Headaches are one of the most common reasons that people see their primary care physician and they account for 20% of outpatient visits to neurologists.  Persons with chronic headaches report disabling symptoms that interfere with daily activities.  Many have sought numerous different treatment approaches, have accepted that their headaches are a fact of life and have become dependent on medications to relieve their symptoms.

The International Headache Society has classified hundreds of different types of headaches into two categories: primary headaches and secondary headaches.  Primary headaches are the most common headache type and have a single cause.  They include migraine, tension-type, cluster and others. Secondary headaches are classified according to their causes.  Examples of secondary headaches are headaches attributed to temporomandibular joint (TMJ) disorders and cervicogenic headaches, which are attributed to mechanical disorders of the neck.  Both are treated by various clinicians including osteopaths, dentists, chiropractors, massage therapists, and physical therapists.

Sources of headaches are often a combination of factors, including musculoskeletal, psychological, neurovascular, nutritional and chemical imbalances in the brain.  Some headaches relate to or are indicative of a disease process; some are life threatening and others benign.  Thus, a thorough medical evaluation is necessary with any onset of a new or ongoing headache.  Most researchers agree that there is a musculoskeletal component in tension-type, cervicogenic, and TMJ disorder related headaches.

A thorough physical therapy examination attempts to determine the type of headache and to define the neuromusculoskeletal factors contributing to it.  Muscle tension, joint dysfunction of the neck and jaw, poor posture and stress are factors that can be addressed and treated by a skilled physical therapist trained in manual therapy.

The muscles of the face, head, neck and may contain tight bands and contraction knots called myofascial trigger points.  Trigger points found in these muscles typically refer pain to the head, causing headaches.  Manual physical therapy addressing muscle tension involves the release of those trigger points, stretching the involved muscle and soft tissue, and restoring normal muscle function.  Trigger point release can be accomplished by manual techniques and dry-needling.  Dry-needling is a technique in which a thin acupuncture needle is used to deactivate the trigger points and proves to be highly effective.

Dysfunction in the spinal joints of the upper neck and of the TMJ can directly cause headaches or can trigger migraine or tension-type headaches.  Treatment of spine dysfunction may include mobilization/manipulation of the spine or jaw and the performance of stabilization exercises of the neck and shoulder girdle.  In the case of TMJ dysfunction, referral to a dentist may be indicated for splint therapy and other dental interventions.

Prolonged poor posture of the head, neck and shoulders leads to the overloading of muscles, which in turn results in the development of trigger points and altered mechanics of the spine and TMJ.  Physical therapy treatment may include education for postural correction and prescription of a postural strengthening program.  In cases where stress is a contributing factor — which it almost always is — treatment would include education with relaxation and breathing techniques.

If you are a headache sufferer and you are looking for a way to manage your headaches beyond using medication, talk to a manually trained physical therapist about possible conservative treatment options.

March 10th, 2009- The Executive Committee of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) charged the Practice Affairs Committee to investigate the basis of “dry needling” within physical therapist practice.  Following an extensive review of the literature and discussions among the committee members the Practice Affairs Committee brought forth the following position for the Executive Committee to review:

AAOMPT Executive Committee Position Statement:

It is the Position of the AAOMPT Executive Committee that dry needling is within the scope of physical therapist practice.

Support Statement:

Dry needling is a neurophysiological evidence-based treatment technique that requires effective manual assessment of the neuromuscular system.  Physical therapists are well trained to utilize dry needling in conjunction with manual physical therapy interventions.  Research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation.

This has been approved as an official position of the AAOMPT Executive Committee.  In October at the AAOMPT Annual Conference in Washington, DC the AAOMPT Membership will have the opportunity to determine if this should be accepted as a Position of the AAOMPT Membership.  As an FYI, this process is very similar to how the APTA process works wherein, there are official positions of the APTA Board and official positions of the Association that come from the APTA House of Delegates.  In some cases the APTA Board will pass a position statement and in time the House of Delegates may pass the same or similar position statement.

Dry needling is an effective and efficient therapy method for the treatment of myofascial trigger points.  Trigger point dry needling is performed by medical doctors, physical therapists, nurses, chiropractors, and dentists that are specifically trained in the technique. The approach is based on Western anatomical and physiological principles. The technique utilizes fine solid acupuncture needles to release trigger points in muscle, but in all other aspects it is different than traditional acupuncture. Other terminology used to describe similar techniques to dry needling includes intramuscular stimulation (IMS) and twitch-obtaining intramuscular stimulation.

Dr. Janet Travell first described trigger point injections in the early 1940’s. Injections are performed by injecting trigger points primarily with saline or analgesics. Through the years it has been shown that it is not the substance that is being injected that is providing the therapeutic benefit, but rather the mechanical stimulus of the needle hitting the trigger point. When a needle tip hits a trigger point, a characteristic ‘local twitch’ is noted by the clinician and the client. This local twitch is involuntary. It has been shown that the elicitation of local twitch responses is the most important aspect in obtaining a successful therapeutic outcome for trigger point deactivation. There are a number of hypotheses as to the reasons why dry needling works. Dry needling and the subsequent local twitch responses may mechanically disrupt the contracted nature of the trigger point. Dry needling stimulates certain sensors in the body which modulate pain signals. Dry needling and the subsequent local twitch responses can cause local biochemical changes and result in an increase of blood flow in the trigger point area.

The benefits of trigger point release through dry needling include a decrease in the tightness and the pain associated with a particular muscle. Often times an immediate improvement is noted. Dry needling is tolerable for most, but not all people. A limited amount of muscle soreness is to be expected for 1-2 days, after which the soreness resolves. Dry needling is never used as an isolated treatment; it is followed by myofascial release and soft tissue work to minimize soreness and to maximize connective tissue flexibility. Other important aspects of musculoskeletal improvement of pain and function requires addressing possible contributing factors which includes the presence of joint or spinal dysfunction, postural imbalances, poor coordination of movement and poor posture and body mechanics with activities of daily living.

Not all medical professionals are trained in the assessment or treatment of myofascial trigger points. Trigger point dry needling requires highly specialized training. One must be adept at finding trigger points before one can attempt to treat them. If you have suffered of pain or tightness of muscular origin, I would urge to consider the possibility of trigger point dry needling as a treatment option. It has made a world of difference in many people’s lives.