Chapter 7 César Fernández-de-las-Peñas; Ana Isabel-de-la-Llave-Rincón; Ricardo Ortega-Santiago; Bárbara Torres-Chica; Jan Dommerholt Neck, head, and orofacial pain syndromes are among the most common problems seen in daily clinical practice. Headache is the most prevalent neurological pain disorder seen by physicians and experienced by almost everyone (Bendtsen & Jensen, 2010). Orofacial pain of muscular origin is as prevalent as headache (Svensson, 2007). The lifetime and point prevalence of neck pain are almost as high as low back pain. Neck pain affects 45%–54% of the general population at some time during their lives (Côte et al., 1998) and can result in severe disability (Côte et al., 2000). The lifetime prevalence of idiopathic neck pain has been estimated to be between 67% and 71%, indicating that approximately two-thirds of the general population will experience an episode of neck pain at some time during their life (Picavet et al., 2000). In a systematic review Fejer and colleagues (2006) found the 1-year prevalence for neck pain ranging from 16.7% to 75.1%. The economic burden of neck pain involves high annual compensation costs (Manchikanti et al., 2009). Among the different primary headaches, migraine and frequent tension-type headache represent the most common forms (Bendtsen & Jensen, 2006). Globally, the percentage of adults with headache is 10% for migraine, 38% for tension-type headache, and 3% for chronic daily headache (Jensen & Stovner, 2008). Migraine is considered the sixth most disabling illness in the world (Migraine Research Foundation, 2018). In the US, about 18% of women, 6% of men, and 10% of children—equivalent to approximately 38 million people—suffer from migraine headaches (Bonafede et al., 2017). An estimated 4 million people suffer from daily chronic migraines (Migraine Research Foundation, 2018). The global prevalence of tension-type headaches in the adult population is as high as 42% (Ferrante et al., 2013). A recent systematic review showed that the prevalence of nonspecific chronic headache after head injury in children was 39%, with a prevalence of chronic posttraumatic headache of 7.6%. Migraine and tension-type headaches were the most common headaches (Shaw et al., 2018). In the general population, the prevalence rate of cervicogenic headache is reported as 4.1% (Sjaastad & Bakketeig, 2008). In patients with cervical spine disorders requiring surgery, the prevalence of cervicogenic headache was 21.4% (Shimohata et al., 2017). The prevalence of cervicogenic headache is, however, difficult to determine because current epidemiological studies have used different criteria for its diagnosis (Haldeman & Dagenais, 2001). Headaches cause substantial disability for patients and their families, as well as to global society (Stovner et al., 2007). In the US, the estimated total cost in 1998 was $14.4 billion for 22 million migraine sufferers (Hu et al., 1999). In Europe, the estimated cost was €13.8 billion for headaches in general (Raggi & Leonardi, 2015). According to the Global Burden of Disease Study (2015), headache, particularly tension-type headache, was the second most prevalent disorder in the world. Clinically, orofacial pain is usually associated with headaches. Its prevalence is, however, under debate, with studies showing prevalence rates between 3% and 15% in the Western population (LeResche, 1997). Isong and colleagues (2008) determined that the prevalence of orofacial pain was 4.6% (6.3% for women; 2.8% for men). Neck, head, and facial pain are also common clinical manifestations of patients suffering from whiplash-associated disorders (Drottning et al., 2002). Neck injuries after motor-vehicle accidents comprised 28% of all injuries seen in emergency room departments in 2000 (Quinlan et al., 2004). In the US, the incidence rate was 4.2 per 1000 inhabitants (Sterner et al., 2003), whereas the prevalence rate was 1% (Richter et al., 2000). The annual costs of motor-vehicle crashes in the US from 1999 to 2001 were estimated at $346 billion, with $43 billion attributed to whiplash (Zaloshnja et al., 2006). These pain syndromes have common clinical features and are often comorbid entities, suggesting a common nociceptive pathway with sensitisation mechanisms mediated through the trigeminal nucleus caudalis. The exact pathogenesis of the pain is not completely understood. Simons and colleagues (1999) described the referred pain elicited from trigger points (TrPs) in several muscles that can play a relevant role in the presentation of these syndromes. In this chapter we cover dry needling (DN) of TrPs in the head and neck musculature based on clinical and scientific reasoning. Since 2006, an increasing number of studies have confirmed the relevance of TrPs in head, neck, and face pain syndromes (Fernández-de-las-Peñas et al., 2007a; Fernández-de-las-Peñas, 2015). A recent systematic review and a meta-analysis support the presence of active TrPs in different spinal pain disorders, including mechanical neck pain and headaches (Lluch et al., 2015; Chiarotto et al., 2016). Clinicians should consider that differences in the pain characteristics of tension-type, cervicogenic, and migraine headaches may implicate different structures and mechanisms, which may be contributing to nociceptive irritation of the trigeminal nucleus caudalis. For instance, tension-type headache is characterised by pressing or tightening pain, pressure or bandlike tightness, and increased tenderness on palpation of the neck and shoulder muscles (ICHD-III, 2013), which resemble clinical descriptions of pain from TrPs (Simons et al., 1999; Gerwin, 2005; Fernández-de-las-Peñas, 2015). We summarise pertinent clinical and scientific evidence related to TrPs in head, neck, and face pain syndromes. There is scientific data that referred pain from masticatory muscles can be involved in orofacial pain syndromes (Svensson & Graven-Nielsen, 2001). Experimental studies reproduced motor and sensory disturbances, including hyperalgesia and referred pain, similar to those reported for temporomandibular pain patients after injecting irritating substances into the masseter muscle (Svensson et al., 2003a, 2003b, 2008). Svensson (2007) suggested that different muscles such as the masseter are involved in the pathophysiology of temporomandibular pain, whereas the upper trapezius and suboccipital muscles, for example, may be more common in tension-type headaches. Mortazavi and colleagues (2010) considered myofascial pain as one of the most common causes of chronic orofacial pain. Overall, few studies investigating the presence of TrPs in temporomandibular pain have been conducted. Wright (2000) found in a sample of 190 patients with temporomandibular pain that the upper trapezius (60%), lateral pterygoid (50%), and masseter (47%) muscles were the most common sources of referred pain into the craniofacial region. The cheek area, ear, and forehead were the most frequently reported sites of referred-pain generation. Unfortunately, this study did not include a control group, and patients were not examined in a blinded fashion. Fernández-de-las-Peñas and colleagues (2010) conducted a blind-controlled study in which patients with myofascial temporomandibular (TMD) pain and healthy controls were examined for TrPs in the neck and head muscles. They found that active TrPs in the masticatory muscles—i.e., the superficial masseter (78%), temporalis (73%), and deep masseter (72%)—were more prevalent than TrPs within the neck and shoulder muscles, including the upper trapezius (64%), suboccipital (60%), and sternocleidomastoid (48%) muscles. This would be expected because masticatory TrPs are more likely to play a role in temporomandibular pain, whereas neck and shoulder TrPs would play a greater role in headaches. Alonso-Blanco and colleagues (2012) observed that women with temporomandibular pain exhibited more active TrPs in the temporalis and masseter muscles than women with fibromyalgia syndrome and that TrP referred pain areas were mostly located in the orofacial region in temporomandibular pain, but more pronounced in the cervical spine in subjects with fibromyalgia syndrome. DN of the masticatory muscles is effective for decreasing pain and increasing function in patients with bruxism (Blasco-Bonora & Martín-Pintado-Zugasti, 2017) and temporomandibular pain disorders (Dıraçoğlu et al., 2012; González-Pérez et al., 2015), which supports a potential myogenic role in these disorders. TrPs in the neck and shoulder muscles may be implicated in symptoms of the neck, which are commonly seen with patients suffering from temporomandibular pain (De Wijer et al., 1999). Preliminary evidence suggested that treatments targeting the cervical spine are beneficial in decreasing pain intensity and pressure pain sensitivity over the masticatory muscles and in increasing pain-free mouth opening in patients with myofascial TMD (La Touche et al., 2009). Botulinum toxin injections of the masseter and temporalis muscles reduced the pain in 77% of the subjects and reduced bruxism in 87%) (Connelly et al., 2017). In contrast, a systematic review showed only moderate short-term effects of botulinum injections (Khalifeh et al., 2016). Gerwin (2012) analysed why there are such discrepancies in the literature on botulinum toxin injections and TrPs and concluded that dosages, outcome measures, and timelines for assessment are commonly inappropriately selected. Tension-type headache (TTH) is a type of headache with clear scientific evidence of an aetiological role for TrPs (Fernández-de-las-Peñas & Schoenen, 2009; Fernández-de-las-Peñas, 2015). A scope review concluded that, among the musculoskeletal pain disorders associated with TTH, TrPs are proposed as the main physical outcome for assessing nociceptive pain mechanisms in this headache (Abboud et al., 2013). Marcus and colleagues (1999) reported that patients with TTH had a greater number of either active or latent TrPs than healthy controls; however, this study did not specify in which muscles TrPs most frequently were found. In a series of blinded-controlled studies, Fernández-de-las-Peñas and colleagues found that active TrPs were extremely prevalent in individuals with chronic and episodic TTH. Patients with chronic TTH have active TrPs in: the extraocular superior oblique muscles (86%) (Fernández-de-las-Peñas et al., 2005a); the suboccipital muscles (65%) (Fernández-de-las-Peñas et al., 2006a); the upper trapezius muscle (50%–70%) (Fernández-de-las-Peñas et al., 2006b, 2007b); the temporalis muscle (60%–70%) (Fernández-de-las-Peñas et al., 2006b, 2007c); the sternocleidomastoid muscle (50%–60%) (Fernández-de-las-Peñas et al., 2006b); and the extraocular rectus lateralis muscles (60%) (Fernández-de-las-Peñas et al., 2009). Patients with chronic TTH and active TrPs in these muscles exhibited more severe headaches with greater intensity, frequency, and duration than patients with chronic TTH and latent TrPs in the same muscles (Fernández-de-las-Peñas et al., 2007e). Given that temporal summation of pain is centrally mediated (Vierck et al., 1997), a temporal integration of nociceptive signals from muscle TrPs by central nociceptive neurons is probable, leading to sensitisation of central pathways in chronic TTH (Bendtsen & Schoenen, 2006). Couppe and colleagues (2007) also found a higher prevalence of TrPs in the upper trapezius muscle (85%) in patients with chronic TTH. In addition TrPs were found in children with chronic TTH. A case series of nine 13-year-old girls with TTH suggested that TrPs do play an important role in at least a subgroup of children with TTH (Von Stülpnagel et al., 2009). These girls received TrP treatments twice a week. After 6.5 sessions, the headache frequency was reduced by 67.7%, the intensity by 74.3%, and the mean duration by 77.3% (Von Stülpnagel et al., 2009). In a blinded-controlled study, Fernández-de-las-Peñas and colleagues (2011a) reported that in children with chronic TTH and a mean age of 8, the suboccipital (80%), the temporalis (54%), the ocular superior oblique (28%–30%), the upper trapezius (20%), and the sternocleidomastoid (12%–26%) muscles harbored most TrPs. Active TrPs have also been reported in episodic TTH but less frequently. The most common muscles with active TrPs included: the superior oblique muscle (15%) (Fernández-de-las-Peñas et al., 2005a); the suboccipital muscles (60%) (Fernández-de-las-Peñas et al., 2006c); the sternocleidomastoid (20%); the temporalis (45%); and the upper trapezius muscle (35%) (Fernández-de-las-Peñas et al., 2007d). Another study confirmed that active TrPs are more prevalent in chronic TTH than in episodic TTH (Sohn et al., 2010). The association of active TrPs with episodic TTH does not support the hypothesis that active TrPs are always a consequence of central sensitisation because central sensitisation is not as common in episodic TTH as in chronic TTH (Fernández-de-las-Peñas et al., 2006d). Not included in this study are TrPs located in other muscles, such as the masseter, splenius capitis, scalene, levator scapulae muscles, which may also contribute to the pain symptoms in individuals with TTH. Current evidence suggests that TrP referred pain and associated muscle hyperalgesia seem to be clinically important factors in TTH. Damping the nociceptive peripheral drive may not only reduce the number of TTH attacks but may also prevent or delay the transition from episodic into chronic TTH or both (Arendt-Nielsen et al., 2016). Recently this hypothesis has been confirmed by a study demonstrating that the number of active and latent TrPs was significantly and negatively associated with widespread pressure pain hypersensitivity in patients with frequent episodic or chronic TTH (Palacios-Ceña et al., 2016). Finally, a few studies explored the effects of the treatment of TrP in patients with chronic TTH. Moraska and Chandler (2008) demonstrated in a pilot study that a structured massage program targeted at inactivating TrPs was effective for reducing headache pain and disability in individuals with TTH; however, this study did not include a control group. The same authors reported that a TrP massage program improved psychological measures, particularly depression and the number of events deemed as stressful (Moraska & Chandler, 2009). Moraska and colleagues (2015) found that the manual therapy treatment of TrP in cervical muscles was effective in reducing headache in a sample of TTH, but there was also a placebo effect of TrP manual therapy. Fernández-de-las-Peñas and colleagues (2008) developed a preliminary clinical prediction rule to identify women with chronic TTH who would most likely experience short-term favourable outcomes after TrP manual therapy. Four variables were identified for immediate success and two for 1-month success (Table 7.1). If all variables (4 + LR: 5.9) were present, the chance of experiencing immediate benefit from TrP treatment improved from 54% to 87.4% (Fernández-de-las-Peñas et al., 2008). However, a limitation of this study was its relatively small sample size (n = 35). A second clinical prediction rule in which women with chronic TTH received a multimodal therapy session identified eight variables for short-term success (Fernández-de-las-Peñas et al., 2011b). The variables are listed in Table 7.2. If five of the eight variables (5 + LR: 7.1) were present, the chance of experiencing successful treatment improved from 47% to 86.3% (Fernández-de-las-Peñas et al., 2011b). Therapeutic procedures included both joint mobilisations to the cervical and thoracic spine and soft tissue TrP therapies such as soft tissue stroking, pressure release, and muscle energy techniques applied to the neck, head, and shoulder musculature and to the temporalis, suboccipital, upper trapezius, sternocleidomastoid, and splenius capitis muscles (Fernández-de-las-Peñas et al., 2011b). These clinical prediction rules support the role of TrPs in the management of TTH; however, further studies are needed to validate the current data. Table 7.1 • Headache duration (hours per day) (< 8.5) • Headache frequency (< 5.5) • Body pain (< 47) from the SF-36 questionnaire • Vitality (< 47.5) from the SF-36 questionnaire • Bodily pain (< 47) from the SF-36 questionnaire From: Fernández-de-las-Peñas, C., Cleland, J.A., Cuadrado, M.L., Pareja, J. (2008). Predictor variables for identifying patients with chronic tension type headache who are likely to achieve short-term success with muscle trigger point therapy. Cephalalgia, 28, 264–275. The probability of success is calculated using the positive likelihood ratios and assumes a pretest probability of 54%. Table 7.2 • Presence left sternocleidomastoid muscle TrP • Presence suboccipital muscle TrPs • Presence of left superior oblique muscle TrP • Cervical rotation to the left > 69 degrees • Total tenderness score < 20.5 • Neck Disability Index < 18.5 • Referred pain area of right upper trapezius muscle TrP > 42.23 From: Fernández-de-las-Peñas, C., Cleland, J.A., Palomeque-del-Cerro, L., et al. (2011b). Development of a clinical prediction rule for identifying women with tension-type headache who are likely to achieve short-term success with joint mobilization and muscle trigger point therapy. Headache, 51, 246–261. The probability of success is calculated using the positive likelihood ratios and assumes a pretest probability of 47%. ∗ Unable to calculate as all subjects met 1 and 2 variables. There are a small number of studies investigating the effects of DN and TTH. De Abreu Venâncio and colleagues (2008) compared the effects of TrP injections using lidocaine to TrP DN in the management of headaches of myofascial origin. They found that TrP DN was equally effective for decreasing the intensity, the frequency, and the duration of the headache and for the use of rescue medication than injections using lidocaine alone or combined with corticoids. In another study the same authors reported that TrP DN was equally effective as botulinum toxin A for decreasing the intensity, the frequency, and duration of the pain, but DN was less effective for the use of rescue medication (De Abreu Venâncio et al., 2009). These results are similar to those by Harden and associates (2009), who reported that patients who received botulinum toxin A injections over active TrPs experienced reductions in headache frequency in the short term, but the effects dissipated by week 12. Headache intensity also revealed a decrease in the botulinum toxin A group, but not in the control group (Harden et al., 2009). Therefore although TrP DN is proposed as a potential effective treatment for headaches (Kietrys et al., 2014; Fernández-de-las-Peñas & Cuadrado, 2016), there are only a small number of studies investigating this topic (France et al., 2014). It is interesting to note that the American Headache Society has recently accepted the use of TrP injections for the management of many types of headaches (Robbins et al., 2014), supporting that myofascial TrPs seem to be relevant for headaches. TrPs have also been found in patients with migraine headache. In unilateral migraines, active TrPs in the upper trapezius (30%), sternocleidomastoid (45%), and temporalis (40%) muscles were located only on the symptomatic side (Fernández-de-las-Peñas et al., 2006e). TrPs in the extraocular superior oblique muscle (50%) were present in the symptomatic, but not in the nonsymptomatic side (Fernández-de-las-Peñas et al., 2006f). A study of 92 patients with bilateral migraine showed that 94% exhibited TrPs in the temporalis and suboccipital muscles compared with 29% of controls (Calandre et al., 2006). The number of TrPs was related to the frequency of migraine headaches and the duration of the disease (Calandre et al., 2006). A recent study noted that the presence of TrPs was similar between women with episodic or chronic migraine supporting a role in the chronification of this headache (Ferracini et al., 2017). Referred pain from active TrPs reproduced the pain features of migraine headache (Giamberardino et al., 2007; Fernández-de-las-Peñas et al., 2006e). Nevertheless, an association of TrPs with migraine does not necessarily constitute a causal relationship. The presence of TrPs indicates that peripheral nociceptive input from TrPs into the trigeminal nucleus may act as a migraine trigger. A link between pain generators of the neck, head, and shoulder muscles and migraine attacks may be the activation of the trigeminal nerve nucleus caudalis, and hence the activation of the trigeminovascular system. In such instance, TrPs located in any muscle innervated by the trigeminal nerve or the upper cervical nerves may be considered as ‘irritative thorns’ that can precipitate, perpetuate, or aggravate migraine. Obviously, other triggers also exist for migraine. Evidence supporting a triggering role of TrPs in migraine comes from the resolution of migraine headache by treating TrPs in neck and shoulder muscles with lidocaine or saline injections (Tfelt-Hansen et al., 1981). In addition, inactivation of active TrPs in migraine patients not only reduced the electrical pain threshold in the headache area of pain referral, but also reduced the number of headache attacks over the 60 days of the treatment period (Giamberardino et al., 2007). Garcia-Leiva and colleagues (2007) reported that TrP injection with ropivacaine (10 mg) was effective for reducing frequency and intensity of migraine attacks. The combination of TrP treatment and medication was more effective than medication alone for the management of migraine (Ghanbari et al., 2015). Sollmann and colleagues (2016) conducted a pilot study, examining the potential of peripheral magnetic stimulation of the upper treatment for the treatment of headaches, and they found a significant decrease in the number of migraine attacks, in the migraine intensity, and a reduction in analgesic medication usage when comparing the pre- and poststimulation assessments. TrPs have been also investigated in other headaches, such as cervicogenic and cluster headaches. Jaeger (1989) found in a cohort of 11 individuals with cervicogenic headache that all patients showed at least three TrPs on the symptomatic side, especially in the sternocleidomastoid and temporalis muscles. Patients who were treated reported a significant decrease in their headache frequency and intensity, which supports the role of TrPs in headache pain perception in this headache disorder (Jaeger, 1989). Roth and colleagues (2007) described a case report in which pain from TrPs in the sternocleidomastoid muscle mimicked the symptoms of cervicogenic headache. In a small clinical trial, Bodes-Pardo and colleagues (2013) found 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 in cervicogenic headache pain. Although TrPs can contribute to pain of cervicogenic headaches, it seems that referred pain from the upper cervical joints is the main source (Aprill et al., 2002). It is conceivable that the potential role of TrPs has not yet been properly studied in cervicogenic headache pain. Therefore further studies are required to elucidate the role of TrPs in this headache disorder. Calandre and colleagues (2008) studied the presence of TrPs in 12 patients with cluster headaches. All patients showed active TrPs reproducing their headache. In this case series TrP injection was successful in about 80% of the patients. The authors suggested that, in some patients, TrPs may trigger cluster headaches (Calandre et al., 2008). In a systematic review, Ashkenazi and colleagues (2010) reported few controlled studies on the efficacy of peripheral nerve blocks and almost none on the use of TrP injections. They concluded that the technique, the type, and the doses of the anaesthetics used for nerve blockade varied greatly among studies, but, in general, the results were positive. Nevertheless this finding should be considered with caution due to the limitations of the included studies (Ashkenazi et al., 2010). Neck pain can have a traumatic or an insidious onset. A traumatic onset is seen, for example, after a whiplash injury (Dommerholt, 2005, 2010). An example of an insidious cause is mechanical neck pain, which is defined as generalised neck or shoulder pain with symptoms provoked by neck postures, by movement, or by palpation of the cervical muscles. Fernández-de-las-Peñas and colleagues (2007f) found that patients with mechanical insidious neck pain exhibited active TrPs in the upper trapezius (20%), the sternocleidomastoid (14%), the suboccipital (50%), and the levator scapulae (15%) muscles. A recent population-based study observed that active TrPs in the upper trapezius muscle were the most prevalent (94%), followed by TrPs in the levator scapulae (82%), multifidi (78%), and splenius cervicis (62.5%) muscles in patients with mechanical neck pain (Cerezo-Téllez et al., 2016a). The presence of TrPs in the upper trapezius muscle has been associated with the presence of cervical joint dysfunction at the levels of the C3 and C4 vertebrae in individuals suffering from neck pain (Fernández-de-las-Peñas et al., 2005b). Therefore clinicians should include the assessment and treatment of joint mobility in the management of TrPs in individuals with mechanical neck pain (Fernández-de-las-Peñas 2009). Jung and colleagues (2016) recommended making a diagnosis of laryngeal myofascial pain when voice symptoms improve after needling of the intrinsic laryngeal muscles, combined with an unusual sensation during the needling procedure reminiscent of a local twitch response, a vocal fold movement abnormality, a history of voice abuse, and the absence of a vocal fold mucosal or neurological disorder. Researchers from Israel and the US examined the referred pain patterns of latent TrPs in the longus colli muscle in 35 healthy physicians attending a postgraduate course on DN. Although the subjects were not naïve concerning the topic, possibly introducing a bias, they found that TrP in the longus colli muscle feature mostly anterior local pain, but also included referred pain to the ipsilateral ear. A small percentage of subjects reported pain referral to the contralateral side or to the ipsilateral posterior cervical spine and occiput (Minerbi et al., 2017). There is some evidence of the effectiveness of TrPs manual techniques in the management of mechanical neck pain. For instance, Montañez-Aguilera and colleagues (2010) reported that an ischemic compression technique was effective in the treatment of TrPs in a patient with neck pain. Bablis and colleagues (2008) found that the application of Neuro Emotional Technique, a technique incorporating central and peripheral components to alleviate the effects of distressing stimuli, may be effective for reducing pain and mechanical sensitivity over TrPs in patients with chronic neck pain. Ay and colleagues (2017) studied the effectiveness of kinesio taping on cervical myofascial pain and concluded that there was a significant improvement for pain and cervical flexion and extension, but not for cervical rotations and lateroflexion. In a comparative study of active and passive treatments of latent TrPs in the upper trapezius muscle, Kojidi and colleagues (2016) found that both approaches significantly decreased the sensitivity of myofascial TPs, increased flexibility of muscle fibres, and improved range of motion. In another study, nonthrust mobilisation techniques directed to the cervical spine and scapula were effective in pain reduction, with 3-month follow up assessments (Yildirim et al., 2016). A Spanish study showed a similar reduction of chronic neck pain using either DN and stretching, TrP compression combined with massage, or upper cervical anterior–posterior mobilisation, lateral glides to C4-C5, and a neural thoracic mobilisation (Campa-Moran et al., 2015). Ganesh and colleagues (2016) confirmed that manual TrP therapy of the upper trapezius muscle and cervical mobilisations can be effective. Different studies have reported that DN is effective for improving pain and related disability in individuals with nonspecific neck pain (Mejuto-Vázquez et al., 2014; Gerber et al., 2015; Cerezo-Téllez et al., 2016b), but no clear differences exist between manual therapy and DN for the management of mechanical neck pain (Llamas-Ramos et al., 2014; De Meulemeester et al., 2017). This is further supported by a few systematic reviews (Caigne et al., 2015; Liu et al., 2015). León-Hernández and colleagues (2016) established that the combination of percutaneous electrical stimulation and DN was more effective than DN alone to reduce pain in patients with chronic myofascial neck pain. Shanmugam and Mathias (2017) noted an immediate effect on pain and range of motion with DN in patients with acute facet joint lock, but they did not include a control group in their study. In another study, Ma and colleagues (2010) demonstrated that a miniscalpel-needle release was superior for reducing pain in patients with TrPs in the upper trapezius muscle compared with an acupuncture needling treatment or self-neck stretching exercises. TrPs have been also associated with neck pain of traumatic origin, such as whiplash-associated neck pain (Dommerholt, 2005, 2010; Dommerholt et al., 2005). Schuller and associates (2000) found that 80% of 1096 individuals involved in low-velocity collisions reported muscle pain. In a review of the literature, Fernández-de-las-Peñas and colleagues found that the muscles most commonly affected by TrPs were the scalene muscles (Gerwin & Dommerholt, 1998), the splenius capitis, the upper trapezius, the posterior neck, the sternocleidomastoid (Baker, 1986), and the pectoralis minor muscles (Hong & Simons, 1993). Ettlin and colleagues (2008) reported that semispinalis capitis muscle TrPs were more frequent in patients with whiplash-associated neck pain (85%) than in patients with nontraumatic neck pain (35%) or fibromyalgia (57%). TrPs in the upper trapezius (70%–80%), the levator scapulae (60%–70%), the sternocleidomastoid (40%–50%), and the masseter (20%–30%) muscles were similar among these pain groups. The longus colli muscles are commonly involved in whiplash injuries (Elliott, et al., 2010, 2011), as they are the farthest removed from the axis of rotation of the cervical spine and therefore prone to significant strain and deformation. Peterson and colleagues (2015) confirmed that after whiplash, deformation and deformation rates of the longus coli, sternocleidomastoid, and longus capitis muscles are altered. Whiplash injuries often result in weakness of the longus colli muscles (Prushansky et al., 2005; Pearson et al., 2009), greater rates of cervical instability, a reversal of the cervical lordosis, vertigo (Liu et al., 2017), and a loss of muscular endurance (Kumbhare et al., 2005). The longus colli muscle appears to play a key role in stabilisation of the cervical spine (Kettler et al., 2002), posture, and maintaining the cervical lordosis (Mayoux-Benhamou et al., 1994), but the exact mechanisms are not well understood (Kennedy et al., 2017). Fernández-Pérez and colleagues (2012) observed that individuals with acute whiplash-associated neck pain exhibited a higher prevalence of active TrPs in the levator scapulae and upper trapezius muscles and that the number of active TrPs increased with higher neck pain intensity and the number of days since the accident. Additionally it seems that active TrPs are more prevalent in whiplash-associated neck pain than in mechanical neck pain (Castaldo et al., 2014). The presence of TrPs in individuals with whiplash-associated neck pain can be related to the fact that these patients usually exhibit reduced cervical stability, muscle inhibition, and hyperirritability of the cervical muscles (Headley, 2005). Finally, a few studies have demonstrated the effects of TrP inactivation in patients with whiplash-associated neck pain. Freeman and colleagues (2009) showed that infiltrations of 1% lidocaine into TrPs in the upper trapezius were effective in the short term for increasing cervical range of motion and pressure pain thresholds in individuals with chronic whiplash-associated pain. Carroll and colleagues (2008) reported that injections of botulinum toxin type A of cervical TrPs decreased pain in patients with chronic whiplash-related neck pain. A recent randomised clinical trial reported that DN and exercise was more effective than sham DN and exercise in reducing disability at 6 and 12 months in individuals with chronic whiplash-related neck pain, although its clinical relevance was questioned (Sterling et al., 2015).
Deep Dry Needling of the Head and Neck Muscles
Introduction
Clinical presentation of trigger points in head and neck pain syndromes
Trigger Points in Headache and Orofacial Pain Populations
Myofascial trigger points in temporomandibular pain
Myofascial trigger points in tension-type headache
Number of Predictor Variables Present
Sensitivity
Specificity
Positive Likelihood Ratio
Probability of Success (%)
4 +
0.37 (0.17, 0.61)
0.94 (0.68, 0.99)
5.9 (0.80, 42.9)
87.4
3 +
0.84 (0.60, 0.96)
0.75 (0.47, 0.92)
3.4 (1.4, 8.0)
80.0
2 +
0.94 (0.72, 0.99)
0.19 (0.05, 0.50)
1.2 (9.0, 1.5)
58.5
1 +
1.0 (0.79, 1.0)
0.12 (0.02, 0.41)
1.1 (0.95, 1.4)
56.4
Number of Predictor Variables Present
Sensitivity
Specificity
Positive Likelihood Ratio
Probability of Success (%)
2 +
0.58 (0.34, 0.79)
0.88 (0.60, 0.98)
4.6 (1.2, 17.9)
84.4
1 +
0.95 (0.72, 0.99)
0.56 (0.31, 0.79)
2.2 (1.2, 3.8)
72.1
Number of Predictor Variables Present
Sensitivity
Specificity
Positive Likelihood Ratio
Probability of Success (%)
8
0.1 (0.01, 0.2)
1.0 (0.89, 1.0)
∞
100
7 +
0.22 (0.10, 0.40)
1.0 (0.89, 1.0)
∞
100
6 +
0.53 (0.36, 0.69)
1.0 (0.89, 1.0)
∞
100
5 +
0.89 (0.73, 0.96)
0.88 (0.72, 0.95)
7.1 (3.1, 16.3)
86.3
4 +
0.97 (0.84, 0.99)
0.7 (0.53, 0.83)
3.2 (2.0, 5.2)
73.94
3 +
1 (0.87, 1.0)
0.23 (0.11, 0.39)
1.3 (1.1, 1.5)
53.6
2 +∗
1 +∗
Myofascial trigger points in migraine headache
Myofascial trigger points in other headaches
Trigger Points in Neck Pain Populations
Dry needling of head muscles
Corrugator Supercilii Muscle
Procerus Muscle
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