DiagnosticTree/EyeEyebrow
{
"tree_id": "eye-eyebrow-pain", "region": "Eye and Eyebrow Pain", "start": "agg-1",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Acute angle-closure glaucoma",
"question": "Is there sudden onset periorbital or frontal pain with visual blurring, coloured halos around lights, nausea or vomiting, and a hard red eye?",
"rationale": "Acute angle-closure glaucoma is a sight-threatening emergency presenting as severe periorbital pain with visual symptoms. It must be excluded before myofascial assessment.",
"action": "Emergency ophthalmology referral same day. Do not proceed with musculoskeletal assessment."
},
{
"id": "rf-e2",
"label": "Cavernous sinus thrombosis",
"question": "Is there periorbital pain with proptosis (forward protrusion of the eye), chemosis (conjunctival oedema), ophthalmoplegia, or fever?",
"rationale": "Cavernous sinus thrombosis presents as periorbital pain with signs of orbital congestion and cranial nerve involvement.",
"action": "Call emergency services immediately."
},
{
"id": "rf-e3",
"label": "Posterior communicating artery aneurysm",
"question": "Is there new onset orbital or periorbital pain with ipsilateral oculomotor nerve palsy — drooping eyelid, dilated pupil, eye deviated down and out?",
"rationale": "A posterior communicating artery aneurysm compresses CN III producing painful ophthalmoplegia — a true Horner sign with ptosis AND mydriasis and ophthalmoplegia is the distinguishing feature from myofascial palpebral narrowing.",
"action": "Call emergency services immediately. CT angiography urgently required."
},
{
"id": "rf-e4",
"label": "Orbital cellulitis",
"question": "Is there periorbital swelling with fever, restricted eye movement, proptosis, or reduced visual acuity?",
"rationale": "Orbital cellulitis is a sight and life-threatening emergency requiring immediate antibiotics.",
"action": "Emergency medical referral immediately."
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Temporal arteritis",
"question": "Is the patient aged 50+ with jaw claudication (pain building with chewing then easing), scalp tenderness, or a non-pulsatile tender temporal artery? New visual symptoms?",
"rationale": "Temporal arteritis produces orbital and periorbital pain and can cause sudden irreversible blindness. Same-day ESR required.",
"action": "Same-day GP referral + ESR and CRP. Do not delay for musculoskeletal assessment."
},
{
"id": "rf-u2",
"label": "True Horner Syndrome",
"question": "Is there ptosis WITH ipsilateral pupil constriction (miosis) — the affected pupil is smaller than the other, especially in dim light?",
"rationale": "True Horner syndrome (ptosis + miosis ± anhidrosis) requires exclusion of a Pancoast tumour, carotid dissection, or brainstem lesion. Myofascial palpebral narrowing from SCM or orbicularis oculi TrPs produces apparent ptosis WITHOUT miosis — pupils remain equal.",
"action": "If miosis is present, urgent neurology or ophthalmology referral. MRI brain/neck/chest required."
},
{
"id": "rf-u3",
"label": "Optic neuritis",
"question": "Is there eye pain worsened by eye movement, reduced visual acuity, or colour desaturation on the affected side?",
"rationale": "Optic neuritis presents as periorbital pain worsened by eye movement with reduced vision or colour vision — often the first presentation of multiple sclerosis.",
"action": "Urgent ophthalmology or neurology referral. MRI brain required."
}
]
},
"nodes": {
"agg-1": {
"type": "choice",
"question": "What is the PRIMARY mechanism or pattern associated with the eye or eyebrow pain?",
"clinical_rationale": "Eight muscles refer pain to the eye and eyebrow region. They separate into three mechanism groups. Jaw activity (chewing, clenching, bruxism) implicates temporalis TrP₁ and masseter superficial — the masticatory pair. Neck and postural loading covers SCM sternal, trapezius TrP₁, splenius cervicis, and the suboccipital/occipitalis group. Local perorbital signs — jumping print when reading, nose and upper lip referral, palpebral narrowing without miosis — are specific to orbicularis oculi, which is almost always a satellite of SCM sternal. This three-way split avoids the false dichotomy of jaw vs neck and captures orbicularis oculi efficiently without always routing through the SCM sternal pathway.",
"options": [
{
"label": "Jaw activity aggravates — chewing, clenching, biting, or bruxism",
"sublabel": "Jaw use reproduces or worsens the eye or eyebrow pain; may also have tooth sensitivity",
"next": "jaw-pattern-split-1"
},
{
"label": "Neck movement, posture, or shoulder loading aggravates",
"sublabel": "Rotation, flexion, sustained forward head position, shoulder elevation, or carrying load worsens the orbital or supraorbital pain",
"next": "autonomic-split-1"
},
{
"label": "Local perorbital signs — jumping print when reading, OR pain to the side of the nose and upper lip",
"sublabel": "Letters appear to jump or vibrate when reading black text on white; OR pain traces from the eye to the side of the nose and cheek",
"next": "exam-orbicularis-1"
}
]
},
"jaw-pattern-split-1": {
"type": "choice",
"question": "Which pattern best describes the eye or eyebrow pain in the jaw-aggravated group?",
"clinical_rationale": "Temporalis TrP₁ refers pain forward along the supraorbital ridge toward the eyebrow and sometimes downward to the upper incisor teeth — a spoke pattern from the anterior temporal fossa. Masseter superficial TrPs refer to the cheek, lower jaw, upper and lower molar teeth, maxilla (often described as sinusitis), eyebrow, and temple — a broader cheek-centred pattern with infraorbital components. Both produce tooth hypersensitivity but in different tooth zones. Distinguishing them by pattern first avoids unnecessary sequential binary questions.",
"options": [
{
"label": "Pain at the eyebrow or supraorbital ridge — spoke-like referral from the temple forward",
"sublabel": "May also refer to the upper incisor teeth; pain from the temporal fossa directed toward the eyebrow and orbit",
"next": "exam-temporalis-1"
},
{
"label": "Pain to the eyebrow, cheek, and infraorbital area — often described as sinus pain",
"sublabel": "Broader cheek-centred pattern; may also have tooth hypersensitivity in the molar region; no dental cause found",
"next": "exam-masseter-1"
}
]
},
"exam-temporalis-1": {
"type": "examination",
"question": "Does flat palpation of the anterior temporalis — in the zone of ATrP₁ near the musculotendinous junction above and in front of the ear — reproduce the supraorbital or eyebrow pain?",
"exam_type": "palpation",
"landmark": "ATrP₁ is at the anterior musculotendinous junction of the temporalis, near the coronoid process. Palpate in the anterior temporal fossa with firm flat pressure — the first spoke refers forward along the supraorbital ridge and downward to the upper incisor teeth. Confirm whether the patient also has upper tooth hypersensitivity (percussion, heat, cold, biting pressure) without dental pathology — this confirms ATrP₁ referral. CAUTION: the temporal artery runs through the muscle — palpate for pulsation and avoid during injection.",
"positive_finding": "Focal tenderness at ATrP₁ reproducing supraorbital or eyebrow pain. Upper incisor or premolar tooth hypersensitivity may coexist.",
"muscles_implicated": ["Temporalis (ATrP₁)"],
"yes": "result-temporalis",
"no": "exam-masseter-1"
},
"exam-masseter-1": {
"type": "examination",
"question": "Does flat or pincer palpation of the superficial masseter — from the zygomatic arch downward to the lower jaw border — reproduce the cheek, infraorbital, or eyebrow pain?",
"exam_type": "palpation",
"landmark": "Superficial masseter: palpate from the zygomatic arch downward over the body of the masseter to the gonial angle. The upper anterior TrP zone refers to the cheek, infraorbital area, eyebrow, and upper teeth. Confirm: (1) tooth hypersensitivity to percussion, heat, and cold across a zone (not a single tooth) — confirms myofascial referral rather than dental pathology; (2) absence of true sinusitis features (no fever, no nasal discharge, normal radiographs) when the patient describes sinus-like pain; (3) jaw deviation toward the affected side on slow mouth opening.",
"positive_finding": "Focal tenderness in the upper anterior masseter zone reproducing cheek, infraorbital, or eyebrow pain. Zone tooth hypersensitivity without dental pathology.",
"muscles_implicated": ["Masseter (Superficial)"],
"yes": "result-masseter",
"no": "autonomic-split-1"
},
"autonomic-split-1": {
"type": "symptom",
"question": "Are there ipsilateral AUTONOMIC phenomena alongside the eye or orbital pain — profuse tearing, rhinitis (watering or blocked nose on the same side), conjunctival redness, or apparent eyelid drooping WITHOUT pupil constriction?",
"symptom_name": "Autonomic phenomena — tearing, rhinitis, palpebral narrowing without miosis",
"muscles_implicated": ["SCM (Sternal Division)"],
"muscles_excluded": ["Trapezius TrP₁", "Splenius Cervicis", "Suboccipital Group", "Occipitalis"],
"clinical_rationale": "Autonomic phenomena are specific to the sternal division of the SCM. In the eye and eyebrow region, SCM sternal is the chief essential source — it refers to the supraorbital ridge, orbit, and cheek, and its autonomic phenomena are often more alarming than the pain itself. Tearing is frequently misattributed to eye disease. Palpebral fissure narrowing mimics Horner ptosis but without miosis — pupils remain equal and reactive. The absence of miosis is the key feature distinguishing SCM from true Horner syndrome.",
"yes": "exam-scm-sternal-1",
"no": "near-vision-split-1"
},
"exam-scm-sternal-1": {
"type": "examination",
"question": "Does pincer palpation of the SCM sternal head — grasping the full belly from mastoid to sternum — reproduce the orbital, supraorbital, or cheek pain? Does the SCM Compression Test (firmly gripping the belly while the patient swallows) resolve a concurrent sore throat?",
"exam_type": "palpation",
"landmark": "Patient supine, head rotated slightly toward the TrP side. Grasp the full sternal belly in a pincer grip from mastoid to sternum, rolling it between thumb and forefinger to identify taut bands. SCM Compression Test: firmly grip the belly and ask the patient to swallow — resolution of pharyngeal pain is pathognomonic of a sternal central TrP. Note palpebral fissure width — narrowing on the TrP side without miosis confirms sternal division involvement. Also note the habitual head position — head tilts toward the TrP side.",
"positive_finding": "Reproduces orbital, supraorbital, or cheek pain. Tearing or conjunctival redness on the same side. SCM Compression Test may relieve sore throat.",
"muscles_implicated": ["SCM (Sternal Division)"],
"yes": "jumpy-print-screen-1",
"no": "near-vision-split-1"
},
"jumpy-print-screen-1": {
"type": "symptom",
"question": "Does the patient describe 'jumpy print' — when reading black text on a white page, do the letters appear to jump, vibrate, or shift, making it difficult to focus on the line?",
"symptom_name": "Jumpy print — letters appear to jump when reading",
"muscles_implicated": ["Orbicularis Oculi"],
"clinical_rationale": "Jumpy print is pathognomonic for orbicularis oculi TrP involvement and resolves with TrP inactivation. It is specifically produced by strong black-and-white contrast (text on a page, venetian blinds, window frames). SCM sternal TrPs can also produce a visual disturbance with high-contrast vertical lines (the venetian blinds phenomenon), but jumpy print during reading is specific to orbicularis oculi. Because orbicularis oculi TrPs develop as satellites of SCM sternal TrPs, the SCM has already been identified in this pathway — both should be treated, with SCM first.",
"yes": "result-scm-and-orbicularis",
"no": "result-scm-sternal"
},
"near-vision-split-1": {
"type": "symptom",
"question": "Is there ipsilateral blurring of NEAR vision — transient difficulty focusing on close objects on the same side as the eye or orbital pain?",
"symptom_name": "Ipsilateral near-vision blurring",
"muscles_implicated": ["Splenius Cervicis"],
"muscles_excluded": ["Trapezius TrP₁", "Suboccipital Group", "Occipitalis"],
"clinical_rationale": "Ipsilateral near-vision blurring is pathognomonic for the splenius cervicis upper TrP and is not produced by any other muscle contributing to eye and eyebrow pain. Its presence makes splenius cervicis the leading candidate. Its absence routes to the remaining three muscles, which are separated by pain quality in the next choice node.",
"yes": "exam-splenius-1",
"no": "posterior-eye-split-1"
},
"exam-splenius-1": {
"type": "examination",
"question": "Does deep palpation through the trapezius at the C₁–C₃ level — approximately 3–4 cm lateral to the midline — reproduce the diffuse orbital or intracranial pain and near-vision blurring? Is cervical rotation restricted toward the involved side?",
"exam_type": "palpation",
"landmark": "The splenius cervicis lies beneath the trapezius and is not directly accessible from behind. Press firmly through the trapezius at C₁–C₃, approximately 3–4 cm lateral to the midline. The upper TrP refers a diffuse pain through the inside of the head to the back of the eye. Assess cervical rotation: ask the patient to rotate toward the involved side — end-range restriction or provocation of the orbital pain is consistent. This muscle typically only becomes accessible after levator scapulae and upper trapezius TrPs have been inactivated.",
"positive_finding": "Deep palpation reproduces diffuse orbital or intracranial pain. Near-vision blurring provoked or present. Cervical rotation restricted toward the involved side.",
"muscles_implicated": ["Splenius Cervicis"],
"yes": "result-splenius-cervicis",
"no": "posterior-eye-split-1"
},
"posterior-eye-split-1": {
"type": "choice",
"question": "Which of these best describes the quality of the eye or orbital pain in the neck-aggravated group?",
"clinical_rationale": "Three muscles remain after SCM sternal and splenius cervicis have been screened. Upper trapezius TrP₁ produces posterolateral neck-to-orbit referral at high intensity — always with shoulder loading as the primary aggravator and ipsilateral head tilt. The suboccipital group produces diffuse, poorly localised deep head pain that radiates toward the eye — described as ghostly or penetrating, with AA rotation restriction. Occipitalis produces deep pain through the skull to behind the eye — with the cardinal sign of pillow intolerance at night. These three qualities are distinct enough to function as a choice node.",
"options": [
{
"label": "Shoulder loading, neck elevation, or head tilt aggravates — orbital pain at the back of the eye at high intensity",
"sublabel": "Carrying a bag on the same shoulder or neck load reproduces the pain; head tends to tilt toward the pain side",
"next": "exam-trapezius-1"
},
{
"label": "Diffuse, poorly localised deep pain that seems to penetrate inside the skull toward the eye — described as ghostly or all over inside",
"sublabel": "No clear shoulder or flexion component; pain is deep and poorly defined; may have AA rotation restriction",
"next": "exam-suboccipital-1"
},
{
"label": "Deep aching through the skull to behind the eye — worst at night when resting the head on a pillow",
"sublabel": "Cannot bear the weight of the back of the head on a pillow; moist heat to the occiput relieves the pain",
"next": "exam-occipitalis-1"
}
]
},
"exam-trapezius-1": {
"type": "examination",
"question": "Does pincer palpation of upper trapezius TrP₁ — at the most vertical midportion of the anterior border — reproduce the orbital or back-of-eye pain at high stimulus intensity?",
"exam_type": "palpation",
"landmark": "TrP₁ is at the midportion of the anterior border of the upper trapezius, in the most vertical fibres. Grasp with a firm pincer grip — at high stimulus intensity this TrP refers to the side of the head, centring in the temple and the back of the orbit. Note ipsilateral head tilt (ear toward the TrP shoulder) — a consistent postural sign. Confirm that shoulder carrying on the same side reproduces or worsens the orbital pain.",
"positive_finding": "Orbital or back-of-orbit pain reproduced at high stimulus intensity by TrP₁ pincer palpation. Ipsilateral head tilt present. Shoulder loading aggravates.",
"muscles_implicated": ["Upper Trapezius (TrP₁)"],
"yes": "result-trapezius",
"no": "exam-suboccipital-1"
},
"exam-suboccipital-1": {
"type": "examination",
"question": "Does deep suboccipital palpation — firmly pressing just below the nuchal line between the midline and the mastoid — reproduce a diffuse poorly localised head pain radiating toward the eye? Is atlantoaxial rotation restricted with the neck in slight flexion?",
"exam_type": "palpation",
"landmark": "Palpate firmly in the suboccipital triangle, inferior to the nuchal line. Characteristic reproduction: diffuse, poorly localised aching that feels penetrating or 'all over inside.' AA rotation test: patient supine, examiner rotates the head with the neck in slight flexion (chin slightly tucked to isolate C₁/C₂) — restriction confirms AA involvement. CAUTION: vertebral artery traverses the suboccipital triangle — injection requires expert anatomical knowledge.",
"positive_finding": "Deep suboccipital palpation reproduces diffuse poorly localised pain radiating toward the eye. AA rotation restricted.",
"muscles_implicated": ["Suboccipital Group"],
"yes": "result-suboccipital",
"no": "exam-occipitalis-1"
},
"exam-occipitalis-1": {
"type": "examination",
"question": "Does flat palpation of the occipitalis belly — in the small hollow just above the superior nuchal line approximately 4 cm lateral to the midline — reproduce a deep aching pain through the skull toward the back of the eye? Does the patient report inability to rest the back of the head on a pillow at night?",
"exam_type": "palpation",
"landmark": "Occipitalis TrP: palpate in the small hollow just above the superior nuchal line, approximately 4 cm lateral to the midline, in the subcutaneous fascia of the occiput. Press firmly through the scalp skin — the muscle is superficial. Pillow intolerance: the patient cannot bear head weight on a pillow at night and must sleep on their side. Moist heat test: apply a warm pack to the occiput — if this relieves the pain, it favours myofascial origin (occipitalis TrPs) over nerve entrapment.",
"positive_finding": "Focal tenderness at the occipitalis belly reproducing through-the-skull deep orbital pain. Pillow intolerance reported. Moist heat relieves.",
"muscles_implicated": ["Occipitalis (Occipitofrontalis)"],
"yes": "result-occipitalis",
"no": "exam-orbicularis-1"
},
"exam-orbicularis-1": {
"type": "examination",
"question": "Does flat palpation of the upper orbital portion of the orbicularis oculi — running the fingertip firmly along the upper orbital rim from the medial canthus toward the lateral corner — reproduce a tender spot that refers pain to the side of the nose, cheek, or upper lip? Does the patient have jumpy print when reading?",
"exam_type": "palpation",
"landmark": "Flat palpation of the upper orbital rim: with the patient looking downward, use the fingertip to palpate firmly along the bony upper orbital rim from the medial canthus to the lateral angle. The TrP is typically found in the upper orbital portion, running along the orbital rim. Referral is to the side of the nose, cheek near the nose, and upper lip — not to the eyebrow or forehead. Confirm: jumpy print during reading? Palpebral fissure narrowing on the affected side? Pupils equal and reactive?",
"positive_finding": "Focal tenderness along the upper orbital rim reproducing nose-cheek-lip referral pattern. Jumpy print symptom present. Palpebral narrowing without miosis.",
"muscles_implicated": ["Orbicularis Oculi"],
"yes": "result-orbicularis",
"no": "result-overlap"
},
"result-temporalis": {
"type": "result",
"diagnosis": "Temporalis ATrP₁ — Supraorbital and Eyebrow Referral",
"confidence": "high",
"wiki_page": "Muscle:Temporalis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.9 Temporalis",
"notes": "ATrP₁ at the anterior musculotendinous junction of the temporalis refers pain forward along the supraorbital ridge and downward to the upper incisor teeth. The eyebrow and supraorbital pain is part of the first spoke pattern of the temporalis fan. Tooth hypersensitivity (to percussion, heat, cold, and biting pressure) in the incisor-premolar zone without dental pathology is a cardinal associated feature — unaware clinicians may needlessly extract healthy teeth or extirpate pulps. The temporal artery runs through the muscle — identify it by palpation and avoid it during injection. Treatment is not complete until upper trapezius and SCM key TrPs have been inactivated.",
"treatment_hint": "Ischemic compression and spray and stretch with jaw opening to stretch limit. Address bruxism and clenching. Treat upper trapezius and SCM first — temporalis is frequently their satellite.",
"also_consider": ["Upper Trapezius (key TrP)", "SCM Sternal (key TrP)", "Masseter Superficial"],
"less_likely": [
{ "muscle": "Masseter Superficial", "reason": "Spoke pattern directed at the supraorbital ridge and incisor teeth is specific to ATrP₁; masseter produces a broader cheek and molar tooth pattern" },
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena; jaw activity is the primary aggravator, not neck posture" },
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring; jaw aggravation and spoke pattern are specific to temporalis" }
],
"confirmatory": [
"ATrP₁ tenderness at the anterior temporal fossa reproducing supraorbital or eyebrow pain — the familiar pain, not just local tenderness",
"Upper tooth hypersensitivity (incisor zone) without dental pathology — confirms ATrP₁ referral",
"Spoke pattern: pain directed forward along the supraorbital ridge toward the eyebrow",
"Temporal artery confirmed pulsatile — non-pulsatile tender artery requires temporal arteritis exclusion"
],
"satellite_trps": ["Masseter", "SCM (key TrP)", "Upper Trapezius (key TrP)"],
"landing_page_topics": [
"ATrP₁–₃ spoke patterns and tooth group referral",
"CTrP₄ posterior belly — back-of-head referral without teeth",
"Temporal artery anatomy and injection caution",
"Satellite relationship with upper trapezius and SCM"
],
"related_pages": [
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" },
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" }
]
},
"result-masseter": {
"type": "result",
"diagnosis": "Masseter — Superficial Head Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Masseter",
"chapter_ref": "Travell & Simons Vol.1 — Ch.8 Masseter",
"notes": "Superficial masseter TrPs refer to the cheek, lower jaw, upper and lower molar teeth, maxilla (commonly described as sinusitis), eyebrow, and temple. The eyebrow referral arises from the upper anterior TrP zone. Tooth hypersensitivity across a zone of upper and lower molars (not a single tooth) is cardinal. Sinusitis-like maxillary pain without fever, nasal discharge, or radiographic changes is a frequent presenting complaint — the patient has already been evaluated by an ENT specialist or GP with normal findings. Jaw deviation toward the affected side on slow mouth opening is a useful clinical sign. Treatment is not complete until SCM and upper trapezius key TrPs have been inactivated.",
"treatment_hint": "Pincer palpation with one finger inside the mouth and one outside. Spray and stretch, intraoral massage. Address parafunctional habits — clenching and bruxism. Treat SCM and upper trapezius as key TrPs first.",
"also_consider": ["Upper Trapezius (key TrP)", "SCM Sternal (key TrP)", "Temporalis ATrP₁"],
"less_likely": [
{ "muscle": "Temporalis ATrP₁", "reason": "Cheek-centred pattern with molar tooth hypersensitivity distinguishes masseter from the supraorbital spoke of temporalis ATrP₁" },
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena; jaw activity is the primary aggravator" },
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring; cheek and molar pattern is specific to masseter" }
],
"confirmatory": [
"Tenderness in the upper anterior masseter zone reproducing cheek, infraorbital, or eyebrow pain",
"Zone tooth hypersensitivity (upper and lower molars) across multiple teeth without dental pathology",
"Sinusitis-like maxillary pain with normal sinus radiographs — confirms anterior-superior TrP referral",
"Jaw deviation toward the affected side on slow mouth opening"
],
"satellite_trps": ["Temporalis", "Medial Pterygoid", "SCM (key TrP)", "Upper Trapezius (key TrP)"],
"landing_page_topics": [
"Superficial vs deep masseter TrPs — eyebrow/cheek vs tinnitus/ear distinction",
"Sinusitis misdiagnosis — normal imaging with masseter referral",
"Tooth hypersensitivity and unnecessary dental treatment prevention",
"Jaw deviation sign on opening"
],
"related_pages": [
{ "label": "Temporalis TrP →", "page": "Muscle:Temporalis" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-scm-sternal": {
"type": "result",
"diagnosis": "SCM Trigger Point — Sternal Division",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
"notes": "The sternal division of the SCM is the chief essential source of eye and eyebrow pain in the head and neck TrP taxonomy. It refers to the supraorbital ridge, orbit, cheek, temple, and vertex. The cardinal distinguishing features are the autonomic phenomena: profuse tearing (often the most alarming symptom to the patient), rhinitis, and palpebral fissure narrowing without miosis. The palpebral narrowing closely resembles Horner ptosis but pupils remain equal and reactive. Head tilts toward the TrP side. Visual disturbance with strongly contrasted vertical lines (venetian blinds, window frames) is a specific associated feature. Treating SCM sternal frequently resolves orbicularis oculi satellite TrPs without direct treatment.",
"treatment_hint": "Pincer palpation and spray and stretch, superior to inferior. SCM Compression Test confirms sternal central TrP. Correct forward head posture. Treat SCM before orbicularis oculi — the satellite will often resolve.",
"also_consider": ["Orbicularis Oculi (satellite)", "Upper Trapezius", "Temporalis (satellite)"],
"less_likely": [
{ "muscle": "Orbicularis Oculi", "reason": "SCM sternal is the key TrP — orbicularis oculi is its satellite; treat SCM first. Jumpy print screen was negative." },
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring; autonomic phenomena are specific to SCM sternal division" },
{ "muscle": "Temporalis ATrP₁", "reason": "No jaw aggravation identified; autonomic phenomena argue for SCM sternal division" }
],
"confirmatory": [
"SCM Compression Test positive — pharyngeal pain resolves on gripping the sternal belly during swallowing",
"Profuse ipsilateral tearing — often the most alarming symptom",
"Rhinitis on TrP side — ipsilateral nasal congestion without infection",
"Palpebral fissure narrowing without miosis — pupils equal and reactive; exclude true Horner syndrome",
"Head tilts toward TrP side",
"Venetian blinds visual disturbance — with strongly contrasted vertical lines, not blurred or double vision"
],
"satellite_trps": ["Orbicularis Oculi", "Zygomaticus Major", "Frontalis", "Masseter", "Temporalis"],
"landing_page_topics": [
"Horner syndrome exclusion — full protocol",
"Venetian blinds vs jumpy print — SCM visual vs orbicularis oculi visual",
"CN XI entrapment monitoring",
"Satellite TrP treatment sequence — SCM before facial muscles"
],
"related_pages": [
{ "label": "Orbicularis Oculi TrP →", "page": "Muscle:Orbicularis_Oculi" },
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" }
]
},
"result-scm-and-orbicularis": {
"type": "result",
"diagnosis": "SCM Sternal Division + Orbicularis Oculi Satellite Trigger Points",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 SCM; Ch.13 Orbicularis Oculi",
"notes": "Both the SCM sternal division and orbicularis oculi are active. Jumpy print (letters appearing to jump or vibrate when reading black text) is pathognomonic for orbicularis oculi TrP involvement and resolves with TrP inactivation. The relationship is typically satellite: SCM sternal refers to the orbit and the orbicularis oculi develops TrPs in response — but the relationship is bidirectional, and chronic orbital pain from any cause can maintain orbicularis overload. Palpebral fissure narrowing from orbicularis oculi TrPs closely resembles Horner ptosis but pupils remain equal and reactive. Treat SCM first — the orbicularis oculi satellite often resolves without direct treatment.",
"treatment_hint": "Treat SCM sternal division first — spray and stretch, pincer palpation, SCM Compression Test. Then reassess orbicularis oculi. If jumpy print persists after SCM treatment: flat palpation along the upper orbital rim; eliminate squinting and frowning habits; address any uncorrected refractive error driving habitual squinting.",
"also_consider": ["Upper Trapezius", "Frontalis"],
"less_likely": [
{ "muscle": "Splenius Cervicis", "reason": "Near-vision blurring is distinct from jumpy print — jumpy print is specific to orbicularis oculi; both muscles active here with SCM confirmed" },
{ "muscle": "Suboccipital Group", "reason": "SCM sternal confirmed as primary source; orbicularis oculi satellite identified by jumpy print" }
],
"confirmatory": [
"SCM Compression Test positive — sternal division confirmed",
"Jumpy print when reading black text on white — pathognomonic for orbicularis oculi TrP involvement",
"Palpebral fissure narrowing without miosis — both SCM and orbicularis oculi contribute to this sign",
"Treat SCM first — jumpy print and palpebral narrowing often resolve without direct orbicularis oculi treatment"
],
"satellite_trps": ["Orbicularis Oculi", "Zygomaticus Major", "Frontalis", "Masseter"],
"landing_page_topics": [
"Jumpy print — mechanism and resolution with TrP treatment",
"Horner syndrome exclusion",
"Bidirectional satellite relationship between SCM and orbicularis oculi",
"Treatment sequence — SCM before orbicularis oculi"
],
"related_pages": [
{ "label": "Orbicularis Oculi TrP →", "page": "Muscle:Orbicularis_Oculi" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-splenius-cervicis": {
"type": "result",
"diagnosis": "Splenius Cervicis Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Splenius_Cervicis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.15 Splenius Cervicis",
"notes": "The upper TrP of the splenius cervicis refers a diffuse pain through the inside of the head to the back of the eye — an intracranial quality. Ipsilateral near-vision blurring is pathognomonic and highly specific: transient difficulty focusing on close objects on the same side as the orbital pain. This feature is not produced by any other muscle in the eye and eyebrow group. The muscle lies beneath the trapezius and is not readily palpable — its involvement often only becomes apparent after levator scapulae and upper trapezius TrPs have been inactivated.",
"treatment_hint": "Treat levator scapulae and upper trapezius first. Spray and stretch with contralateral rotation and slight flexion. Correct sustained ipsilateral rotation postures.",
"also_consider": ["Upper Trapezius (key TrP)", "Levator Scapulae (key TrP)", "Splenius Capitis", "Suboccipital Group"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena; near-vision blurring is specific to splenius cervicis" },
{ "muscle": "Suboccipital Group", "reason": "Near-vision blurring is pathognomonic for splenius cervicis; suboccipital pain is diffuse and ghostly without vision blur" },
{ "muscle": "Occipitalis", "reason": "Near-vision blurring and intracranial quality distinguish splenius cervicis from occipitalis through-the-skull pattern" }
],
"confirmatory": [
"Ipsilateral near-vision blurring — pathognomonic for splenius cervicis upper TrP",
"Diffuse intracranial pain to the back of the eye — ache inside the skull quality",
"Cervical rotation restricted toward the involved side",
"Deep palpation through trapezius at C₁–C₃ reproduces the orbital pain",
"Becomes apparent after levator scapulae and upper trapezius TrPs treated"
],
"satellite_trps": ["Suboccipital Group", "Splenius Capitis", "Levator Scapulae (key TrP)"],
"landing_page_topics": [
"Near-vision blurring — mechanism and clinical significance",
"Upper vs lower TrP — orbital vs angle-of-neck referral",
"Palpation through trapezius technique",
"Satellite relationship with levator scapulae"
],
"related_pages": [
{ "label": "Levator Scapulae TrP →", "page": "Muscle:Levator_Scapulae" },
{ "label": "Suboccipital Group →", "page": "Muscle:Suboccipital" }
]
},
"result-trapezius": {
"type": "result",
"diagnosis": "Upper Trapezius TrP₁ — Back-of-Orbit Referral",
"confidence": "moderate",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "TrP₁ at the anterior border of the upper trapezius is the most common TrP in the body. At high intensity, its temporal referral extends to centre in the temple and the back of the orbit. The orbital component is a spillover pattern — the primary referral is posterolateral neck to mastoid and temple. Ipsilateral head tilt is the consistent postural sign. Shoulder loading (carrying a bag on the same side) is the most common daily perpetuating factor. Upper trapezius is also a key TrP driving temporalis, SCM, and semispinalis capitis as satellites — treating it first is essential.",
"treatment_hint": "Pincer palpation and spray and stretch with side-bending away and contralateral rotation. Correct shoulder elevation — bags on the ipsilateral shoulder are the dominant perpetuating factor. Address levator scapulae concurrently.",
"also_consider": ["Levator Scapulae", "SCM", "Temporalis (satellite)", "Semispinalis Capitis (satellite)"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena; shoulder loading is the primary aggravator" },
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring; shoulder loading and head tilt distinguish trapezius from splenius cervicis" },
{ "muscle": "Suboccipital Group", "reason": "Focal posterolateral referral to back of orbit is distinct from the diffuse ghostly suboccipital pattern" }
],
"confirmatory": [
"TrP₁ at anterior border of upper trapezius reproduces orbital pain at high stimulus intensity",
"Primary referral is posterolateral neck to mastoid — orbital pain is a high-intensity spillover",
"Ipsilateral head tilt — ear toward the TrP shoulder",
"Shoulder carrying on the same side reproduces or worsens the orbital pain"
],
"satellite_trps": ["Temporalis", "SCM", "Semispinalis Capitis", "Levator Scapulae"],
"landing_page_topics": [
"TrP₁ through TrP₇ — full referral patterns",
"Shoulder carry and workstation correction",
"Satellite relationship with temporalis and SCM"
],
"related_pages": [
{ "label": "Temporalis TrP →", "page": "Muscle:Temporalis" },
{ "label": "Levator Scapulae TrP →", "page": "Muscle:Levator_Scapulae" }
]
},
"result-suboccipital": {
"type": "result",
"diagnosis": "Suboccipital Group Trigger Points",
"confidence": "moderate",
"wiki_page": "Muscle:Suboccipital",
"chapter_ref": "Travell & Simons Vol.1 — Ch.17 Suboccipital Muscles",
"notes": "Suboccipital TrPs produce characteristically diffuse, poorly localised deep head pain — described as ghostly or penetrating, feeling 'all over inside.' Pain radiates from the occiput toward the eye and forehead. These muscles cannot be individually identified by palpation — involvement is inferred from atlantoaxial rotation restriction. They nearly always develop as satellites of semispinalis capitis or splenius capitis. Treating those key muscles first often resolves suboccipital activity without direct treatment.",
"treatment_hint": "Treat semispinalis capitis and splenius capitis key TrPs first. Suboccipital decompression (occipital hold). Keep suboccipital region warm. CAUTION: vertebral artery in the suboccipital triangle — injection for expert practitioners only.",
"also_consider": ["Semispinalis Capitis (key TrP)", "Splenius Capitis (key TrP)", "Upper Trapezius", "Splenius Cervicis"],
"less_likely": [
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring; diffuse ghostly quality and AA rotation restriction are specific to suboccipital group" },
{ "muscle": "Occipitalis", "reason": "Suboccipital pain is diffuse and poorly localised; occipitalis produces focused through-the-skull orbital pain with pillow intolerance" },
{ "muscle": "Upper Trapezius", "reason": "Ghostly diffuse quality and AA rotation restriction distinguish suboccipital from focal trapezius referral" }
],
"confirmatory": [
"Diffuse poorly localised pain described as penetrating or 'all over inside the skull' radiating toward the eye",
"Deep suboccipital palpation below nuchal line reproduces the diffuse head pain",
"Atlantoaxial rotation restricted with neck in slight flexion",
"Nearly always satellite TrPs — confirm semispinalis capitis and splenius capitis as key TrPs"
],
"satellite_trps": ["Semispinalis Cervicis", "Upper Trapezius (key TrP)", "Splenius Capitis (key TrP)"],
"landing_page_topics": [
"AA and OA examination technique",
"Suboccipital decompression",
"Vertebral artery anatomy and injection caution",
"Satellite relationship with semispinalis and splenius capitis"
],
"related_pages": [
{ "label": "Semispinalis Capitis →", "page": "Muscle:Semispinalis_Capitis" },
{ "label": "Splenius Capitis →", "page": "Muscle:Splenius_Capitis" }
]
},
"result-occipitalis": {
"type": "result",
"diagnosis": "Occipitalis Trigger Point (Occipitofrontalis — Occipital Belly)",
"confidence": "moderate",
"wiki_page": "Muscle:Occipitofrontalis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.14 Occipitofrontalis",
"notes": "The occipitalis belly refers pain diffusely over the back of the head and through the cranium, causing intense deep pain behind the eye — a through-the-skull referral. The defining clinical sign is inability to bear the weight of the back of the head on a pillow at night — the patient must sleep on their side. Moist heat to the occiput relieves myofascial pain, distinguishing it from nerve entrapment which is not relieved by heat. Occipitalis TrPs develop most commonly as satellites of posterior cervical TrPs (semispinalis cervicis, posterior digastric).",
"treatment_hint": "Treat semispinalis cervicis and posterior digastric key TrPs first — occipitalis often resolves without direct treatment. Moist heat. Flat palpation and ischemic compression.",
"also_consider": ["Semispinalis Cervicis (key TrP)", "Posterior Digastric (key TrP)", "Greater Occipital Nerve Entrapment"],
"less_likely": [
{ "muscle": "Suboccipital Group", "reason": "Through-the-skull focused orbital pain and pillow intolerance are specific to occipitalis; suboccipital pain is diffuse and ghostly" },
{ "muscle": "Splenius Cervicis", "reason": "No near-vision blurring; through-the-skull with pillow intolerance is specific to occipitalis" },
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena; through-the-skull quality and pillow intolerance argue for occipitalis" }
],
"confirmatory": [
"Cannot bear weight of back of head on pillow — must sleep on side; defining clinical sign",
"Focal tenderness at occipitalis TrP: small hollow above nuchal line approximately 4 cm lateral to midline",
"Through-the-skull referral to behind the eye — deep aching, not superficial tingling",
"Moist heat to occiput relieves the pain — distinguishes myofascial from nerve entrapment origin"
],
"satellite_trps": ["Frontalis", "Semispinalis Cervicis (key TrP)", "Posterior Digastric (key TrP)"],
"landing_page_topics": [
"Through-the-skull referral pattern",
"Pillow intolerance as diagnostic sign",
"Moist heat test — myofascial vs nerve entrapment",
"Satellite relationship with posterior cervical muscles"
],
"related_pages": [
{ "label": "Occipitofrontalis page →", "page": "Muscle:Occipitofrontalis" },
{ "label": "Semispinalis Cervicis →", "page": "Muscle:Semispinalis_Cervicis" }
]
},
"result-orbicularis": {
"type": "result",
"diagnosis": "Orbicularis Oculi Trigger Point",
"confidence": "moderate",
"wiki_page": "Muscle:Orbicularis_Oculi",
"chapter_ref": "Travell & Simons Vol.1 — Ch.13 Orbicularis Oculi",
"notes": "TrPs in the upper orbital portion of the orbicularis oculi refer pain to the side of the nose, cheek near the nose, and upper lip — a pattern that is unique in this region. The jumpy print symptom (letters appearing to jump or vibrate when reading black text on a white background) is pathognomonic and resolves with TrP inactivation. Palpebral fissure narrowing on the affected side closely resembles Horner ptosis — but pupils remain equal and reactive, and there is no enophthalmos. On testing upward gaze, the patient may tilt the head backward because they cannot raise the upper eyelid sufficiently. These TrPs develop most commonly as satellites of SCM sternal division TrPs — SCM should always be examined and treated regardless of whether it was identified as the primary source.",
"treatment_hint": "Examine and treat SCM sternal division — orbicularis oculi is almost always its satellite. If direct treatment needed: flat palpation along upper orbital rim from medial to lateral canthus; gentle ischemic compression. Eliminate habitual frowning and squinting. Address uncorrected refractive error.",
"also_consider": ["SCM Sternal Division (key TrP)", "Frontalis"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "Jumpy print and nose/lip referral are specific to orbicularis oculi — but SCM is almost certainly the key TrP; examine it regardless" },
{ "muscle": "Splenius Cervicis", "reason": "Near-vision blurring is distinct from jumpy print; nose and lip referral is specific to orbicularis oculi" },
{ "muscle": "Temporalis", "reason": "No jaw aggravation; nose-cheek-lip referral pattern is specific to orbicularis oculi" }
],
"confirmatory": [
"Jumpy print — letters jump or vibrate when reading black text on white; pathognomonic, resolves with TrP inactivation",
"Focal tenderness along the upper orbital rim reproducing nose, cheek, or upper lip referral",
"Palpebral fissure narrowing without miosis — pupils equal and reactive",
"On upward gaze: patient tilts head backward because they cannot raise the upper eyelid sufficiently",
"Examine SCM sternal division regardless — orbicularis oculi is almost invariably its satellite"
],
"satellite_trps": ["SCM Sternal Division (key TrP)", "Frontalis"],
"landing_page_topics": [
"Jumpy print — mechanism and resolution",
"Horner syndrome exclusion protocol",
"Nose and lip referral — unique pattern in the head region",
"Satellite relationship with SCM sternal division",
"Uncorrected refractive error as perpetuating factor"
],
"related_pages": [
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Occipitofrontalis →", "page": "Muscle:Occipitofrontalis" }
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings are inconclusive. Eye and eyebrow pain with negative systematic examination should prompt consideration of a non-myofascial cause, or an upstream key TrP (upper trapezius, levator scapulae) activating one or more satellites. Perform a broader screen.",
"screen_these": [
"SCM sternal head — full pincer palpation; SCM Compression Test; confirm or exclude autonomic phenomena and jumpy print",
"Temporalis anterior zone (ATrP₁) — flat palpation; confirm jaw aggravation and tooth hypersensitivity",
"Masseter superficial — pincer palpation with intraoral digit; zone tooth hypersensitivity; jaw deviation",
"Splenius cervicis — deep palpation through trapezius at C₁–C₃; near-vision blurring; rotation restriction",
"Upper trapezius TrP₁ — anterior border pincer palpation; shoulder loading; head tilt",
"Suboccipital group — suboccipital palpation; AA rotation test",
"Occipitalis — nuchal hollow palpation; pillow intolerance; moist heat test",
"Orbicularis oculi — upper orbital rim flat palpation; jumpy print; palpebral narrowing without miosis"
],
"wiki_page": "Differential:Eye_Eyebrow_Pain"
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "True Horner Syndrome",
"confidence": "rare — critical",
"mimics": "Apparent ptosis with periorbital pain — overlaps closely with SCM sternal and orbicularis oculi TrP presentations",
"distinguishing_feature": "True Horner: ptosis WITH ipsilateral miosis (pupil constriction) — the smaller pupil is more obvious in dim light. Myofascial palpebral narrowing: no miosis — pupils remain equal and reactive. True Horner requires exclusion of Pancoast tumour (apical lung cancer), carotid dissection, and brainstem lesion.",
"action": "Confirm miosis in dim light. If miosis present, urgent neurology referral. MRI brain, neck, and chest required."
},
{
"id": "bd-2",
"condition": "Acute Angle-Closure Glaucoma",
"confidence": "rare — emergency",
"mimics": "Severe frontal and periorbital pain — may be confused with temporalis or SCM referral at initial presentation",
"distinguishing_feature": "Sudden onset. Visual blurring, coloured halos around lights, nausea. Hard red eye with mid-dilated non-reactive pupil. Increased intraocular pressure on tonometry.",
"action": "Emergency ophthalmology referral. This is a red flag condition already covered in the checklist."
},
{
"id": "bd-3",
"condition": "Cluster Headache",
"confidence": "rare",
"mimics": "Severe unilateral periorbital pain with ipsilateral tearing, rhinitis, and ptosis — overlaps directly with SCM sternal division autonomic phenomena",
"distinguishing_feature": "Classic cluster: strictly periorbital, 15–180 minutes, episodic bouts with complete remission. True Horner syndrome with miosis during attacks. SCM sternal TrP autonomic phenomena: no miosis, no episodic bouts, chronic not episodic, tearing and rhinitis are persistent not attack-related.",
"action": "Confirm miosis during the painful episode. Examine for SCM TrPs in all cluster patients — an SCM TrP contributed to a cluster headache case in Ch.5. Refer to neurology for cluster prophylaxis."
},
{
"id": "bd-4",
"condition": "Optic Neuritis",
"confidence": "rare",
"mimics": "Eye pain — may be confused with periorbital or retrobulbar myofascial pain",
"distinguishing_feature": "Eye pain worsened by eye movement (moving the eyeball in any direction provokes pain). Reduced visual acuity. Colour desaturation — colours appear washed out on the affected side. Marcus Gunn pupil (relative afferent pupillary defect) on swinging flashlight test.",
"action": "Urgent ophthalmology or neurology referral. MRI brain. This condition is a red flag covered in the checklist."
},
{
"id": "bd-5",
"condition": "Migraine With Aura",
"confidence": "uncommon",
"mimics": "Periorbital and orbital pain alongside visual aura — the muscle pain component overlaps with SCM sternal and temporalis referral",
"distinguishing_feature": "Aura: visual disturbances (scintillating scotoma, fortification spectra) lasting 20–60 minutes before headache. However, pericranial TrP tenderness is present in migraine patients even between attacks and is a treatable component. The SCM sternal venetian-blinds visual phenomenon and the orbicularis oculi jumpy print are not aura — they are persistent, not resolving in 60 minutes.",
"action": "Screen for pericranial TrPs in all migraine patients. TrP treatment reduces the myofascial trigger component without replacing migraine management."
},
{
"id": "bd-6",
"condition": "Sinusitis",
"confidence": "uncommon",
"mimics": "Periorbital and infraorbital pain — masseter superficial and SCM sternal TrPs commonly produce pain described as sinus pain",
"distinguishing_feature": "True sinusitis: fever, purulent nasal discharge, radiographic mucosal thickening or opacification. Myofascial sinus-like pain: normal radiographs, no fever, no discharge, reproduced by palpating the relevant TrPs.",
"action": "Palpate relevant TrPs before requesting sinus imaging. Request CT sinuses only if clinical features (fever, purulent discharge) make true sinusitis plausible."
},
{
"id": "bd-7",
"condition": "Temporal Arteritis",
"confidence": "uncommon — critical in over-50s",
"mimics": "Temporal and periorbital pain — overlaps with temporalis and upper trapezius TrP patterns; sudden visual loss may occur",
"distinguishing_feature": "Jaw claudication pathognomonic. Age over 50. Tender non-pulsatile temporal or occipital artery. ESR typically >50 mm/hr. Sudden visual loss (anterior ischaemic optic neuropathy) may occur without warning.",
"action": "This is a red flag condition covered in the checklist. Same-day ESR and CRP in any patient over 50 with new orbital or temporal pain."
},
{
"id": "bd-8",
"condition": "Uncorrected Refractive Error or Astigmatism",
"confidence": "common",
"mimics": "Periorbital and eyebrow pain from habitual squinting and frowning — activates and perpetuates orbicularis oculi and frontalis TrPs",
"distinguishing_feature": "Pain associated with sustained near work or reading. Habitual squinting observed clinically. Jumpy print or visual discomfort with text. Refractive error confirmed on optometry testing. TrPs may be present but recur until the underlying refractive error is corrected.",
"action": "Refer for optometry assessment alongside TrP treatment. TrP inactivation will not be sustained if habitual squinting from uncorrected refractive error continues."
}
]
}