Seminars in Pain Medicine Vol. 2 No.

2 2004

Musculoskeletal Head and Neck Pain

JOANNE BORG-STEIN, MD

ABSTRACT
Musculoskeletal head and neck pain is an extremely common clinical syndrome in
outpatient pain practice. Cervical structures are a frequent cause of headache and must
be differentiated from primary headache disorders. Convergence of cervical and trigeminal nociceptive pathways in the upper part of the cervical spinal cord is the
neurophysiologic basis of this connection. An interdisciplinary pain management
approach that addresses psychosocial factors, pharmacologic and interventional pain
management and incorporates progressive exercise training is most likely to be effective. This review discusses the comprehensive evaluation and management of musculoskeletal head and neck pain with a focus on cervicogenic headache, cervical myofascial pain, and temperomandibular dysfunction.
Key words:

highly sensitive areas in muscle. They are characterized by hypersensitive, palpable taut bands of muscle
that are painful to palpation, reproduce the patients
symptoms, and cause referred pain. Other head and
neck symptoms that may be associated with cervical
myofascial pain include cervicogenic dizziness, disequilibrium, and tinnitus.2
Temperomandibular dysfunction (TMD) is a clinical
syndrome of pain in the region of the temperomandibular joint. Etiology is often multifactorial and can
be related to local mechanical, inflammatory, or arthritic processes of the joint itself. Alternatively, pain
can be referred from cervical structures to the region.
Myofascial pain of the masticatory muscles is often
involved as well.3

Musculoskeletal head and neck pain syndromes are

common in outpatient musculoskeletal pain practice. The underlying neurologic and musculoskeletal
causes of pain are variable and can overlap in any
one individual. In the management of these patients,
it is important to accurately identify and treat these
pain generators to optimize patient outcome. It is the
purpose of this review to discuss three main categories of musculoskeletal head and neck pain: cervicogenic headache; cervical myofascial pain and headache; and temperomandibular dysfunction.
Cervicogenic headache is defined as a chronic hemicranial pain in which the source of the pain is the
cervical structures. The exact pathophysiology and
pain source are debated but may include articular,
discogenic, ligamentous, neurogenic, and muscular
structures. Cervicogenic headache may be the primary cause of headache or may coexist with other
primary headache diagnoses.1
Cervical myofascial pain and headache refers to pain
derived from myofascial trigger points that are small,

Epidemiology
The precise incidence of cervicogenic headache is
unknown; however, prevalence estimates range from
0.4% to 2.5% of the general population to 15% to
20% of patients with chronic headache.1 Myofascial
pain has a high prevalence among patients with regional pain complaints. The prevalence is 30% in a
general medical clinic and 85% to 93% in patients
presenting to specialty pain management centers.4,5
Cervical trauma in whiplash patients is followed by
neck pain in 62% to 100% of cases and headache in

From the Department of Physical Medicine and Rehabilitation,

Harvard Medical School, Boston, MA.
Address reprint requests to Joanne Borg-Stein, MD, NewtonWellesley Hospital Spine Center, 2014 Washington Street, Newton, MA 02462. E-mail: jborgstein@partners.org
2004 Elsevier Inc. All rights reserved.
1537-5897/04/0202-0006/$30.00/0
doi:10.1016/j.spmd.2004.04.004

85

86 Seminars in Pain Medicine Vol. 2 No. 2 June 2004

66% to 87% of patients. Twenty percent to 58% of
patients who sustain whiplash or closed head injury
may have late-onset symptoms of dizziness, vertigo,
and dysequilibrium.6 Cervical osteoarthritis is a common finding in the senior population.

weakness in the distribution of the nerve root. The

occipital nerve, derived from the C-2/C-3 nerve
roots, can become entrapped or injured and may
cause lateral cranial pain.15

Pathophysiology of Myofascial Pain

Neuroanatomic Basis of Cervical Pain
and Headache
There are good neuroanatomic and neurophysiologic studies in animal models that establish the
convergence of cervical sensory and muscle afferent
input onto trigeminal subnucleus caudalis nociceptive and non-nociceptive neurons. The trigeminocervical nucleus is a region of the upper cervical spinal
cord where sensory nerve fibers in the descending
tract of the trigeminal nerve converge with sensory
fibers from the upper cervical roots. This convergence
of upper cervical and trigeminal nociceptive pathways allows the referral of pain signals from the neck
to the trigeminal sensory fields of the face and head.
For example, stimulation of the supraorbital nerve
and the infraorbital nerve elicits responses in splenius and trapezius motor neurons.7,8 There are neurons in the spinal cord that respond to electrical
stimulation of the trigeminal nerve and of the cervical nerves. In particular, overlap between terminals
of the upper three cervical segments and terminals of
the trigeminal nerve provide the neuroanatomic basis for cervical myofascial pain causing headache.
Some of the muscles commonly involved include the
sternocleidomastoid (supplied by C-1, C-2), the trapezius (supplied by C-1, C-2), the splenius capitus
and the cervicus (supplied by C-2, C-3), and the
semispinalis capitus and cervicus (supplied by C-2,
C-3).9
The cervical zygoapophyseal (facet) joints have
well-established referral pain patterns that involve
the head. Bogduk developed maps of the neuroanatomic referral pattern of C-1/C-2, C-2/C-3, and C-3/
C-4, which refer specifically to the head and proximal cervical region.10
The cervical disks have also been studied and have
referral patterns to the head. Several investigators
have described referral patterns for cervical discogenic pain.11-13
In addition, the cervical ligaments may refer pain
to the head and proximal axial cervical spine. Hackett and colleagues described pain radiation to the
head from the suboccipital, interspinous, supraspinous, and intertransverse ligaments.14
Finally, one must consider the neuroanatomy of
the cervical nerve roots. Either a C-2 or C-3 radiculopathy can result in headache pain and associated

Current concepts of chronic myofascial pain generally incorporate a complex interplay between peripheral nociception and central sensitization.16 At
the level of the motor endplate, it is hypothesized
that there is a pathologic increase in the release of
acetylcholine (ACh) by the nerve terminal.17-22 This
increased ACh release in turn is proposed to result in
sustained depolarization of the postjunctional membrane of the muscle fiber and produce sustained
sarcomere shortening and contracture.23
A consequence of a chronically sustained sarcomere shortening may be increased local energy consumption and reduction of local circulation, a combination that may produce local ischemia and
hypoxia.24 This localized muscle ischemia then stimulates the release of neurovasoactive substances that
sensitize afferent fibers in muscle and account for
local tenderness.18
The referred pain resulting from myofascial trigger
points stems from central convergence and facilitation. Convergent connections from deep muscle afferent nociceptors to dorsal horn neurons are facilitated, amplified, and referred to adjacent spinal
segments. In addition, neuroplastic changes are seen
in the dorsal horn and trigeminal nuclei, accounting
for central sensitization.25-27
The sympathetic nervous system presumably plays
a role in the commonly described findings of painful
skin rolling, hypersensitivity to touch, temperature
and blood flow changes, abnormal sweating, reactive
hyperemia, dermatographia, and altered pilomotor
responses that are associated with myofascial pain.28

Clinical Characteristics
Cervicogenic Headache
Patients with cervicogenic headache often report
the onset of symptoms associated with sustained
cervical postures, movement of the neck, or cervical
trauma. The pain may be of insidious onset or may
occur after a specific local trauma. The pain is often
unilateral in the head or face, but occasionally may
be bilateral. The pain is moderate to severe, intermittent or constant, and of a deep, aching quality. Pain
is often triggered by neck movement or digital pres-

Musculoskeletal Head and Neck Pain

sure to the suboccipital, C-2, C-3, or C-4 regions, or

over the greater occipital nerve. There is often restricted cervical range of motion and neck stiffness.7
Patients with cervical facet pain, osteoarthritis, and
spondylosis may complain of pain and limited range
of motion. They often report a sensation of joint
crepitus and difficulty looking up, as cervical extension exacerbates symptoms. Cervical discogenic pain
may present with axial cervical pain, worse with
sitting, sneezing, or cough. Cervical radiculopathy
will follow the relevant dermatome.
On physical examination, patients with cervicognic headache may have restricted range of cervical
motion. Pain on palpation of the facet joint capsule,
ligaments, or associated musculature that reproduces
the patients complaints is a helpful finding. Sensory
testing of the upper cervical dermatomes as well as
strength testing of the myotomes is important. Diagnostic injection with 1% lidocaine may help to establish the pain generator. This may be done with a
selective nerve-root block, intraarticular facet injection, or injection of the ligament.29
Myofascial Pain
Patients with myofascial pain report a deep regional ache that is often accompanied by a sensation
of pulling or tightness. The intensity can vary from
mild to severe. Cervical myofascial pain may be associated with autonomic dysfunction, abnormal
sweating, lacrimation, dermal flushing, and vasomotor and temperature changes. Neuro-otologic symptoms may include imbalance, dizziness, or tinnitus.
Functional complaints include impaired muscle coordination, stiffness, muscle fatigue, and weakness.
On physical examination, the patient may demonstrate abnormal cervical posture, biomechanics, joint
function, muscle strength, and imbalances. The physician should be able to identify active trigger points
in one or several muscles. Four of the most common
muscles that manifest trigger points in patients with
headache include the temporalis, upper trapezius,
splenius capitus, and sternocleidomastoid (Fig 1).2
The trigger point should be identified by gentle palpation across the direction of the muscle fibers. The
examiner appreciates a rope-like nodularity to the
taut band of muscle. Palpation of the area is painful
and reproduces the patients local and referred pain
pattern.
Temperomandibular Dysfunction
Patients with TMD complain of pain with mastication in the region of the angle of the jaw. This is

Joanne Borg-Stein

87

often accompanied by a clicking sensation upon

opening and closing of the mouth. There is often
spreading of pain into the side of the face and to the
ear.
On physical examination there may be limited
opening of the mouth, associated with tenderness to
palpation along the joint line. Muscle tenderness and
trigger points may be found in the muscles of mastication and face, including the masseter, pterygoid,
temporalis, and buccinator. Patients often have pain
and dysfunction in the cervical spine as well. Dental
evaluation may reveal occlusal malalignment, and
abnormal wear pattern of the dentition reflecting
chronic clenching and bruxism.30,31

Differential Diagnosis
The differential diagnosis of musculoskeletal head
and neck pain includes:
1. Other headache types: chronic tension-type
headaches with pericranial tenderness.
2. Migraine, cluster, and hemicrania continua.
3. Cervical synovial facet joint pain.
4. Occipital neuralgia.
5. Head pain associated with temporomandibular disorders.
6. Inflammatory disorders: polymyositis; polymyalgia rheumatica; temporal arteritis; and
rheumatoid arthritis.
7. Neurologic disorders: radiculopathy and entrapment neuropathy.
8. Discogenic disorders: degenerative disk disease; annular tears; protrusion; and herniation.
9. Mechanical stresses: postural dysfunction and
poor ergonomic worksite.
10. Ligamentous sprain.
Diagnostic Testing
Laboratory testing may include complete blood
count (CBC) with erthyrocyte sedimentation rate
(ESR) if there is a suspicion of inflammatory joint
disorders or polymyalgia rheumatica/temporal arteritis. Chemistry panel and thyroid testing may be
indicated to search for systemic diseases that may
adversely affect muscle (ie, thyroid or parathyroid
disorders, and primary muscle disease).
Diagnostic imaging, such as radiography, single
photon emission computed tomography (SPECT)
bone scan, computed tomography (CT)/CT myelography, and magnetic resonance imaging (MRI), cannot provide the diagnosis in isolation, but can lend

88 Seminars in Pain Medicine Vol. 2 No. 2 June 2004

Fig 1. Myofacial pain patterns of the head

and neck showing the trigger point (X) and
its pain referral pattern (solid black and
stripping). Reprinted from Simons et al.,
with permission from Lippincott Williams
& Wilkins.17

support to the clinical impression.7,32 Imaging is important to exclude lesions that may require surgery,
such as Arnold-Chiari malformation, herniated intervertebral disk, central or foraminal stenosis, vertebral
fracture, and spinal tumors.7,33 If structural or vascular lesions of the brain are suspected clinically, then
brain imaging should be obtained.
Diagnostic anesthetic blockade is a valuable tool
to confirm diagnostic impressions and guide further
corticosteroid, neuromodulatory, and neuroablative
pain management procedures. Flouroscopically

guided diagnostic anesthetic blockade of C-2 and

C-3 spinal nerves, third occipital nerve (dorsal ramus
C-3), medial branches supplying the zygapophyseal
joints, intraarticular z-joint injections, and greater
and lesser occipital nerves may be undertaken to
assure accurate and specific localization of the pain
source.29 Cervical discography can be performed to
identify discogenic pain; however, the interpretation
and clinical relevance remain debated.12,13 Diagnostic trigger-point injections with lidocaine may have
therapeutic value as well.

Musculoskeletal Head and Neck Pain

Treatment of Musculoskeletal Head

and Neck Pain
In general, the successful treatment of musculoskeletal head and neck pain involves a multifaceted
approach. Often, a combination of pharmacologic,
nonpharmacologic, interventional, manipulative,
and behavioral medicine techniques are necessary.
The clinician must meticulously evaluate, diagnose,
and treat the pain generators. In addition, sleep disturbance, mood disorders, central sensitization, and
deconditioning should be addressed so that the patient will ultimately be restored to optimal function
and independence.

Pharmacologic Treatment
Pharmacologic treatments for cervicogenic headache, cervical myofascial pain, and TMD are similar.
The medications reviewed here have not been approved specifically by the U.S. Food and Drug Administration (FDA) for these indications. Few randomized, controlled trials exist. The medications
discussed in what follows are presented with currently available medical evidence in combination
with the anectodal clinical experience of physicians
who treat these conditions.
Nonsteroidal anti-inflammatory drugs (NSAIDs). The
NSAIDs are indicated to treat underlying synovial
inflammation from osteoarthritis or neurogenic inflammation secondary to cervical radiculopathy.
There is minimal literature supporting the use of
NSAIDs for the treatment of chronic muscle pain,
myofascial pain, or TMD.34,35
Tramadol. Tramadol is a combination of a weak
mu-opioid agonist and serves as an inhibitor or for
reuptake of serotonin and norepinephrine in the
dorsal horn. There are no published controlled trials
of tramadol as a treatment for myofascial pain; however, several studies support its efficacy in the management of fibromyalgia, chronic back pain, and
osteoarthritis, all of which are commonly associated
with musculoskeletal head and neck pain.36-39
Antidepressants. Tricyclic antidepressants (eg, amitriptylene) have been found effective in the treatment of chronic tension-type headache, fibromyalgia, acute low back pain, and intractable syndromes
with muscle spasm.40 Selective serotonin reuptake
inhibitors have not been studied specifically for myofascial pain, although efficacy has been documented
in fibromyalgia for improving pain, sleep, and providing a global sense of well-being.41
Alpha-2-adrenergic agonists. The two major alpha-2adrenergic agonists available for clinical use are

Joanne Borg-Stein

89

clonidine and tizanidine. Tizanidine acts centrally at

the level of the spinal cord to inhibit spinal polysynaptic pathways and to reduce the release of aspartate,
glutamate, and substance P.42 In addition, tizanidine
has supraspinal effects that increase nociceptive
thresholds and inhibit the responses of spinal neurons.43 In one study of tizanidine, a mixed population of patients with myofascial pain syndrome or
fibromyalgia were observed: tizanidine treatment reduced pain.44
Anticonvulsants. There have been no controlled trials focusing on anticonvulsants in the treatment of
myofascial pain, TMD, or cervicogenic headache.
One open-labeled study of gabapentin, used in the
treatment of chronic daily headache, found possible
efficacy.45 Administration of gabapentin and topiramate may be considered in the treatment of coexistent migraine or neuropathic pain.
Botulinum toxin. Botulinum toxin type A is emerging as a promising (but expensive) new agent used to
treat chronic myofascial pain syndromes and chronic
headaches. In two recent studies of myofascial pain,
botulinum toxin injections provided greater relief of
pain symptoms compared with placebo.46,47 In studies of migraine headache, chronic daily headache
(15 days of headache per month), tension-type
headache, and post-whiplash headache, patients reported decreased pain after treatment with botulinum toxin type A. A more recently available preparation, botulinum toxin type B, has also been shown
to provide relief for patients with post-whiplash
headache.47 There may be a peripheral and central
mechanism that explains the apparent efficacy of
botulinum toxin in the treatment of chronic
pain.48,49

Nonpharmacologic Treatment
Postural, mechanical, and ergonomic modifications.
Cervical muscle and skeletal dysfunction may be
caused and perpetuated by abnormal postures, especially those related to poor ergonomics at home and
in the workplace. Correction of awkward postures
and ergonomic management is often an effective
component of treatment.50,51
Stress reduction. Stress reduction techniques, including cognitive-behavioral programs, meditation,
progressive relaxation training, and biofeedback,
should be incorporated into chronic pain rehabilitation programs.52
Acupuncture. A growing body of evidence supports
the efficacy of acupuncture in the treatment of myofascial pain, neck pain, and headache. The limited
amount of high-quality data suggest that traditional

90 Seminars in Pain Medicine Vol. 2 No. 2 June 2004

acupuncture is effective for relieving pain, improving
global ratings, and reducing morning stiffness in
chronic muscle pain.53 Birch and Jamison found relevant acupuncture (over points relevant to myofascial neck pain) to be superior to NSAID treatment
and irrelevant acupuncture (superficial needling over
points not related to neck pain) in a group of 46
patients with chronic myofascial pain.54 Areas that
need to be addressed in future randomized trials
include the duration of benefit of acupuncture, the
optimal acupuncture techniques, and the value of
booster treatments.
Exercise. Stretching forms the basis of exercise treatment of myofascial pain. This treatment addresses
muscle tightness and shortening as well as restricted
motion associated with myofascial pain and osteoarthritis. Patients should be encouraged to remain
active, but perform daily activities in a gentle, lightly
loaded manner. A graded stabilization and strengthening program should be undertaken to maximize
the functional outcome.55,56 Aerobic exercise should
be included in the overall musculoskeletal and cardiovascular fitness program to prevent recurrence. In
TMD, a combination of specific active and passive
jaw movement exercises, correction of body posture,
and relaxation techniques are helpful.57
Nutrition/diet. There is no specific diet that is recommended for chronic pain. Studies suggest that
omega-3 fatty acids have an anti-inflammatory effect
equivalent to NSAIDs and thus may have some theoretical value in patients with cervical osteoarthritis.58 Patients with TMD benefit from a softer mechanical diet and avoiding repetitive activity such as
gum chewing.59
Manipulative and physical therapy. An experienced
and skilled physical therapist, osteopath, or chiropractor often can reduce symptoms with manual
therapy such as mobilization, manipulation, and
myofascial release techniques. These may be directed
to the cervical spine, jaw, and surrounding soft tissue
structures. Although patients often report improvement with a hands-on approach, there are few
well-done trials that support these anecdotal reports.
More research is needed in this area. Most importantly, manual therapies should be combined with a
progressive conditioning and stabilization exercise
program.60-62
Therapeutic injections. Trigger point injection: Trigger point injections are useful for areas of recalcitrant
myofascial pain. The patient should be informed that
this treatment has a limited role in the long-term
management of myofascial pain, but will reduce the
pain and facilitate an active exercise and self-management program. Three consecutive injections are
often recommended in chronic myofascial pain, with

reassessment after the third injection to evaluate the

efficacy of the injections and to determine whether
further injections are needed. The effectiveness of
needling depends on the needle-eliciting local twitch
responses.63
Cervical zygoapophyseal (facet) joint injection
and radiofrequency neurotomy: Therapeutic intraarticular z-joint injections can help alleviate pain related to arthritic or traumatically injured joints. During radiofrequency neurotomy, the medial branch of
the dorsal ramus of the spinal nerve, which supplies
the z-joint and midline structures, is lesioned. A
therapeutic neurotomy is considered only if diagnostic anesthetic injection with control blocks is positive.64 There is limited evidence that radiofrequency
denervation offers short-term relief for chronic neck
pain of cervicobrachial origin.65
Selective nerve root injection: In the presence of
cervical radiculopathy, a corticosteroid-selective
nerve-root injection may be performed to reduce
radicular pain.66
Ligament injection: Chronically injured, strained,
and painful ligaments of the cervical spine may respond to local injection. Some clinicians report success with corticosteroid ligament injections. Ligament injection of proliferant solutions such as
hypertonic dextrose (known as prolotherapy or regenerative injection therapy), presumably decreases
pain by improving ligament strength and promoting
healing; however, there have been no studies that
specifically address cervicogenic headache, TMD, or
cervical myofascial pain.67

Conclusions
The management of chronic musculoskeletal head
and neck pain represents a common, yet formidable
challenge to the pain practitioner. The dense network
of connective tissue structures, in combination with
overlapping jaw and primary headache disorders,
makes the differential diagnosis complex. Often, an
interdisciplinary approach guided by a compassionate provider can be successful. Further research to
guide diagnosis and treatment in this area is clearly
needed.

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