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Trigger Points in the Suboccipital Muscles and Forward Head Posture in Tension-Type Headache


  • César Fernández-de-las-Peñas PT,

  • Cristina Alonso-Blanco PT,

  • Maria Luz Cuadrado MD, PhD,

  • Robert D. Gerwin MD,

  • Juan A. Pareja MD, PhD

  • From the Department of Physical Therapy (Dr. Fernández-de-las-Peñas and Ms. Alonso-Blanco); Department of Neurology, University Rey Juan Carlos, Alcorcón, Madrid, Spain (Drs. Cuadrado and Pareja); Foundation Hospital Alcorcón, Neurology, Alcorcón, Madrid, Spain (Drs. Cuadrado and Pareja); John Hopkins University, Neurology, Baltimore, MD (Dr. Gerwin); and Pain and Rehabilitation Medicine, Neurology, Bethesda, MD (Dr. Gerwin).

Address all correspondence to César Fernández-de-las-Peñas, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain.


Objective.—To assess the presence of trigger points (TrPs) in the suboccipital muscles and forward head posture (FHP) in subjects with chronic tension-type headache (CTTH) and in healthy subjects, and to evaluate the relationship of TrPs and FHP with headache intensity, duration, and frequency.

Background.—Tension-type headache (TTH) is a prototypical headache in which myofascial TrPs in the cervical and pericranial musculature can play an important role.

Design.—A blinded, controlled pilot study.

Methods.—Twenty CTTH subjects and 20 matched controls without headache participated. TrPs were identified by eliciting referred pain with palpation, and increased referred pain with muscle contraction. Side-view pictures of each subject were taken in sitting and standing positions, in order to assess FHP by measuring the craniovertebral angle. Both measures were taken by a blinded assessor. A headache diary was kept for 4 weeks in order to assess headache intensity, frequency, and duration.

Results.—Sixty-five percent (13/20) CTTH subjects showed active TrPs and 35% (7/20) had latent TrPs in the suboccipital muscles. Six (30%) controls also had latent TrPs. Differences in the presence of suboccipital muscle TrPs between both the groups were significant for active TrPs (P < .001) but not for latent TrPs (P > .5). CTTH subjects with active TrPs reported a greater headache intensity and frequency than those with latent TrPs (P < .05). The degree of FHP was greater in CTTH subjects than in controls in both sitting and standing positions (P < .01). Within the CTTH group, there was a negative correlation between the craniovertebral angle and the frequency of headache (rs=−0.6, P < .01, in sitting position; rs=−0.5, P < .05, in standing position). CTTH subjects with active TrPs had a greater FHP than those with latent TrPs, though this difference was not significant.

Conclusions.—Suboccipital active TrPs and FHP were associated with CTTH. CCTH subjects with active TrPs reported a greater headache intensity and frequency than those with latent TrPs. The degree of FHP correlated positively with headache duration, headache frequency, and the presence of suboccipital active TrPs.