דיקור יבש וכאבי ראש
Is Dry Needling Effective in Treating Headache-Related Myofascial Pain Syndrome?
Matan Sadot
tDPT program, The College of St. Scholastica
PTH 7730: Evidence Based Practice—Fall 2021
Marie-Louise Merkx-Quinn, PT, DPT
December 4, 2021
Introduction
Some 90% of the world’s population has suffered from headache at least once in their lives. The World Health Organization (WHO) estimates that at least 47% of the population suffers from headaches regularly (Stovner et al., 2007). Migraines headaches, tension-type headaches (TTH), and cervicogenic headaches, among others, may significantly impact one’s social, physical, and athletic lifestyle. Among 328 illnesses and injuries in 195 countries, TTH and migraine headache are the third and sixth most common primary headache syndromes, respectively. There are many different types of primary headaches, but TTH is the most prevalent (Haldeman & Dagenais, 2001). It usually produces discomfort from the forehead to the occiput and to the sides. Tenderness or low-grade soreness may be felt in the neck when there is a pain in the lower back (Olesen & Steiner, 2004). Migraine sufferers have severe headaches, nausea, and vomiting due to routine physical exertion such as walking, climbing stairs, or hiking. Migraine headaches often last four to seventy-two hours and are characterized by a single focal point on one side of the brain. Despite a number of migraine studies, the migraine mechanism is still not fully understood. Cervicogenic headaches create chronic pain that originates in the neck area and radiates to the head and shoulders (Calandre et al., 2006). Their symptoms are often unilateral, most of the spread occurring in the occipitofrontal region. Patients with persistent headaches are 15%–20% more likely than the general population to develop cervicogenic headaches (Bir et al., 2017). Symptoms of TTH and cervicogenic headaches are similar in many ways. It is not uncommon for cervicogenic and tension-type headaches to overlap; some develop both types of headache at once. There is no known etiology for stress and cervicogenic headaches.
Pharmacological and non-pharmacological methods may be used to treat headaches. Pharmacological treatments are thought to be the main ones despite their potential side effects. Accordingly, non-pharmacological treatments are used to mitigate the drug use and alleviate its side effects. Kalichman et al. (2010) define myofascial pain as a form of discomfort that originates in the muscles or their associated fascia and is frequently accompanied by myofascial trigger points (TrPs)—a hyperirritable patch that is intensely localized within in a palpable band of skeletal muscle fibers. TrPs are symptoms that develop in the neck and head region and are linked to migraine, cervicogenic, and tension headaches. If detected and appropriately managed, cervical myofascial pain may be a tolerable component of headache treatment.
Physiotherapy and headache management studies have recently piqued the curiosity of certain researchers who explore alternative therapeutic approaches to traditional medicine. When it comes to treating pain issues, dry needling is a skilled technique that is becoming increasingly popular among physical therapists, physicians, and chiropractors. It entails the insertion of a tiny gauge needle into trigger sites that have been discovered. In this procedure, a needle is used to enter the muscle and deactivate TrPs without anesthesia. The needle is used to remove TrPs once they have been deactivated. The benefits of DN are numerous and include a reduction in local, referred, and widespread pain, increased range of motion and muscle activation patterns, and normalization of the immediate chemical environment of active myofascial trigger points (Kalichman & Vulfsons, 2010). Despite its widespread use, the efficacy of dry needling in treating headaches remains debatable compared with other techniques. As a result, a new literature evaluation is necessary. The main goal of this review is to determine if dry needling is an effective therapy for reducing the pain, severity, and frequency of cervicogenic headaches caused by myofascial pain syndrome.
Methods
Several online databases—the College of St. Scholastica’s SOLAR, PubMed, and Google Scholar—were screened for evidence of dry needling and its effect on TrPs-related headache syndromes. In the search, performed on 5 November 2021, selected keywords specific to the intervention and the related pain disorders, including dry needling, headache, tension-type headache, and migraine were used. Three searches were conducted on the search date. The articles that I sought were limited to Randomized Controlled Trials (RCTs), English language, and published after 2015. Systematic reviews, narrative reviews, and case reports were excluded. Studies were excluded if a fine needle was only inserted into acupoints in the neck and head regions (“Acupuncture”) and if patients were less than 18 years of age. The initial searches returned eight studies. I reviewed the titles and abstracts and dismissed two studies because they failed to meet the criteria. After reading the remaining six abstracts, I discarded two additional studies in order to retain only those that described control-group interventions without drugs or medication—the four studies in this review.
Critical Literature Reviews
Rezaeian, T., Mosallanezhad, Z., Nourbakhsh, M. R., Noroozi, M., & Sajedi, F. (2020). Effects of dry needling technique into trigger points of the sternocleidomastoid muscle in migraine headache: A randomized controlled trial. American journal of physical medicine and rehabilitation, 99(12), 1129–1137.
https://doi.org/10.1097/PHM.0000000000001504
Rezaeian et al. asked how dry needling (DN) in the sternocleidomastoid (SCM) muscle affects migraine sufferers. They wished to examine the effect of DN on symptom relief, including drug consumption and pain frequency, intensity, and duration. They also tested objective results that included DN effect on pressure pain threshold (PPT), muscle thickness, and cervical range of motion (CROM). The 46 participants in the study were adults (age 25–55) who had been diagnosed with migraine headaches using the International Classification of Headache Disorders criteria (Olesen & Steiner, 2004). Subjects had active TrPs in their SCM muscle. Any history of neck injuries or related medical disorders was cause for exclusion from the trial. Participants were randomly allocated into two groups: DN (N=23) and sham dry needling (N=23). The sample size was calculated on the basis of a pilot study performed on ten subjects. A test type I error of 0.05 and a test type II error of 0.20 led to 20 subjects in each group who met the requirements. The study lasted one week, during which the groups received three interventions, and the parameters evaluated were included in a questionnaire (validation not mentioned) of drug consumption and headache frequency, intensity, and duration. In addition, PPT, muscle thickness, and CROM were evaluated at baseline, after intervention, and after one month of follow-up. Single blinding was used in this trial, meaning that the physiotherapist who administered the treatment was unaware of the aims of the study and the participants were apprised only of their group allocation. Normal distribution was assessed using the Shapiro-Wilk test, and the results showed normal distribution in all checked variables (P-value > 0.05). An independent t-test was used to differentiate the means of the two groups by their demographic data. (No significant difference in age, weight, height, and BMI was found.) Another t-test was performed to assess differences between the groups in the baseline parameters. Differences in the groups’ outcome data after intervention and follow-up were analyzed by means of two x three repeated-measure variance analyses. ICC was used to assess intra-tester reliability (0.84, indicating good reliability) of the PPT measurement. The P-value was considered < 0.05. The investigators discovered statistically significant intervention effects for all variables (P < 0.001) after intervention and follow-up, including medication use; headache frequency, intensity, and duration; PPT; SCM muscle thickness; and CROM. After DN application, a statistically significant reduction in the headache measures was observed. The findings confirmed the positive effects of DN on the treatment of migraine headaches caused by TrPs. Nevertheless, we should adopt these findings with caution due to their limitations. Validation of the primary measurement tool (the headache diary) was not mentioned, the participants were not blinded, and no clinical significance measures to amplify the strength and clinical applicability of the study were taken, limiting the findings to indicating the relation of SCM dry needling and migraine to proposed alternative treatment to the pathology.
Sedighi, A., Nakhostin Ansari, N., & Naghdi, S. (2017). Comparison of acute effects of superficial and deep dry needling into trigger points of suboccipital and upper trapezius muscles in patients with cervicogenic headache. Journal of bodywork and movement therapies, 21(4), 810–814.
https://doi.org/10.1016/j.jbmt.2017.01.002
In this study, the efficacy of dry needling (DN) in the suboccipital and upper trapezius muscles in patients with cervicogenic headaches (CeH) was investigated in detail. The investigators pursued this goal using a personal headache diary, trigger point discomfort, cervical range of motion (CROM), and the Functional Rating Index self-report questionnaire. Thirty individuals (8 men, 22 women) aged 19–60 years old who had CeH and were eligible for the study were asked to participate and to present a CeH diagnosis that met the criteria of Sjaastad and Fredriksen (2000). The reliability of these criteria ranged from acceptable to excellent (Van Suijlekom et al., 2000). The participants were randomly allocated to two groups: DN (N=15) and superficial dry needling (SDN) (N=15). They also had to demonstrate active and latent TrPs in the suboccipital and upper trapezius muscles as the precipitants of their headaches. Any history of neck injuries or associated medical disorders was grounds for exclusion from the trial. Intervention included one treatment only. The headache-related parameters and cervical spine physical tests were evaluated three times: baseline, immediately after treatment, and one week later. Each patient had their own headache index (HI), muscular tenderness estimation, and cervical range of motion (CROM) evaluation. The Functional Rating Index-Questionnaire (FRIQ) was used to assess function, and the Persian version of the questionnaire was verified. The determination of sample size was absent in this paper. By chance, needling was administered in the same place, but at a different depth, to both the intervention and the sham groups. The t-test, the Freidman test, the Wilcoxon test, and the ANOVA (one-way analysis of variance) repeated measure test were set to determine the presence or absence of a significant difference between the means of the two groups. No validity or reliability tests were carried out in this study. The investigators concluded that patients with CeH who received DN had beneficial impacts on the headache index (p < 0.001) when compared with the SDN group (as a factor of headache intensity, frequency, decreasing trigger point tenderness, improvement in active CROM, and functional rating index). According to the ‘‘ findings, DN appears to be a promising therapy option for individuals with CeH who have referred pain from active TrPs in the suboccipital and upper trapezius muscles that match the headache pain pattern. The study had major limitations, including a small and uncertainly calculated sample size, lack of validation, and the absence of intra-rater reliability standards. Furthermore, there was no indication of blinding—one practitioner carried out the entire intervention—and it is unclear who oversaw the data analysis. The statistical power of this study was poor to moderate and the results may have been biased by random and systematic error due to the lack of sample size calculation and the absence of a defined significance level in this study. Therefore, the results were unlikely to detect any presence of a difference between the needling groups. The findings should be treated with great caution. Furthermore, there was no mention of a validity or reliability test, confidence intervals, or any other statistical method that may have been employed to support the ’findings. This paper may be used to illustrate the relationship among the suboccipital and upper trapezius muscles, dry needling, and migraine headaches, but its advice should be taken with caution.
Kamali, F., Mohamadi, M., Fakheri, L., & Mohammadnejad, F. (2019). Dry needling versus friction massage to treat tension type headache: A randomized clinical trial. Journal of bodywork and movement therapies, 23(1), 89–93.
https://doi.org/10.1016/j.jbmt.2018.01.009
Kamali et al. (2019) examined the effects of dry needling (DN) and friction massage on changes in tension-type-headache (TTH) symptoms. For the study, 44 subjects of all genders were recruited who had suffered from diagnosed active TrPs and TTH symptoms for at least six months. Participants with cervical illness or neck injuries were ruled out. The sample size was calculated on the basis of data from a previous study (Ghanbari et al., 2012). Participants were randomly allocated to two equal groups: DN (N=20) and friction massage (N=20), There was neither a sham DN nor a placebo group in this experiment. Three treatments for one week were included in this short-term study, with data collected at baseline and 48 hours after the last session. Self-reported headache frequency and intensity, pressure pain threshold (PPT), and cervical range of motion (CROM) were among the parameters. The algometer and goniometer reliability and validity tools had already been established (Kinser et al., 2009). Participants were blinded to the study purpose were and unaware of the opposite group allocation. The clinician who performed the interventions and the researcher who analyzed the data were not blinded in any way. The threshold for significance was set at 0.05. For between-group comparisons, the investigators used ANCOVA. Because of the non-normal distribution of data, a paired t-test and a Wilcoxon test were utilized for within-group comparisons. According to the findings, both intervention strategies dramatically reduced headache frequency and intensity while also increasing PPT locally. Apart from neck extension, which increased within the DN group, neither technique changed CROM. In the between-group assessments, PPT increased significantly (p < 0.05) when DN instead of friction massage was used. In other outcome variables, there were no statistically significant differences between the groups. This study demonstrated that both DN and friction massage effectively alleviated symptoms in TTH patients. According to the investigators, both therapies effectively mitigated headache frequency and intensity while increasing CROM. They qualified their findings by pointing out that research on larger samples or longer-term interventions might differ from the two techniques within the parameters examined. The study had noteworthy limitations: no indication of blinding the investigators, no way to deduce anything about intra-rater reliability, short intervention duration (up to ten days), vagueness about the measurement tools (self-reports), and no statistical analyses for diagnostic accuracy in regard to the purpose of the study. Thus, caution is needed in estimating and treating TrPs with TTH therapies and different intervention program methodologies should be explored.
Togha, M., Bahrpeyma, F., Jafari, M., & Nasiri, A. (2020). A sonographic comparison of the effects of dry needling and ischemic compression on the active trigger point of the sternocleidomastoid muscle associated with cervicogenic headache: A randomized trial. Journal of back and musculoskeletal rehabilitation, 33(5), 749–759.
https://doi.org/10.3233/BMR-171077
The purpose of this study was to use sonography to investigate the effects of dry needling (DN) and ischemia compression (IC) on the symptoms of cervicogenic headache (CeH). According to the authors’ clinical experience and hypotheses, the DN technique might be more effective in managing TrPs. The study was performed on 29 female volunteers over age 18 who had been diagnosed with CeH originating in TrPs in the SCM muscle according to the ICHD3 criteria (Olesen & Steiner, 2004). Subjects with a history of cervical or neck injuries or disease, as well as any contraindications to DN, were banned. Participants were randomly allocated to three groups: DN (N=10), IC (N=9), and control (N=10). Interventions were repeated four times over eight days, with one-day breaks between each session. The control group received no treatment. Two weeks before and after treatments, headache intensity, duration, and frequency; TrPs elastic modulus and area (sonography images taken with and without stress, TrPs elastic modulus estimated using the stress-strain relationship, and the TrPs area, calculated by converting the pictures to binary), and the PPT were calculated. There was no mention of validation for either of the tools of measurement (self-reported reports and PPT algometer). The application of sonography to measure structural biomechanical changes was described in depth, including the procedure and previous investigations. The results were described using mean, standard deviation, and confidence intervals. Groups were compared using ANOVA. The investigators used Bonferroni’s post hoc analysis approach. Headache symptoms and TrPs elastic modulus, RIE, and TrPs area were correlated using the Pearson correlation coefficient. P-value was set to 0.05.A statistically significant improvement in headache intensity, duration, frequency, PPT, and TrPs area (P < 0.05) was seen in both the DN and IC groups. DN and IC showed no statistically significant differences (P > 0.05). TrPs elastic modulus and headache severity were significantly correlated by Pearson correlation (P < 0.05). Basing themselves on the findings, the investigators concluded that the frequency of headache symptoms, the PPT, and the TrPs area improved significantly in both intervention groups and that DN did not beat IC in terms of improving the features evaluated in the study during the short-term follow-up. Limitations of the study include the absence of sample-size calculation and statistical power tests; moreover, the homogeneous female-only groups may impair the scalability of the results to the practical domain. Participants and clinicians were blind to group allocation and evaluations and the results show adequate double-blinding. Acceptable clinical standards and analyses were performed in this research and the use of unique measurement methods yielded data on headache and TrPs therapy. Nevertheless, the short-term nature of the study and its small and homogeneous samples weakened the power of the findings.
Discussion
Chronic headaches may significantly reduce quality of life (QoL). Physiotherapy involving dry needling and other modalities may help alleviate headache sufferers’ pain, disability, and QoL impairment. The goal of this study was to determine whether dry needling is an effective treatment for those who suffer from cervicogenic headaches caused by myofascial pain syndrome. The foregoing literature review and evaluation of studies leave the answers to many questions unclear. The interpretation of the results of the studies was fair due to the homogeneity of their baseline characteristics, control conditions, treatments, and short length. Dry needling yielded statistically significant results in all four experiments but could not establish superiority over alternative treatments. In addition, no side effects were reported. Dry needling compared with sham needling: Both Rezaeian et al. (2020) and Sedighi et al. (2017), who compared DN with sham needling, showed statistically significant improvement immediately after the intervention and at one-month follow-up (P < 0.05) changes in headache frequency, severity, and duration; medicine use; muscle thickness; pressure pain threshold; and cervical range of motion. One possible reason for this is the selection of the control therapy in these studies: dry needling was chosen as the procedure in one study whereas superficial needling was chosen as the control treatment in the other. Both choices were likely to be troublesome in view of the current conviction that any needle penetrating the body and causing a physiological change is significant. The lack of a real “control” in either strategy, which might have explained the occurrence of a placebo response, can be explained by this. Dry needling compared with manual therapy: Kamali et al. (2019) and Togha et al. (2020) compared the effects of DN with those of manual treatment including ischemia pressure (IC) and friction massage. Both studies found statistically significant improvement (P < 0.05) in decreased headache severity, duration, and frequency; PPT; and TrPs areas 48 hours after intervention and two weeks after intervention, respectively. No statistically significant differences between DN and IC were found. The use of dry needling dramatically enhanced the pain threshold compared to friction massage. There were no statistically significant (P < 0.05) differences between the groups in any other outcome variable examined. Dry needling evaluation using sonography: real-time non-invasive ultrasound imaging of muscles, fasciae, and other soft tissues is widely used. Biomechanical characteristics of tissues may be described using ultrasound. Moreover, images of TrPs may show differences in echogenicity and stiffness from surrounding tissues, possibly implying that TrPs have weaker local muscles (Sikdar et al., 2009). Preliminary objective assessments of TrPs contributed to inevitable disagreements over the effectiveness of various therapeutic approaches. By measuring changes in TrPs and headache symptoms, ultrasound imaging may reveal the effectiveness of various treatment options. This approach was utilized in two separate studies: Togha et al. (2020) and Rezaeian et al. (2020). According to Rezaeian et al. (2020), SCM muscle thickness increased significantly both immediately after intervention and after a one-month follow-up (P < 0.001). Togha et al. (2020), using an innovative approach to calculate the elastic modulus and area of TrPs (Jafari et al., 2017), found a significant Pearson correlation (P < 0.05) between headache symptoms and the elastic modulus and area of TRPs, which were used to evaluate muscle changes. The studies evaluated had severe limitations including lack of blinding; only one of them (Togha et al., 2020) was double-blinded. In addition, in Kamali et al. (2019) and Sedighi et al. (2017), both the intervention and the control groups seem to have received intervention from the same practitioner. Moreover, it was not always possible to understand the calculation of sample sizes prior to all the experiments; this attenuated the statistical power of the data collected. In addition, the measuring instruments (headache diary and index) were validated in only one of the studies (Togha et al., 2020). It appeared from the findings of this study that dry needling might help treat the complaints of migraine, tension-type headache, and cervicogenic headache. One of the disadvantages observed in all trials was the short duration of the intervention. The findings of the current report should be interpreted with caution due to the possibility of bias and statistical irregularities in the reviewed studies. In contrast, trial analyses such Gildir et al. (2019) yield similar results with greater sample size and effect, showing that dry Needling may make a substantial therapeutic impact considering the prevalence of the disorders. Additional future research options should look at the use of dry needling in combination with conventional physiotherapy techniques rather than dry needling alone in the management of headache myofascial pain syndrome.
Conclusion
Dry needling may be beneficial in treating symptoms of migraine, tension-type, and cervicogenic headaches, among other conditions. However, the current body of evidence on its effectiveness in the treatment of this phenomenon is mixed. Future research of higher methodological quality, a lower chance of bias, and a larger sample size is required to confirm the findings of these studies.
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