Manual Therapy 17 (2012) 456e458

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Manual Therapy
journal homepage: www.elsevier.com/math

Case report

Tension e Type e Headache treated by Positional Release Therapy: A case report

Marzieh Mohamadi, Ali Ghanbari*, Abbas Rahimi jaberi
Shiraz University of Medical Sciences, Shiraz, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Tension Type Headache (T.T.H) is the most prevalent headache. Myofascial abnormalities & trigger points
Received 3 January 2012 are important in this type of headache which can be managed by Positional Release Therapy (PRT). This is
Received in revised form a report of a 47 years old female patient with Tension Type Headache treated by Positional Release
7 April 2012
Therapy for her trigger points. She had a constant dull headache, which continued all the day for 9
Accepted 8 April 2012
months. A physiotherapist evaluated the patient and found active trigger points in her cervical muscles.
Then, she received Positional Release Therapy for her trigger points. After 3 treatment sessions, the
Keywords:
patient’s headache stopped completely. During the 8 months following the treatment she was without
Tension Type Headache
Trigger point
pain, and did not use any medication. Positional Release Therapy was effective in treating Tension Type
Positional Release Therapy Headache. This suggests that PRT could be an alternative treatment to medication in patients with T.T.H if
the effectiveness of that can be confirmed by further studies.
Ó 2012 Elsevier Ltd. All rights reserved.

1. Introduction PRT is a technique in which muscles are placed in a position of

greatest comfort and this causes normalization of muscle hyper-
Headache is defined as pain anywhere in the head or neck tonicity & fascial tension, a reduction of joint hypomobility,
(Dorland,1980). The brain lacks pain receptors, but other areas of the increased circulation & reduced swelling, decreased pain and
head and neck such as arteries, veins, cranial & spinal nerves, head & increased muscular strength (D’Ambrogio et al., 1997).
neck muscles and meninges can sense pain (Edlow et al., 2009). Several studies have reported the reduction of headache
Tension-Type-Headache (T.T.H) which is the most prevalent symptoms after the management of trigger points by different
headache (Bendtsen et al., 2010; Fernández-de-las-Peñas et al., procedures (Moraska and Chandler, 2008; Von Stülpnagel et al.,
2008) has a muscular origin (Page, 2011) and its resultant 2009; Venancio et al., 2009) but the effectiveness of PRT in the
disability is more than other primary headaches (Bendtsen et al., improvement of patients with T.T.H remains unclear. This is a report
2010). The patient’s history and negative neurological findings are of a patient with T.T.H and trigger points in her cervical muscles,
the diagnostic criteria in T.T.H (Bronfort et al., 2010). In this type of who was helped by trigger point management with PRT.
headache, the musculoskeletal impairments and myofascial &
postural abnormalities are important (Fernández-de-las-Peñas 2. Case report
et al., 2006a; Sohn et al., 2010). Fernandez et al. (2006a) reported
that headache parameters (intensity, duration, frequency) are A 47 years old female with a constant, dull headache that
greater in T.T.H patients with any trigger points in the head and continued all the day for 9 months was seen by a neurologist. Her
neck muscles than patients without trigger points. pain was band-like and frequently involved the right side. She
A trigger point is a hyperirritable spot in skeletal muscle which seldom had nausea and vomiting.
can be active or latent (Ross, 2004). Active trigger points can cause Magnetic Resonance Imaging (MRI) was ordered for this patient.
headaches (Ross, 2004). When neurological and imaging investi- Because of normal MRI & neurological findings, she received
gations are normal, trigger points should be considered as the Tricyclic Antidepressant (TCAs) as prophylactic & Non-steroidal
possible etiology for headache (Sattari, 2007). Treatment options for Anti-inflammatory Drugs (NSAIDs) as abortive tablets with the
trigger points include: trigger point injections, dry-needling, diagnosis of T.T.H, but after one month, there was no improvement
stretching exercise, massage therapy and Positional Release in her symptoms. Further blood test and electromyography/nerve
Therapy (PRT) (Ross, 2004; D’Ambrogio et al., 1997). conduction velocity (EMG/NCV) investigations revealed normal
findings. Then the patient was referred to a psychologist and
received psychological consultation without any improvement.
* Corresponding author. Tel.: þ98 7116271551; fax: þ98 7116272495. Finally, she was referred to the physiotherapy clinic for treatment of
E-mail address: [email protected] (A. Ghanbari). her trigger points in cervical muscles.

1356-689X/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2012.04.005
 M. Mohamadi et al. / Manual Therapy 17 (2012) 456e458 457

Fig. 1. Pain distribution and location of trigger points: A - Suboccipital muscles (Opimumsportsperformance, 2010), B - Sternocleidomastoid muscle (Test.Backtozerobiz, 2012),
C - Trapezius muscle (Round-Earth, 2012), D - Spinalis muscles (Round-Earth, 2012).

The patient stated that her pain initiated from the shoulder and Unfortunately, after this time and following a family conflict, her
neck and then radiated to the head. (See Fig. 1) She complained of headache returned.
a relatively constant pain during the day from awakening in
morning till night. Her headache was worse during activities such 3. Discussion
as cooking or driving in which the head and neck were maintained
in a static position. Trigger points have a basic role in many chronic pain syndromes
On observing the patient, she had a kyphotic, rounded shoulder (Ross, 2004). Harden et al. (2009) state that trigger points are
and forward head posture. The patient’s cervical region was rigid associated with end-plate disorder and increased release of
and when she was asked to look one side, she did not rotate her acetylcholine which result in local ischemia and finally sensitiza-
neck appropriately and turned her trunk instead. She had limitation tion of nociceptors. There is an increased release of inflammatory
of range of motion in the neck, shoulder or thoracic spine because chemical substances such as histamine, prostaglandins, bradykinin
of pain, which made the measurement of the true range of motion and serotonin in trigger point’s site (Davidoff, 1998; Harden et al.,
difficult. On palpation, there were tender spots that elicited radic- 2009). These substances can affect the membrane of polymodal
ular pain to the head. Physical examination revealed active trigger nociceptive receptors and cause peripheral sensitization which
points in the right trapezius, left sternocleidomastoid, right & left result in central sensitization and chronic pain (Davidoff, 1998).
obliqus capitis superior, left rectus capitis anterior and interspinalis On the other hand, it is proven that central sensitization is the
muscle of C4 segment. The existence of trigger points was basis of primary headaches such as T.T.H (Bradley et al., 2003).
confirmed if there was a positive jump sign and headache provo- Sensitization of the trigeminal nerve can cause a migraine head-
cation by deep pressure on them. ache and central sensitization from trigger points result in T.T.H
The patient received Positional Release Therapy (PRT) as (Fernández-de-las-Peñas et al., 2007; Fernández-de-las-Peñas
described by D’Ambrogio et al. (1997) to treat, her trigger points. et al., 2006b). Calandre et al. (2006) claim that peripheral sensiti-
While the patient was lying in a supine position, the therapist zation can be effective in the pathophysiology of cluster headache.
placed each muscle in a specific position as follows: In PRT, the muscles are placed in greatest comfort position. the
resultant relaxation of tissue leads to an improvement in vascular
- Trapezius muscle: the patient’s head was laterally flexed circulation and removal of the chemical mediators of inflammation
toward the trigger point and her shoulder was abducted to (D’Ambrogio et al., 1997). Thus, PRT may eliminate the peripheral &
approximately 90 . central sensitization. This technique may also reduce the central
- Sternocleidomastoid muscle: the patient’s mid cervical area sensitization directly by the damping influence on the facilitated
was markedly flexed and laterally flexed toward the trigger segment in the spinal cord (D’Ambrogio et al., 1997). Therefore, it is
point. hypothesized that PRT affects the pathogenesis of T.T.H, and this
- Obliqus capitis superior muscle: the patient’s occiput was could be a plausible explanation for the improvement in this
extended on C1. patient. The recurrence of the patient’s headache following a family
- Rectus capitis anterior muscle: the patient’s occiput was flexed. conflict confirms that “mental stress can activate trigger points”
- Interspinalis muscle: the patient’s head was extended moder- (Sauer and Biancalana, 2009).
ately and laterally flexed & rotated away from the trigger point.
4. Conclusion
In each position the therapist monitored the trigger point by her
index finger and maintained that position until the release was felt. The authors propose that PRT may be an effective treatment for
This could take from 5 to 20 min. Each trigger point was treated T.T.H patients with trigger points in cervical muscles. This tech-
once in a session (D’Ambrogio et al., 1997). nique may be used as an alternative or an adjunct to other thera-
At the first session, the patient was requested to value her pies. The effectiveness of this form of treatment should be
headache intensity in Numeric Pain Index (NPI) (Ross, 2004). The confirmed by further clinical research.
examiner assessed the pain intensity in each session. At the end of
first treatment session, there was no change in NPI. At the end of Acknowledgment
second session, her pain reduced from 10 to 8. After 3 treatment
sessions, the patient’s headache stopped completely. Throughout The authors are thankful to the physiotherapy clinic of Reha-
the next 8 months, she had no pain and did not use any medication. bilitation School of Shiraz University of Medical Sciences.
458 M. Mohamadi et al. / Manual Therapy 17 (2012) 456e458

References Fernández-De-Las-Peñas C, Cleland J, Cuadrado M, Pareja J. Predictor variables for

identifying patients with chronic tension-type headache who are likely to
achieve short-term success with muscle trigger point therapy. Cephalalgia
Bendtsen L, Evers S, Linde M, Mitsikostas D, Sandrini G, Schoenen J. EFNS guideline
2008;28:264e75.
on the treatment of tensionetype headache e report of an EFNS task force.
Harden RN, Cottrill J, Gagnon CM, Smitherman TA, Weinland SR, Tann B, et al.
European Journal of Neurology 2010;17:1318e25.
Botulinum toxin A in the treatment of chronic tension-type headache with
Bradley WG, Daroff RB, Fenichel G, Jankovic J. Neurology in clinical practice edition.
cervical myofascial trigger points: a randomized, double-blind, placebo-
Butterworth Heinemann; 2003.
controlled pilot study. headache. The Journal of Head and Face Pain 2009;49:
Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual thera-
732e43.
pies: the UK evidence report. Chiropractic & Osteopathy 2010;18.
Moraska A, Chandler C. Changes in clinical parameters in patients with tension-type
Calandre E, Hidalgo J, García-Leiva J, Rico-Villademoros F. Trigger point evaluation
headache following massage therapy: a pilot study. The Journal of Manual &
in migraine patients: an indication of peripheral sensitization linked to
Manipulative Therapy 2008;16:106.
migraine predisposition? European Journal of Neurology 2006;13:244e9.
Opimumsportsperformance. 2010. http://optimumsportsperformance.com/blogfa/?
Davidoff R. Trigger points and myofascial pain: toward understanding how they
p¼1307 [Online]. [accessed 05.04.12].
affect headaches. Cephalalgia 1998;18:436e48.
Page P. Cervicogenic headaches: an evidence-led approach to clinical management.
Dorland WAN. Dorland’s medical dictionary. Saunders Press; 1980.
International Journal of Sports Physical Therapy 2011;6:254.
D’ambrogio KJ, Roth GB, Robertson J, Halperin S, Wiley M. Positional release
Ross EL. Pain management. Elsevier Health Sciences; 2004.
therapy: assessment and treatment of musculoskeletal dysfunction. Mosby;
Round-Earth. 2012. http://round-earth.com/HeadPainIntro.html [Online]. [accessed
1997.
05.04.12].
Edlow JA, Panagos PD, Godwin SA, Thomas Tl, Decker WW. Clinical policy: critical
Sattari S. Headache with myofascial origin. Shiraz E-Medical Journal 2007;8.
issues in the evaluation and management of adult patients presenting to the
Sauer S, Biancalana M. Trigger point therapy for low back pain: a self-treatment
emergency department with acute headache. Journal of Emergency Nursing
workbook. New Harbinger Pubns Inc.; 2009.
2009;35:e43e71.
Sohn J, Choi H, Lee S, Jun A. Differences in cervical musculoskeletal impairment
Fernández-De-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD, Pareja JA.
Myofascial trigger points and their relationship to headache clinical parameters between episodic and chronic tension-type headache. Cephalalgia 2010;30:1514.
Test.Backtozerobiz. 2012. www.test.backtozerobiz/About-Acupuncture-Physical-
in chronic tension-type headache. Headache: The Journal of Head and Face Pain
Medicine [Online]. [accessed 05.04.12].
2006a;46:1264e72.
Venancio RA, Alencar Jr F, Zamperini C. Botulinum toxin, lidocaine, and dry-
Fernández-De-Las-Peñas C, Cuadrado M, Pareja J. Myofascial trigger points, neck
needling injections in patients with myofascial pain and headaches. Cranio
mobility and forward head posture in unilateral migraine. Cephalalgia 2006b;
2009;27:46e53.
26:1061e70.
Von Stülpnagel C, Reilich P, Straube A, Schäfer J, Blaschek A, Sh Lee, et al. Myofascial
Fernández-De-Las-Peñas C, Cuadrado M, Arendt-Nielsen L, Simons D, Pareja J.
trigger points in children with tension-type headache: a new diagnostic and
Myofascial trigger points and sensitization: an updated pain model for tension-
therapeutic option. Journal of Child Neurology 2009;24:406e9.
type headache. Cephalalgia 2007;27:383e93.