Quantitative magnetic resonance imaging of the upper trapezius muscles - assessment of myofascial trigger points in patients with migraine

Nico Sollmann, Nina Mathonia, Dominik Weidlich, Michaela Bonfert, Sebastian A Schroeder, Katharina A Badura, Tabea Renner, Florian Trepte-Freisleder, Carl Ganter, Sandro M Krieg, Claus Zimmer, Ernst J Rummeny, Dimitrios C Karampinos, Thomas Baum, Mirjam N Landgraf, Florian Heinen, Nico Sollmann, Nina Mathonia, Dominik Weidlich, Michaela Bonfert, Sebastian A Schroeder, Katharina A Badura, Tabea Renner, Florian Trepte-Freisleder, Carl Ganter, Sandro M Krieg, Claus Zimmer, Ernst J Rummeny, Dimitrios C Karampinos, Thomas Baum, Mirjam N Landgraf, Florian Heinen

Abstract

Background: Research in migraine points towards central-peripheral complexity with a widespread pattern of structures involved. Migraine-associated neck and shoulder muscle pain has clinically been conceptualized as myofascial trigger points (mTrPs). However, concepts remain controversial, and the identification of mTrPs is mostly restricted to manual palpation in clinical routine. This study investigates a more objective, quantitative assessment of mTrPs by means of magnetic resonance imaging (MRI) with T2 mapping.

Methods: Ten subjects (nine females, 25.6 ± 5.2 years) with a diagnosis of migraine according to ICHD-3 underwent bilateral manual palpation of the upper trapezius muscles to localize mTrPs. Capsules were attached to the skin adjacent to the palpated mTrPs for marking. MRI of the neck and shoulder region was performed at 3 T, including a T2-prepared, three-dimensional (3D) turbo spin echo (TSE) sequence. The T2-prepared 3D TSE sequence was used to generate T2 maps, followed by manual placement of regions of interest (ROIs) covering the trapezius muscles of both sides and signal alterations attributable to mTrPs.

Results: The trapezius muscles showed an average T2 value of 27.7 ± 1.4 ms for the right and an average T2 value of 28.7 ± 1.0 ms for the left side (p = 0.1055). Concerning signal alterations in T2 maps attributed to mTrPs, nine values were obtained for the right (32.3 ± 2.5 ms) and left side (33.0 ± 1.5 ms), respectively (p = 0.0781). When comparing the T2 values of the trapezius muscles to the T2 values extracted from the signal alterations attributed to the mTrPs of the ipsilateral side, we observed a statistically significant difference (p = 0.0039). T2 hyperintensities according to visual image inspection were only reported in four subjects for the right and in two subjects for the left side.

Conclusions: Our approach enables the identification of mTrPs and their quantification in terms of T2 mapping even in the absence of qualitative signal alterations. Thus, it (1) might potentially challenge the current gold-standard method of physical examination of mTrPs, (2) could allow for more targeted and objectively verifiable interventions, and (3) could add valuable models to understand better central-peripheral mechanisms in migraine.

Keywords: Magnetic resonance imaging; Migraine; Myofascial trigger points; T2 mapping; Trapezius muscle; Trigemino-cervical complex.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Magnetic resonance imaging (MRI) including T2 mapping of the upper trapezius muscles. This figure captures an exemplary case by showing representative axial slices of the T2-weighted DIXON turbo spin echo (TSE) sequence (upper row). The left upper corner shows the T2-weighted DIXON TSE water image, the right upper corner captures the T2-weighted DIXON TSE fat image. Furthermore, T2 maps as derived from the T2-prepared TSE sequence are displayed (lower row). The left lower corner pictures the color-coded T2 map, the right lower corner shows the same color-coded T2 map after manual placement of regions of interest (ROIs) in the right upper trapezius muscle and with respect to a signal alteration (T2 elevation) within the muscle. In this exemplary case, the signal alteration was located in the area of a manually defined myofascial trigger point (mTrP), as indicated by the spatial relation to superficially attached nitroglycerine capsules as markers. The signal alteration in terms of the circumscribed T2 elevation shows a T2-hyperintense correlate in the T2-weighted DIXON TSE water image
Fig. 2
Fig. 2
T2 values of the upper trapezius muscles and myofascial trigger points (mTrPs). The graphs show the T2 values (in ms) of each subject derived from the regions of interest (ROIs) enclosing the trapezius muscles and signal alterations attributed to mTrPs of the right and left side, respectively. Measurements in trapezius muscles were obtained in all subjects bilaterally, whereas measurements of T2 values of signal alterations attributed to mTrPs were achieved in nine subjects per side, respectively (due to missing detectable signal alterations in the remaining subjects). Horizontal lines represent the mean with the standard deviation (SD). A statistically significant difference was observed between measurements for both sides, respectively (p = 0.0039)
Fig. 3
Fig. 3
Localization of myofascial trigger points (mTrPs) within the upper trapezius muscles. The graphs intend to provide information on the localization of mTrPs within trapezius muscles by capturing the linearly measured distances between the signal alteration attributed to the mTrP and the muscle insertion of the trapezius muscle (x-axis) in relation to the entire length of the trapezius muscle (y-axis) for both sides, respectively. Measurements of T2 values of signal alterations attributed to mTrPs were achieved in nine subjects per side

References

    1. Global Burden of Disease Study C Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743–800. doi: 10.1016/S0140-6736(15)60692-4.
    1. Stovner LJ, Andree C. Prevalence of headache in Europe: a review for the Eurolight project. J Headache Pain. 2010;11(4):289–299. doi: 10.1007/s10194-010-0217-0.
    1. Edvinsson L. Aspects on the pathophysiology of migraine and cluster headache. Pharmacol Toxicol. 2001;89(2):65–73. doi: 10.1034/j.1600-0773.2001.d01-137.x.
    1. Goadsby PJ, Lipton RB, Ferrari MD. Migraine--current understanding and treatment. N Engl J Med. 2002;346(4):257–270. doi: 10.1056/NEJMra010917.
    1. Fernandez-de-Las-Penas C, Simons D, Cuadrado ML, Pareja J. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr Pain Headache Rep. 2007;11(5):365–372. doi: 10.1007/s11916-007-0219-z.
    1. Fernandez-de-Las-Penas C. Myofascial head pain. Curr Pain Headache Rep. 2015;19(7):28. doi: 10.1007/s11916-015-0503-2.
    1. Olesen J. Clinical and pathophysiological observations in migraine and tension-type headache explained by integration of vascular, supraspinal and myofascial inputs. Pain. 1991;46(2):125–132. doi: 10.1016/0304-3959(91)90066-7.
    1. Simons DG, Travell J, Simons LS. Myofascial pain and dysfunction: the trigger point manual. 2. Baltimore: Williams & Wilkins; 1999.
    1. Blaschek A, Decke S, Albers L, Schroeder AS, Lehmann S, Straube A, Landgraf MN, Heinen F, von Kries R. Self-reported neck pain is associated with migraine but not with tension-type headache in adolescents. Cephalalgia. 2014;34(11):895–903. doi: 10.1177/0333102414523338.
    1. Blaschek A, Milde-Busch A, Straube A, Schankin C, Langhagen T, Jahn K, Schroder SA, Reiter K, von Kries R, Heinen F. Self-reported muscle pain in adolescents with migraine and tension-type headache. Cephalalgia. 2012;32(3):241–249. doi: 10.1177/0333102411434808.
    1. Fernandez-de-Las-Penas C, Cuadrado ML, Pareja JA. Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Cephalalgia. 2006;26(9):1061–1070. doi: 10.1111/j.1468-2982.2006.01162.x.
    1. Calandre EP, Hidalgo J, Garcia-Leiva JM, Rico-Villademoros F. Trigger point evaluation in migraine patients: an indication of peripheral sensitization linked to migraine predisposition? Eur J Neurol. 2006;13(3):244–249. doi: 10.1111/j.1468-1331.2006.01181.x.
    1. Ferracini GN, Chaves TC, Dach F, Bevilaqua-Grossi D, Fernandez-de-Las-Penas C, Speciali JG. Relationship between active trigger points and head/neck posture in patients with migraine. Am J Phys Med Rehabil / Association of Academic Physiatrists. 2016;95(11):831–839. doi: 10.1097/PHM.0000000000000510.
    1. Ferracini GN, Florencio LL, Dach F, Chaves TC, Palacios-Cena M, Fernandez-de-Las-Penas C, Bevilaqua-Grossi D, Speciali JG. Myofascial trigger points and migraine-related disability in women with episodic and chronic migraine. Clin J Pain. 2017;33(2):109–115. doi: 10.1097/AJP.0000000000000387.
    1. Tali D, Menahem I, Vered E, Kalichman L. Upper cervical mobility, posture and myofascial trigger points in subjects with episodic migraine: case-control study. J Bodyw Mov Ther. 2014;18(4):569–575. doi: 10.1016/j.jbmt.2014.01.006.
    1. Landgraf MN, Biebl JT, Langhagen T, Hannibal I, Eggert T, Vill K, Gerstl L, Albers L, von Kries R, Straube A, et al. Children with migraine: provocation of headache via pressure to myofascial trigger points in the trapezius muscle? - a prospective controlled observational study. Eur J Pain. 2018;22(2):385–392. doi: 10.1002/ejp.1127.
    1. Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L. Myofascial trigger points then and now: a historical and scientific perspective. PM R. 2015;7(7):746–761. doi: 10.1016/j.pmrj.2015.01.024.
    1. Do TP, Heldarskard GF, Kolding LT, Hvedstrup J, Schytz HW. Myofascial trigger points in migraine and tension-type headache. J Headache Pain. 2018;19(1):84. doi: 10.1186/s10194-018-0913-8.
    1. Wolfe F, Simons DG, Fricton J, Bennett RM, Goldenberg DL, Gerwin R, Hathaway D, McCain GA, Russell IJ, Sanders HO, et al. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol. 1992;19(6):944–951.
    1. Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain. 2009;25(1):80–89. doi: 10.1097/AJP.0b013e31817e13b6.
    1. Landgraf MN, Ertl-Wagner B, Koerte IK, Thienel J, Langhagen T, Straube A, von Kries R, Reilich P, Pomschar A, Heinen F. Alterations in the trapezius muscle in young patients with migraine--a pilot case series with MRI. Eur J Paediatr Neurol. 2015;19(3):372–376. doi: 10.1016/j.ejpn.2014.12.021.
    1. Chen Q, Wang HJ, Gay RE, Thompson JM, Manduca A, An KN, Ehman RE, Basford JR. Quantification of Myofascial taut bands. Arch Phys Med Rehabil. 2016;97(1):67–73. doi: 10.1016/j.apmr.2015.09.019.
    1. Sikdar S, Shah JP, Gebreab T, Yen RH, Gilliams E, Danoff J, Gerber LH. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehabil. 2009;90(11):1829–1838. doi: 10.1016/j.apmr.2009.04.015.
    1. Lewis J, Tehan P. A blinded pilot study investigating the use of diagnostic ultrasound for detecting active myofascial trigger points. Pain. 1999;79(1):39–44. doi: 10.1016/S0304-3959(98)00155-9.
    1. Turo D, Otto P, Shah JP, Heimur J, Gebreab T, Armstrong K, Gerber LH, Sikdar S. Ultrasonic tissue characterization of the upper trapezius muscle in patients with myofascial pain syndrome. Conf Proc IEEE Eng Med Biol Soc. 2012;2012:4386–4389.
    1. Ballyns JJ, Shah JP, Hammond J, Gebreab T, Gerber LH, Sikdar S. Objective sonographic measures for characterizing myofascial trigger points associated with cervical pain. J Ultrasound Med. 2011;30(10):1331–1340. doi: 10.7863/jum.2011.30.10.1331.
    1. Zhang Y, Ge HY, Yue SW, Kimura Y, Arendt-Nielsen L. Attenuated skin blood flow response to nociceptive stimulation of latent myofascial trigger points. Arch Phys Med Rehabil. 2009;90(2):325–332. doi: 10.1016/j.apmr.2008.06.037.
    1. Merla A, Ciuffolo F, D'Attilio M, Tecco S, Festa F, De Michele G, Tangherlini A, Romani GL. Functional infrared imaging in the diagnosis of the myofascial pain. Conf Proc IEEE Eng Med Biol Soc. 2004;2:1188–1191.
    1. Simons DG, Hong CZ, Simons LS. Endplate potentials are common to midfiber myofacial trigger points. Am J Phys Med Rehabil / Association of Academic Physiatrists. 2002;81(3):212–222. doi: 10.1097/00002060-200203000-00010.
    1. Ge HY, Monterde S, Graven-Nielsen T, Arendt-Nielsen L. Latent myofascial trigger points are associated with an increased intramuscular electromyographic activity during synergistic muscle activation. J Pain : official journal of the American Pain Society. 2014;15(2):181–187. doi: 10.1016/j.jpain.2013.10.009.
    1. Dibai-Filho AV, Guirro RR. Evaluation of myofascial trigger points using infrared thermography: a critical review of the literature. J Manip Physiol Ther. 2015;38(1):86–92. doi: 10.1016/j.jmpt.2014.10.010.
    1. Weidlich D, Schlaeger S, Kooijman H, Bornert P, Kirschke JS, Rummeny EJ, Haase A, Karampinos DC (2017) T2 mapping with magnetization-prepared 3D TSE based on a modified BIR-4 T2 preparation. NMR Biomed 30(11)
    1. Fernandez-de-las-Penas C, Cuadrado ML, Arendt-Nielsen L, Simons DG, Pareja JA. Myofascial trigger points and sensitization: an updated pain model for tension-type headache. Cephalalgia : an international journal of headache. 2007;27(5):383–393. doi: 10.1111/j.1468-2982.2007.01295.x.
    1. Zhuang X, Tan S, Huang Q. Understanding of myofascial trigger points. Chin Med J. 2014;127(24):4271–4277.
    1. Golub GH, Pereyra V. Differentiation of pseudo-inverses and nonlinear least-squares problems whose variables separate. SIAM J Numer Anal. 1973;10:413–432. doi: 10.1137/0710036.
    1. Kiefer J. Sequential minimax search for a maximum. Proc Am Math Soc. 1953;4:502–506. doi: 10.1090/S0002-9939-1953-0055639-3.
    1. Bartsch T, Goadsby PJ. The trigeminocervical complex and migraine: current concepts and synthesis. Curr Pain Headache Rep. 2003;7(5):371–376. doi: 10.1007/s11916-003-0036-y.
    1. Fernandez-de-las-Penas C, Madeleine P, Caminero AB, Cuadrado ML, Arendt-Nielsen L, Pareja JA. Generalized neck-shoulder hyperalgesia in chronic tension-type headache and unilateral migraine assessed by pressure pain sensitivity topographical maps of the trapezius muscle. Cephalalgia : an international journal of headache. 2010;30(1):77–86. doi: 10.1111/j.1468-2982.2009.01901.x.
    1. Giamberardino MA, Tafuri E, Savini A, Fabrizio A, Affaitati G, Lerza R, Di Ianni L, Lapenna D, Mezzetti A. Contribution of myofascial trigger points to migraine symptoms. J Pain. 2007;8(11):869–878. doi: 10.1016/j.jpain.2007.06.002.
    1. Majumdar S, Orphanoudakis SC, Gmitro A, O'Donnell M, Gore JC. Errors in the measurements of T2 using multiple-echo MRI techniques. II. Effects of static field inhomogeneity. Magn Reson Med : official journal of the Society of Magnetic Resonance in Medicine / Society of Magnetic Resonance in Medicine. 1986;3(4):562–574. doi: 10.1002/mrm.1910030410.
    1. Majumdar S, Orphanoudakis SC, Gmitro A, O'Donnell M, Gore JC. Errors in the measurements of T2 using multiple-echo MRI techniques. I. Effects of radiofrequency pulse imperfections. Magn Reson Med : official journal of the Society of Magnetic Resonance in Medicine / Society of Magnetic Resonance in Medicine. 1986;3(3):397–417. doi: 10.1002/mrm.1910030305.
    1. Diener HC, Charles A, Goadsby PJ, Holle D. New therapeutic approaches for the prevention and treatment of migraine. Lancet Neurol. 2015;14(10):1010–1022. doi: 10.1016/S1474-4422(15)00198-2.
    1. Sollmann N, Trepte-Freisleder F, Albers L, Jung NH, Mall V, Meyer B, Heinen F, Krieg SM, Landgraf MN. Magnetic stimulation of the upper trapezius muscles in patients with migraine - a pilot study. Eur J Paediatr Neurol. 2016;20(6):888–897. doi: 10.1016/j.ejpn.2016.07.022.
    1. Giamberardino MA, Affaitati G, Fabrizio A, Costantini R. Effects of treatment of myofascial trigger points on the pain of fibromyalgia. Curr Pain Headache Rep. 2011;15(5):393–399. doi: 10.1007/s11916-011-0205-3.
    1. Alonso-Blanco C, Fernandez-de-Las-Penas C, de-la-Llave-Rincon AI, Zarco-Moreno P, Galan-Del-Rio F, Svensson P. Characteristics of referred muscle pain to the head from active trigger points in women with myofascial temporomandibular pain and fibromyalgia syndrome. J Headache Pain. 2012;13(8):625–637. doi: 10.1007/s10194-012-0477-y.
    1. Alonso-Blanco C, Fernandez-de-las-Penas C, Morales-Cabezas M, Zarco-Moreno P, Ge HY, Florez-Garcia M. Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. Clin J Pain. 2011;27(5):405–413. doi: 10.1097/AJP.0b013e318210110a.

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