorical data. A 2
× 2 mixed model analysis of variance (ANOVA) with time
(baseline, posttreatment) as within-subjects variable and
group (active treatment or simulated) as between-subjects
variable was used to examine the effects of interventions on
the main outcome (headache intensity). Separated 2 × 2
ANOVA with time as within-subjects variable and group as
between-subjects variable was also used to determined
changes in cervical flexion and extension range of motion,
PPT, and CCFT scores. Separated 2 × 3 mixed model
ANOVA with time (baseline, posttreatment) and side (af-
fected, nonaffected) as the within-subjects variables and
group (active treatment or control) as between-subjects vari-
able was used to examine the effects of the interventions on
lateral-flexion and rotation CROM. To enable comparison
of effect sizes, standardized mean differences (SMDs)
were calculated by dividing mean score differences between
active treatment and simulated by the pooled SD. P b .05
was considered as statistically significant for all analyses.
RESULTS
Fifty-two consecutive subjects with CeH were screened
for possible eligibility criteria. Twenty patients (age, 39 ±
13 years; 7 males, 13 female) satisfied all the eligibility
criteria, agreed to participate, and were randomized to
Journal of Manipulative and Physiological Therapeutics Bodes-Pardo et al 407
Volume 36, Number 7 Myofascial Trigger Points in Cervicogenic Headach

Table 1. Baseline demographics for both groups

Active TrP therapy Simulated therapy P
Clinical features
Sex (male/female) 3/7 4/6 χ2 = 0.220; P = .639
Age (y) 38 ± 15 40 ± 12 t = − 0.243; P = .811
Affected side (right/left) 6/4 4/6 χ2 = 0.371; P = .656
Pain history (mo) 12.4 ± 5.1 14.1 ± 2.1 t = − 0.972; P = .344
Headache frequency (days/month) 7.6 ± 1.5 7.5 ± 2.3 t = 0.114; P = .910
Headache duration (hours/day) 7.2 ± 6.6 5.3 ± 2.7 t = 0.838; P = .414
Headache intensity (NPRS, 0-10) 7.7 ± 1.3 7.9 ± 0.7 t = − 0.388; P = .703
Neck pain intensity (NPRS, 0-10) 7.4 ± 1.4 7.7 ± 0.8 t = − 0.661; P = .517
PPTs (kg/cm2)
C0-C1 zygapophyseal joint affected side 1.8 ± 0.4 1.9 ± 0.5 t = − 0.395; P = .698
C1-C2 zygapophyseal joint affected side 2.0 ± 0.3 1.9 ± 0.4 t = 0.543; P = .594
C2-C3 zygapophyseal joint affected side 2.1 ± 0.2 2.0 ± 0.5 t = 0.058; P = .955
CROM (°)
Cervical flexion 60.0 ± 10.5 57.8 ± 7.4 t = 0.538; P = .597
Cervical extension 56.3 ± 12.3 47.6 ± 20.0 t = 1.172; P = .257
Cervical lateral-flexion affected side 37.8 ± 6.6 33.8 ± 9.3 t = 1.107; P = .300
Cervical lateral-flexion nonaffected side 39.7 ± 6.3 36.4 ± 7.5 t = 1.067; P = .300
Cervical rotation affected side 64.1 ± 9.4 65.1 ± 11.0 t = − 0.218; P = .830
Cervical rotation nonaffected side 67.0 ± 4.2 59.5 ± 12.2 t = 1.836; P = .083
Craniocervical flexion text (mm Hg)
Craniocervical flexion 22.1 ± 0.3 22.6 ± 0.9 t = − 1.555; P = .137
CROM, cervical range of motion; NPRS, numerical pain rating scale; PPT, pressure pain threshhold.

Table 2. Baseline, posttreatment, and change scores for headache intensity, neck pain, and craniocervical flexion test
Outcome group Baseline End of treatment Within-group change scores Between-group differences
Current level of headache (NPRS, 0-10)
Active TrP therapy 7.6 ± 1.2 2.2 ± 1.5 − 5.4 (− 6.6, − 4.2) 5.2 (4.1, 6.4)
Simulated therapy 7.8 ± 0.7 7.6 ± 0.9 − 0.2 (− 0.4, 0.1)
Current level of neck pain (NPRS, 0-10)
Active TrP therapy 7.4 ± 1.4 3.0 ± 1.4 − 4.4 (− 5.9, − 2.9) 4.3 (2.8, 5.7)
Simulated therapy 7.7 ± 0.9 7.6 ± 0.9 − 0.1 (− 0.4, 0.2)
Craniocervical flexion test (mm Hg)
Active TrP therapy 22.1 ± 0.3 25.6± 1.2 3.5 (2.4, 4.5) 3.4 (2.6, 4.4)
Simulated therapy 22.6 ± 0.9 22.7 ± 0.9 0.1 (0.1, 0.3)
Values are expressed as mean ± SD for baseline and posttreatment scores and as mean (95% CI) for within- and between-groups change scores.
NPRS, numerical pain rating scale; TrP, trigger point.

simulated (n = 10) or active treatment (n = 10) group. The
reasons for ineligibility were bilateral symptoms (n = 7), no
active TrPs in the sternocleidomastoid muscle (n = 12),
physical treatment during the previous year (n = 8), and no
limitation of CROM (n = 5). No significant differences
were found for baseline features between groups (Table 1).
Changes in Headache Intensity and Neck Pain
The 2 × 2 ANOVA revealed significant group * time
interactions for headache intensity (F = 98.628; P b .001)
and neck pain intensity (F = 39.565; P b .001): patients
receiving TrP manual therapy intervention experienced
greater decreases in headache intensity and neck pain
intensity as compared with those receiving the simulated
therapy (Table 2). Between-groups effect sizes were large
for both outcomes (SMD, 2.25).
Changes in Deep Cervical Flexors Motor Performance
A significant group * time interaction was also
observed for motor performance of the deep cervical
flexors as measured by the CCFT (F = 53.629; P b .001):
patients receiving TrP therapy intervention experienced a
greater improvement in motor performance of the CCFT
than those receiving the simulated therapy. Again, the
between-group effect size was large (SMD, 1.52). Table 2
shows baseline, postintervention, and within-groups and
between-groups differences with associated 95% CI for the
CCFT score.
Changes in Pressure Pain Sensitivity
The 2 × 2 mixed model ANOVA revealed significant
group * time interactions for PPT over C1-C2 (F = 46.493;
P b .001), C2-C3 (F = 33.495; P b .001), and C3-C4 (F =
408 Bodes-Pardo et al Journal of Manipulative and Physiological Therapeutics
Myofascial Trigger Points in Cervicogenic Headache September 2013

Table 3. Baseline, posttreatment, and change scores for PPTs

Outcome group Baseline End of treatment Within-group change scores Between-groups differences
2
PPT C1/C2 zygapophyseal joint affected side (kg/cm )
Active TrP therapy 1.8 ± 0.4 2.4 ± 0.5 0.5 (0.4, 0.6) 0.4 (0.3, 0.6)
Simulated therapy 1.9 ± 0.5 2.0 ± 0.5 0.1 (0.0, 0.2)
PPT C2/C3 zygapophyseal joint affected side (kg/cm2)
Active TrP therapy 2.0 ± 0.3 2.6 ± 0.4 0.6 (0.4, 0.8) 0.6 (0.4, 0.8)
Simulated therapy 1.9 ± 0.4 1.9 ± 0.5 0.0 (− 0.1, 0.1)
PPT C3/C4 zygapophyseal joint affected side (kg/cm2)
Active TrP therapy 2.0 ± 0.3 2.7 ± 0.3 0.7 (0.5, 0.9) 0.7 (0.4, 0.9)
Simulated therapy 2.0 ± 0.4 2.0 ± 0.5 0.0 (− 0.1, 0.1)
Values are expressed as mean ± SD for baseline and posttreatment scores and as mean (95% CI) for within- and between-groups change scores.
NPRS, numerical pain rating scale; TrP, trigger point.

Table 4. Baseline, posttreatment, and change scores for active CROM

Outcome group Baseline End of treatment Within-group change scores Between-groups differences
Cervical flexion
Active TrP therapy 60.0 ± 10.5 73.4± 7.2 13.4 (9.2, 17.6) 15.9 (10.9, 20.9)
Simulated therapy 57.8 ± 7.4 55.3± 9.8 − 2.5 (− 5.9, 1.0)
Cervical extension
Active TrP therapy 56.3 ± 12.3 68.2± 11.0 11.9 (6.7, 17.0) 9.8 (4.4, 15.2)
Simulated therapy 47.6 ± 20.0 49.7± 16.7 2.1 (− 0.7, 4.9)
Lateral flexion affected side
Active TrP therapy 37.8 ± 6.6 49.8± 8.3 12.0 (8.1, 15.8) 11.5 (7.7, 15.3)
Simulated therapy 33.8 ± 9.3 34.3± 8.6 0.5 (1.0, 1.5)
Lateral flexion non-affected side
Active TrP therapy 39.7 ± 6.3 47.9± 7.9 8.2 (4.2, 12.2) 8.0 (4.1, 11.9)
Simulated therapy 36.4 ± 7.5 36.6± 7.3 0.2 (− 1.1, 1.5)
Rotation affected side
Active TrP therapy 64.1 ± 9.4 77.7± 6.7 13.6 (8.5, 18.6) 13.1 (8.3, 17.8)
Simulated therapy 65.1 ± 11.0 65.6± 10.9 0.5 (− 0.5, 1.5)
Rotation nonaffected side
Active TrP therapy 67.0 ± 4.2 75.5± 5.2 8.5 (3.7, 13.3) 7.2 (2.4, 12.0)
Simulated therapy 59.5 ± 12.2 60.8± 10.1 1.3 (0.7, 3.3)
Values are expressed as mean ± SD for baseline and posttreatment scores and as mean (95% CI) for within- and between-groups change scores.
TrP, trigger point.

45.430; P b .001) zygapophyseal joints. Again, patients
receiving TrP therapy intervention experienced greater
improvements in PPT levels than those receiving simulation
therapy. Between-groups effect sizes were large (SMD,
0.84). Table 3 details baseline, postintervention, and within-
groups and between-groups differences with associated
95% CI for pressure pain sensitivity.
Active CROM
The mixed-model ANOVAs revealed significant group *
time interactions for all CROMs including flexion (F =
44.018; P b .001), extension (F = 14.556; P b .001), lateral-
flexion affected (F = 56.501; P b .001), and rotation (F =
39.476; P b .001): patients receiving the TrP therapy ex-
perienced greater increases in active CROM than those
receiving simulation. The 2 × 3 ANOVA revealed no
significant time * side interactions for rotation (F = 1.771;
P = .192) and lateral-flexion (F = 2.498; P = .123). In such a
way, changes were similar between symptomatic and
nonsymptomatic sides. Between-groups effect sizes were
large in favor of the active treatment group (SMD, N 1.21).
Table 4 details baseline, postintervention, and within-groups
and between-groups difference scores with their associated
95% CI for active CROM.
DISCUSSION
This study showed that a pilot trial could be conducted to
determine if such a study were feasible. The study found
preliminary findings that that manual therapy targeted to
active TrPs in the sternocleidomastoid muscle may be
effective for reducing headache and neck pain intensity and
increasing motor performance of the deep cervical flexors,
PPT, and active CROM when compared with simulated
therapy in patients with CeH showing active TrPs in this
muscle. Between-groups effect sizes were large for all the
variables suggesting a clinical relevance of the changes
after the treatment. In addition, between-group change
scores surpassed the previously reported MCID for pain
Journal of Manipulative and Physiological Therapeutics
Volume 36, Number 7
intensity. These results would support the hypothesis that,
in patients with CeH where the referred pain from active
TrPs in the sternocleidomastoid muscle reproduces the
headache pain pattern, the application of TrP manual
therapies can be an effective approach for these patients.
Our study is novel because previous studies investigating
manual therapies in patients with CeH have only included
joint interventions or exercise, but not TrP therapies. 10-12
There has only been 1 study where the authors applied TrP
manual therapy to the masticatory muscle in individuals
with CeH. 43 The results of our study are consistent with a
previous case report where management of active TrP in the
sternocleidomastoid muscle was effective for the treatment
of a patient with CeH showing affectation of this muscle. 27
It should be noted that lower bound estimates of the 95% CIs
for between-group changes exclude the MCID for pain
intensity, the primary outcome, supporting statistically and
clinically meaningful improvements in reduction of pain.
Some authors suggested that the sternocleidomastoid
muscle may be a particularly common source of myofascial
CeH. 44 Nevertheless, we should consider that not all patients
with CeH exhibit active TrPs in the sternocleidomastoid
muscle. In our study, at least 12 (24%) of 52 patients with
CeH did not have active TrPs in this muscle. It would be
interesting to determine the prevalence of active TrPs in the
neck and head muscles in individuals with CeH.
The mechanisms why TrP manual therapy can be effective
for reducing pain remain speculative. 45 Possible mechanisms
include a reduction of TrP activity, restoration of the length of
the muscle sarcomeres, reactive hyperemia within the TrP
taut band, temporary elongation of the connective tissue, or
reduction of sensitization mechanisms associated to
TrPs. 45,46 Another explanation may be that TrP manual
treatment results in segmental antinociceptive effects. 47 In
agreement with this hypothesis, we found significantly
greater increases in PPT over the affected joints in those
patients receiving TrP therapy. Again, between-groups
differences exhibited large effect sizes, supporting a clinical
effect of the intervention over mechanical sensitivity in those
joints previously found to be hypersensitive in CeH. 48 The
fact that TrP therapy decreases pressure pain sensitivity by
increasing PPT is in line with a previous study. 49 Current and
previous findings would support the antinociceptive effect of
TrP interventions. Nevertheless, it is possible that different
mechanisms are involved at the same time in the therapeutic
effects of TrP manual treatment. Future studies are needed to
determine the mechanisms effects of TrP manual therapies.
We also found that patients with CeH with active TrPs in
the sternocleidomastoid muscle receiving TrP manual therapy
experienced an increase in motor performance of the CCFT.
This finding may be related to the fact that the sternocleido-
mastoid produces cervical flexion as its primary function.
There is evidence associating relative excessive electromyo-
graphic activity of this muscle with weak deep cervical flexor
activity during the CCFT. 37,38 It has been found that patients
Bodes-Pardo et al 409
Myofascial Trigger Points in Cervicogenic Headach
with CeH also exhibit lower motor performance during the
CCFT. 36,50 Therefore, it is further possible that excessive
activity of the sternocleidomastoid muscle during the CCFT
induces TrP activation as previously suggested. 21,39,45 In fact,
some studies have demonstrated that TrPs are associated with
abnormal movement patterns 51 and increased motor neuron
excitability 52 demonstrating the clinical relevance of TrPs in
motor performance. In such scenario, manual therapies
targeted to TrPs in the sternocleidomastoid muscle can
restore the motor control performance of the CCFT.
Finally, we also found an increase in all CROMs after
TrP manual therapy suggesting that TrP therapy can relive
muscle tension of the taut bands in the sternocleidomastoid
muscle. Our results agree with a previous study where
patients with chronic neck pain and dizziness also exhibited
increase in CROM after the application of ischemic
compression over tender neck muscles. 53 In fact, we do
not know if restoration of the length of the sarcomeres can
be related to improvements in active CROM observed in
those patients receiving TrP therapy. Because restricted
CROM has been found to discriminate CeH from other
headache subtypes, 50 it is expected an improvement of this
outcome after a reduction of pain.
Limitations
Although a potential strength of the current controlled
clinical trial was the inclusion of a simulated therapy group,
we should recognize potential limitations. The sample size
was small, which was related to the fact that this was a pilot
randomized, controlled study. Thus, clinical findings still
need to be confirmed with larger studies. We only assessed
the effects of TrP manual therapy at 1-week follow-up
period, so we cannot be certain if differences remain in the
long term. Subject selection was based on CeH clinical
criteria and the presence of active TrP in the sternocleido-
mastoid muscle. Therefore, current results should not be
extrapolated to all patients with CeH. As well, it is possible
that the simulated TrP treatment could have provided some
beneficial effects, although the pressure was minimal.
Finally, only 1 therapist provided the treatment in the
current study, which may limit the generalizability of the
results. Future trials should address these issues and consider
including multiple therapists delivering the interventions.
CONCLUSION
This study provides preliminary evidence that a trial of
this nature is feasible. The findings of this pilot trial sug-
gests that TrP manual therapy may be effective for reducing
headache and neck pain intensity and pressure pain sen-
sitivity and for increasing motor performance of the deep
cervical flexors and active CROM in individuals with CeH
showing active TrPs in the sternocleidomastoid muscle.
Studies including large sample sizes and longer follow-up
periods are suggested.
410 Bodes-Pardo et al
Myofascial Trigger Points in Cervicogenic Headache
Practical Applications
• The application of manual therapy of active TrP in
patients with CeH improved pressure pain sensi-
tivity, CROM, and deep cervical flexors motor
performance.
• Manual therapy in active TrP point of sternoclei-
domastoid muscle decreased the intensity of neck
and head pain in individuals with CeH.
• Future randomized controlled trials are necessary
to determine the validity of these results.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
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