Abstract
BackgroundIn migraine patients with cervical myofascial trigger points whose target areas coincide with migraine sites (M + cTrPs), TrP anesthetic injection reduces migraine symptoms, but the procedure often causes discomfort. This study evaluated if a topical TrP treatment with 3% nimesulide gel has similar efficacy as the injection but produces lesser discomfort with higher acceptability by the patients.MethodsRetrospective analysis of medical charts of M + cTrPs patients in the period January 2012–December 2016 at a single Headache Center. Three groups of 25 patients each were included, all receiving migraine prophylaxis (flunarizine 5 mg/day) for 3 months and symptomatic treatment on demand. Group 1 received no TrP treatment, group 2 received TrP injections (bupivacaine 5 mg/ml at basis, 3rd, 10th, 30th and 60th day), group 3 received daily TrP topical treatment with 1.5 g of 3% nimesulide gel for 15 consecutive days, 15 days interruption and again 15 consecutive days. The following were evaluated: monthly number of migraine attacks and rescue medications, migraine intensity; pain thresholds to skin electrical stimulation (EPTs) and muscle pressure stimulation (PPTs) in TrP and target (basis, 30th, 60th and 180th days); discomfort from, acceptability of and willingness to repeat treatment (end of study). ANOVA for repeated measures and 1-way ANOVA were used to assess temporal trends in each group and comparisons among groups, respectively. Significance level was set at p < 0.05.ResultsMigraine improved over time in all groups, but significantly more and earlier in those receiving TrP treatment vs no TrP treatment (0.02 < p < 0.0001, 30–180 days for intensity and rescue medication, 60–180 days for number). All thresholds in the non-TrP-treated group did not change over time, while significantly improving in both the injection and nimesulide gel groups (0.01 < p < 0.0001, 30–180 days). Improvement of migraine and thresholds did not differ in the two TrP-treated groups. Discomfort was significantly lower, acceptability and willingness to repeat treatment significantly higher (0.05 < p < 0.0001) with gel than injection.ConclusionIn migraine patients, topical treatment of cervical TrPs with 5% nimesulide gel proves equally effective as TrP injection with local anesthetics but more acceptable by the patients. This treatment could be effectively associated to standard migraine prophylaxis to improve therapeutic outcomes.
Highlights
In migraine patients with cervical myofascial trigger points whose target areas coincide with migraine sites (M + cTrPs), TrP anesthetic injection reduces migraine symptoms, but the procedure often causes discomfort
Migraine is highly comorbid with other medical conditions, most of which painful, such as fibromyalgia, visceral pain/chronic pelvic pain, as well as myofascial pain syndromes (MPS) from trigger points (TrPs), i.e., sites of exquisite tenderness located in taut, palpable bands of muscle fibers, whose stimulation produces local pain and pain referred to a distant area, called target [4,5,6,7,8,9,10,11,12,13,14]
Migraine parameters and pain thresholds Group 1 - no TrP treatment +migraine treatment Number and intensity of migraine attacks progressively decreased during the treatment period (ANOVA: p < 0.001), but significant effects were only evident at 60 and 180 days from the start of treatment (0.01 < p < 0.001) (Fig. 1)
Summary
In migraine patients with cervical myofascial trigger points whose target areas coincide with migraine sites (M + cTrPs), TrP anesthetic injection reduces migraine symptoms, but the procedure often causes discomfort. TrPs in cervical muscles of migraineurs most often present target areas coinciding with the sites of migraine pain [9] This specific condition of comorbidity between migraine and cervical TrPs has been shown to be responsible for typical myofascial pain symptoms, and for an increase in the number and intensity of migraine attacks [11, 25]. In these patients, the sensory evaluation at TrP and target level has evidenced a pain hypersensitivity (hyperalgesia, as revealed by a decrease in pain thresholds of the superficial and deep somatic tissues) which is increased with respect to that found in patients with MPS/TrPs only or migraine only [9, 26,27,28,29,30,31]. Present, at the end of the therapeutic cycle, a significant reduction of the mean number of monthly migraine attacks and of their intensity, together with a significant improvement of the somatic hyperalgesia at TrP and target level
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