DiagnosticTree/EyeEyebrow
{
"tree_id": "eye-eyebrow", "region": "Eye and Eyebrow Pain", "start": "rf-screen",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Acute angle-closure glaucoma",
"question": "Is there sudden severe eye pain with blurred vision, halos around lights, nausea, or a fixed mid-dilated pupil?",
"rationale": "Acute angle-closure glaucoma causes rapid irreversible vision loss — hours matter",
"action": "Emergency ophthalmology referral immediately. Do not proceed."
},
{
"id": "rf-e2",
"label": "Subarachnoid haemorrhage",
"question": "Did this headache — including the orbital component — reach maximum severity within seconds to a minute, described as 'the worst ever'?",
"rationale": "Thunderclap onset with orbital pain must exclude subarachnoid haemorrhage",
"action": "Call emergency services immediately. Do not proceed."
},
{
"id": "rf-e3",
"label": "Cavernous sinus thrombosis",
"question": "Is there proptosis (eye bulging forward), restricted eye movement, periorbital swelling, or fever alongside the eye pain?",
"rationale": "Cavernous sinus thrombosis causes orbital signs and is life-threatening",
"action": "Emergency referral immediately. Do not proceed."
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Temporal arteritis (Giant cell arteritis)",
"question": "Is the patient aged 50+ with scalp tenderness, jaw claudication, or any episode of transient visual loss (amaurosis fugax)?",
"rationale": "Temporal arteritis causes permanent blindness within hours of visual symptoms. Transient visual loss is a pre-blindness warning.",
"action": "Same-day GP referral + ESR and CRP. Do not delay for myofascial assessment."
},
{
"id": "rf-u2",
"label": "Orbital cellulitis",
"question": "Is there fever, periorbital erythema and swelling, pain on eye movement, or proptosis?",
"rationale": "Orbital cellulitis can extend intracranially",
"action": "Urgent ENT or ophthalmology referral."
},
{
"id": "rf-u3",
"label": "Horner syndrome",
"question": "Is there a combination of apparent eyelid drooping AND a noticeably smaller pupil on the same side — i.e. miosis with ptosis?",
"rationale": "True Horner syndrome (miosis + ptosis) indicates sympathetic chain pathology — Pancoast tumour, carotid dissection, or brainstem lesion must be excluded",
"action": "Urgent neurological referral. MRI brain/neck and chest imaging required. Note: SCM and masseter TrPs produce apparent ptosis WITHOUT miosis — confirm pupil size before escalating."
}
]
},
"nodes": {
"rf-screen": {
"type": "rom",
"question": "Is jaw movement — chewing, clenching, or wide opening — the PRIMARY activity that aggravates or reproduces the eye or eyebrow pain?",
"movement": "Jaw opening / chewing / clenching",
"direction": "aggravating",
"clinical_rationale": "Jaw movement as the primary aggravator immediately implicates the masticatory muscles. Temporalis TrP₁ refers along the supraorbital ridge; masseter superficial lower border refers to the temple and over the eyebrow.",
"muscles_implicated": ["Temporalis", "Masseter (Superficial)"],
"muscles_excluded": ["SCM Sternal", "Splenius Cervicis", "Trapezius TrP₁", "Suboccipital Group", "Occipitalis", "Orbicularis Oculi"],
"yes": "symptom-jaw-1",
"no": "rom-2"
},
"symptom-jaw-1": {
"type": "symptom",
"question": "Is there hypersensitivity of any upper teeth to percussion, heat, or cold — or does the pain include the temple and feel like a spoke radiating from near the eye upward across the forehead?",
"symptom_name": "Upper tooth hypersensitivity / supraorbital spoke pattern",
"clinical_rationale": "Temporalis TrP₁ (the most anterior attachment TrP) refers in a spoke from the supraorbital ridge downward to the upper incisor teeth. Tooth hypersensitivity to all stimuli without dental pathology is the hallmark. Masseter superficial lower border TrP refers in an arc from the gonial angle to the temple and over the eyebrow — no tooth hypersensitivity.",
"muscles_implicated": ["Temporalis ATrP₁"],
"muscles_excluded": ["Masseter (Superficial)"],
"yes": "exam-temporalis-1",
"no": "exam-masseter-superficial-1"
},
"exam-temporalis-1": {
"type": "examination",
"question": "With the patient's jaw slightly open (relaxed position, not fully open), does flat palpation just above the zygomatic arch in the anterior temporal region — or pressure along the musculotendinous junction near the coronoid process — reproduce the supraorbital or eyebrow pain?",
"exam_type": "palpation",
"landmark": "ATrP₁: musculotendinous junction of anterior temporalis fibres, just above the zygomatic arch near the coronoid process. CTrP₁: central TrP approximately two finger-breadths above the zygomatic arch in the midfibre portion of the anterior belly. Jaws must be slightly open — not closed and not fully open.",
"positive_finding": "Reproduces supraorbital ridge pain, eyebrow ache, or upper tooth hypersensitivity",
"muscles_implicated": ["Temporalis ATrP₁"],
"yes": "result-temporalis",
"no": "exam-masseter-superficial-1"
},
"exam-masseter-superficial-1": {
"type": "examination",
"question": "Does flat palpation or pincer palpation of the lower border of the masseter — near the gonial angle of the mandible — reproduce pain that arcs across the temple or over the eyebrow?",
"exam_type": "palpation",
"landmark": "Lower border / gonial angle TrP: flat palpation at the angle of the mandible (gonial angle), pressing against the periosteum. This is most likely an enthesopathy TrP from sustained bruxism tension. Pincer palpation of the superficial masseter belly using one digit inside the mouth and one outside.",
"positive_finding": "Reproduces temple or eyebrow pain — the arc from the jaw angle to the temple is the characteristic referral",
"muscles_implicated": ["Masseter (Superficial — lower border)"],
"yes": "result-masseter-superficial",
"no": "result-overlap"
},
"rom-2": {
"type": "rom",
"question": "Is the eye or eyebrow pain aggravated, altered, or consistently reproduced by neck movements — rotation, flexion, extension — or by sustained neck/shoulder postures such as looking down, carrying a bag, or holding the arm elevated?",
"movement": "Cervical rotation / extension / shoulder loading",
"direction": "aggravating",
"clinical_rationale": "Neck and shoulder movement implicates the posterior cervical muscles (SCM sternal, splenius cervicis, trapezius TrP₁). Absence of both jaw and neck aggravation with eye pain points to muscles acting directly on the eye region (orbicularis oculi) or those whose referral reaches the orbit from the occiput at rest (suboccipital group, occipitalis).",
"muscles_implicated": ["SCM Sternal", "Splenius Cervicis", "Trapezius TrP₁"],
"muscles_excluded": ["Suboccipital Group", "Occipitalis", "Orbicularis Oculi"],
"yes": "symptom-neck-1",
"no": "rom-3"
},
"symptom-neck-1": {
"type": "symptom",
"question": "Is there ipsilateral tearing, eye redness, apparent drooping of the eyelid, or runny nose on the same side as the eye pain — AND/OR does the patient report apparent blurring or difficulty focusing the ipsilateral eye, particularly for near vision?",
"symptom_name": "Autonomic features (tearing/rhinitis/ptosis) OR ipsilateral near-vision blurring",
"clinical_rationale": "These two groups of associated symptoms identify different muscles. Autonomic features (tearing, rhinitis, palpebral fissure narrowing) are characteristic of SCM sternal division TrPs. Ipsilateral blurring of near vision without dizziness or conjunctivitis is the specific marker of splenius cervicis upper TrP — it may resolve immediately with TrP inactivation. Trapezius TrP₁ has neither autonomic features nor vision blurring.",
"muscles_implicated": ["SCM Sternal", "Splenius Cervicis"],
"muscles_excluded": ["Trapezius TrP₁"],
"yes": "symptom-neck-2",
"no": "symptom-neck-3"
},
"symptom-neck-2": {
"type": "symptom",
"question": "Is the associated symptom primarily AUTONOMIC — tearing, eye redness, apparent lid drooping, or runny nose on the same side? Or is it primarily a VISUAL symptom — blurring of near vision in the same eye, without tearing or redness?",
"symptom_name": "Autonomic vs visual symptom distinction",
"clinical_rationale": "SCM sternal division: autonomic phenomena are the hallmark (lacrimation, rhinorrhoea, conjunctival redness, palpebral fissure narrowing). Splenius cervicis upper TrP: near-vision blurring ipsilaterally is specific — no autonomic features, no dizziness.",
"muscles_implicated": ["SCM Sternal", "Splenius Cervicis"],
"yes_label": "Autonomic features (tearing / rhinitis / ptosis)",
"no_label": "Near-vision blurring only",
"yes": "exam-scm-sternal-1",
"no": "exam-splenius-1"
},
"symptom-neck-3": {
"type": "symptom",
"question": "Is the pain aggravated by arm elevation, carrying a heavy bag on the shoulder, or shoulder loading — and does the pain include the temple as well as the back of the eye?",
"symptom_name": "Shoulder / arm loading aggravation + temple component",
"clinical_rationale": "Trapezius TrP₁ is the most commonly identified myofascial TrP in the body. It refers from the posterolateral neck up to the mastoid, temple, and back of the orbit. It is aggravated by arm loading (carrying, elevated keyboard), sidebending away from the involved side, and shoulder strap pressure — not primarily by cervical rotation.",
"muscles_implicated": ["Trapezius TrP₁"],
"yes": "exam-trapezius-1",
"no": "exam-splenius-1"
},
"exam-scm-sternal-1": {
"type": "examination",
"question": "Does pincer palpation along the sternal head of the SCM — from mastoid to sternum — reproduce the patient's familiar orbital, cheek, or supraorbital pain? Or does SCM compression during swallowing relieve the patient's sore throat if one is present?",
"exam_type": "palpation",
"landmark": "Sternal head: encircle the full muscle belly between thumb and forefinger; palpate from mastoid process downward to sternal attachment. Compress firmly — snapping a taut band may produce a head jerk. SCM Compression Test: grasp SCM in a pincer grip and ask the patient to swallow — positive if pharyngeal pain resolves with compression.",
"positive_finding": "Reproduces orbital pain, supraorbital ache, or cheek pain. Or: sore throat resolves with SCM compression.",
"muscles_implicated": ["SCM Sternal"],
"yes": "result-scm-sternal",
"no": "exam-splenius-1"
},
"exam-splenius-1": {
"type": "examination",
"question": "Does firm digital pressure applied at the upper musculotendinous junction of the splenius cervicis — lateral to the C₁–C₂ spinous processes, anterior to the free border of the upper trapezius — reproduce pain that feels like it goes through the inside of the head to the back of the eye?",
"exam_type": "palpation",
"landmark": "Upper splenius cervicis: approach from the side — slide the palpating finger anterior to the free border of the upper trapezius at approximately C₇ level, pressing medially beyond the levator scapulae. If the levator is not tender but medially directed pressure is painful, this is likely splenius cervicis. Alternatively, posterior approach: 2 cm lateral to midline at C₇, pressing against the cervical laminae. Increases sensitivity: gently flex the neck — this increases tension specifically on the splenius cervicis fibres.",
"positive_finding": "Reproduces a diffuse intracranial pain that focuses strongly behind the eye — described as 'ache inside the skull' or 'pain shooting through the head to the eye'",
"muscles_implicated": ["Splenius Cervicis"],
"yes": "result-splenius",
"no": "exam-trapezius-1"
},
"exam-trapezius-1": {
"type": "examination",
"question": "Does pincer palpation of the anterior free border of the upper trapezius — grasping the most vertical fibres from the clavicle upward — reproduce pain that travels up the posterolateral neck to the temple or behind the eye?",
"exam_type": "palpation",
"landmark": "Upper trapezius TrP₁: patient supine or seated. Pincer grasp of the entire free margin of the upper trapezius, lifting it off the underlying supraspinatus. Roll the muscle firmly between fingers and thumb to locate the nodule and taut band in the most vertical fibres attaching to the clavicle. Sustained compression of the TrP evokes pain referred to the neck, occiput, and temple.",
"positive_finding": "Reproduces posterolateral neck pain, temporal headache, or orbital ache on the same side",
"muscles_implicated": ["Trapezius TrP₁"],
"yes": "result-trapezius",
"no": "result-overlap"
},
"rom-3": {
"type": "rom",
"question": "Is the eye or orbital pain aggravated by lying with the back of the head on a firm surface — such as a hard pillow or a car headrest — or by sustained pressure on the suboccipital region?",
"movement": "Suboccipital / occipital pressure",
"direction": "aggravating",
"clinical_rationale": "Both the occipitalis and the suboccipital group refer pain deeply into the orbit. The key differentiator at this node is pressure sensitivity: the occipitalis TrP is exquisitely tender to direct pressure on the back of the head — patients cannot bear the weight of the head on the pillow. The suboccipitals produce a more diffuse, poorly bordered deep headache that extends toward the eye, without a single focal pressure point.",
"muscles_implicated": ["Occipitalis", "Suboccipital Group"],
"muscles_excluded": ["Orbicularis Oculi"],
"yes": "symptom-posterior-1",
"no": "exam-orbicularis-1"
},
"symptom-posterior-1": {
"type": "symptom",
"question": "Can the patient identify a specific, focal, exquisitely tender spot at the back of the head — approximately 4 cm lateral to the midline just above the superior nuchal line — that they cannot bear the weight of the head on?",
"symptom_name": "Focal occipital tenderness / inability to rest head on pillow",
"clinical_rationale": "Occipitalis TrPs produce a single, well-localised TrP just above the superior nuchal line that is so tender the patient cannot rest the back of their head on a pillow and must lie on their side. The suboccipital group produces a more diffuse, poorly bordered deep headache without a single focal intolerant spot — described as a 'ghostly' headache 'all over' the head.",
"muscles_implicated": ["Occipitalis"],
"muscles_excluded": ["Suboccipital Group"],
"yes": "exam-occipitalis-1",
"no": "exam-suboccipital-1"
},
"exam-occipitalis-1": {
"type": "examination",
"question": "Does flat palpation in the small hollow just above the superior nuchal line — approximately 4 cm lateral to the midline — reproduce the patient's familiar pain that wraps from the occiput through the cranium to the orbit?",
"exam_type": "palpation",
"landmark": "Occipitalis TrP: patient supine. Flat palpation against the occipital bone in a small hollow just above the superior nuchal line, approximately 4 cm (1.5 inches) lateral to the midline. The TrP is identified by focal spot tenderness. Considerable probing of the area may be necessary.",
"positive_finding": "Reproduces pain diffusely over the back of the head and through the cranium, causing intense pain deep in the orbit or 'behind the eye'",
"muscles_implicated": ["Occipitalis"],
"yes": "result-occipitalis",
"no": "exam-suboccipital-1"
},
"exam-suboccipital-1": {
"type": "examination",
"question": "With the patient supine and relaxed, does firm bilateral digital pressure into the suboccipital musculature — just below the occipital ridge on both sides — reproduce a deep, diffuse, poorly-defined headache that the patient recognises as spreading toward the eye and forehead?",
"exam_type": "palpation",
"landmark": "Suboccipital group: patient supine with head supported. Stand at the head of the table; place fingertips of both hands in the suboccipital recess bilaterally, pressing anteriorly against the posterior arch of the atlas and base of occiput. Gently flex the head on the neck (nodding) while palpating for muscular tension and tenderness. Individual muscles cannot be reliably distinguished — look for the familiar diffuse pain response.",
"positive_finding": "Reproduces a diffuse, poorly bordered deep headache extending unilaterally from the occiput toward the eye and forehead — 'ghostly' quality, 'all over'",
"muscles_implicated": ["Suboccipital Group"],
"yes": "result-suboccipital",
"no": "exam-orbicularis-1"
},
"exam-orbicularis-1": {
"type": "examination",
"question": "Does flat palpation crosswise over the muscle fibres of the upper orbital portion of the orbicularis oculi — running the fingertip across the fibres above the eyelid, just beneath the eyebrow and against the orbital bone — reproduce the patient's eye or eyebrow pain?",
"exam_type": "palpation",
"landmark": "Orbicularis oculi TrP: flat palpation above the eyelid, just beneath the eyebrow, pressing against the bone of the orbit. Run the fingertip crosswise (not along) the circular muscle fibres. The TrP is a spot of focal tenderness in a taut band in the upper arc of the orbital portion.",
"positive_finding": "Reproduces pain at the side of the nose, cheek close to the nose, or upper lip. Patient may also report 'jumpy print' — letters appear to jump when reading high-contrast text.",
"muscles_implicated": ["Orbicularis Oculi"],
"yes": "result-orbicularis",
"no": "result-overlap"
},
"result-temporalis": {
"type": "result",
"diagnosis": "Temporalis — ATrP₁ (Anterior Attachment Trigger Point)",
"confidence": "high",
"wiki_page": "Muscle:Temporalis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.9 Temporalis",
"notes": "ATrP₁ is the most anterior attachment TrP, located at the musculotendinous junction near the coronoid process. It refers in a spoke along the supraorbital ridge and downward to the upper incisor teeth. Tooth hypersensitivity to percussion, heat, and cold without dental pathology is the hallmark — unnecessary dental treatment (extraction, root canal) is a common outcome when the muscle is not examined. Jaw opening is usually reduced only 5–10 mm — modest enough that the patient often complains about their bite rather than pain.",
"treatment_hint": "Jaws must be partly open for examination and treatment. Spray and stretch applied bilaterally even if only one side is symptomatic. Temporal artery must be identified and avoided during injection. Release masseter TrP tension before injecting to reduce ecchymosis risk. Inactivate upper trapezius and SCM as key TrPs first.",
"also_consider": ["Masseter (Superficial)", "Upper Trapezius", "SCM Sternal"],
"less_likely": [
{ "muscle": "Masseter Superficial", "reason": "Tooth hypersensitivity present — masseter lower border TrP refers to temple/eyebrow but does not cause tooth hypersensitivity" },
{ "muscle": "SCM Sternal", "reason": "Jaw movement is primary aggravator, not neck movement; no autonomic features" },
{ "muscle": "Splenius Cervicis", "reason": "No intracranial quality; no near-vision blurring; jaw movement aggravates" },
{ "muscle": "Orbicularis Oculi", "reason": "No jumpy print; jaw movement is primary aggravator" }
],
"confirmatory": [
"Tooth hypersensitivity to ALL stimuli (heat, cold, percussion, pressure) in upper teeth without dental pathology — this is the pathognomonic confirmatory finding",
"TrP palpation with jaws partly open reproduces the supraorbital or tooth pain — palpation with jaws closed may give false negative",
"Zigzag deviation on slow jaw opening/closing when posterior fibres (CTrP₄) are co-involved",
"Two-Knuckle Test: jaw opening reduced 5–10 mm only — patient may report 'teeth don't meet right' rather than pain",
"CAUTION: Temporal artery — palpate for pulsations before injection; one finger must monitor the artery throughout"
],
"satellite_trps": ["Masseter", "SCM", "Trapezius/Upper", "Medial Pterygoid", "Lateral Pterygoid"],
"landing_page_topics": [
"Full spoke pattern — ATrP₁–ATrP₃ and CTrP₄ with distinct referral zones",
"Temporal artery identification — injection safety",
"Tooth hypersensitivity differential — avoiding unnecessary dental treatment",
"Temporal arteritis exclusion — age 50+, ESR, jaw claudication",
"Bilateral treatment protocol — mandible connects both sides"
],
"related_pages": [
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" },
{ "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
]
},
"result-masseter-superficial": {
"type": "result",
"diagnosis": "Masseter — Superficial Layer, Lower Border Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Masseter",
"chapter_ref": "Travell & Simons Vol.1 — Ch.8 Masseter",
"notes": "The lower border / gonial angle TrP of the superficial masseter refers pain in an arc from the jaw angle across the temple and over the eyebrow. This is most likely an enthesopathy TrP from sustained bruxism tension at the gonial angle attachment. Tenderness at the gonial angle identified by outside-only flat palpation (not pincer) confirms enthesopathy rather than a mid-belly primary TrP. No tooth hypersensitivity — this distinguishes from temporalis ATrP₁.",
"treatment_hint": "Pincer palpation (one digit inside mouth, one outside). Spray and stretch into contralateral lateral excursion. Address bruxism and parafunctional habits. Check and treat SCM and upper trapezius as key TrPs first — masseter TrPs are commonly satellite to these.",
"also_consider": ["Temporalis ATrP₁", "Upper Trapezius TrP₁", "SCM Sternal"],
"less_likely": [
{ "muscle": "Temporalis ATrP₁", "reason": "No tooth hypersensitivity; gonial angle pattern rather than supraorbital spoke" },
{ "muscle": "SCM Sternal", "reason": "Jaw movement is primary aggravator, not neck movement; no autonomic features" },
{ "muscle": "Splenius Cervicis", "reason": "No intracranial quality; jaw movement aggravates" }
],
"confirmatory": [
"Tenderness at gonial angle on flat palpation (outside finger only) = enthesopathy from bruxism",
"No tooth hypersensitivity — distinguishes from temporalis",
"Pain arc from gonial angle to temple/eyebrow reproduced on palpation",
"Mandibular deviation toward affected side on slow opening",
"Infraorbital puffiness and palpebral fissure narrowing on affected side — venous entrapment of maxillary vein by masseter TrPs"
],
"satellite_trps": ["Temporalis", "Medial Pterygoid", "Orbicularis Oculi"],
"landing_page_topics": [
"Enthesopathy vs primary TrP — palpation technique distinction",
"Venous entrapment — infraorbital puffiness and palpebral narrowing",
"Bruxism and parafunctional habit elimination",
"Bilateral treatment approach"
],
"related_pages": [
{ "label": "Temporalis TrP →", "page": "Muscle:Temporalis" },
{ "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
]
},
"result-scm-sternal": {
"type": "result",
"diagnosis": "SCM — Sternal Division Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
"notes": "The sternal division refers to the cheek, temple, supraorbital ridge, and vertex. The orbital referral produces intense deep pain behind the eye. The autonomic phenomena — profuse ipsilateral tearing, conjunctival redness, rhinitis, apparent lid drooping — are often more alarming than the pain and lead to ophthalmological investigation or a migraine diagnosis. A dry tingling cough TrP near the sternal attachment and sore throat on swallowing (relieved by SCM compression) are pathognomonic of central sternal division involvement.",
"treatment_hint": "Pincer palpation of the sternal head from mastoid to sternum. Spray and stretch superior to inferior. Correct forward head posture — essential for lasting relief. Treating SCM first often resolves satellite TrPs (temporalis, orbicularis oculi, frontalis) spontaneously.",
"also_consider": ["Splenius Cervicis", "Upper Trapezius TrP₁", "Temporalis ATrP₁"],
"less_likely": [
{ "muscle": "Splenius Cervicis", "reason": "Autonomic features present — sternal SCM; splenius cervicis produces vision blurring, not tearing or rhinitis" },
{ "muscle": "Occipitalis", "reason": "No pillow intolerance; autonomic features absent in occipitalis" },
{ "muscle": "Temporalis", "reason": "No jaw movement aggravation; no tooth hypersensitivity" }
],
"confirmatory": [
"SCM Compression Test positive — pharyngeal pain on swallowing resolves when sternal head is compressed",
"Apparent ptosis without miosis — pupils equal and reactive; excludes true Horner syndrome",
"Autonomic phenomena ipsilateral to TrP: tearing, rhinitis, conjunctival redness",
"Visual symptom: venetian blinds / window frame phenomenon — contrast sensitivity disturbance, NOT blurred or double vision",
"Dry tingling cough triggered by palpation near sternal attachment"
],
"satellite_trps": ["Orbicularis Oculi", "Temporalis", "Frontalis", "Platysma", "Scalene muscles"],
"landing_page_topics": [
"Full sternal vs clavicular division symptom profiles",
"Horner syndrome exclusion protocol",
"SCM Compression Test technique",
"Autonomic phenomena — differential from true neurological signs",
"Forward head posture correction"
],
"related_pages": [
{ "label": "Orbicularis Oculi TrP →", "page": "Muscle:Orbicularis_Oculi" },
{ "label": "Temporalis TrP →", "page": "Muscle:Temporalis" }
]
},
"result-splenius": {
"type": "result",
"diagnosis": "Splenius Cervicis — Upper Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Splenius_Cervicis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.15 Splenius Cervicis",
"notes": "The upper splenius cervicis TrP refers a diffuse pain through the inside of the head that focuses strongly behind the eye on the same side — an 'ache inside the skull.' This intracranial, straight-through-the-head quality with posterior-ocular focus is the defining feature and distinguishes it from the diffuse, poorly-bordered suboccipital referral pattern. Ipsilateral blurring of near vision may occur and can resolve immediately with TrP inactivation — a clinically important marker when present. The muscle lies almost entirely beneath the trapezius and is not readily palpable; involvement often only becomes apparent after levator scapulae TrPs have been inactivated.",
"treatment_hint": "Spray and stretch with head rotated 20–30° away from the involved side and gently flexed toward the opposite side. Spray must cover the angle of the shoulder and the lateral aspect of the head as far forward as the eye. Treat levator scapulae TrPs concurrently. Caution: a few patients have fainted during injection due to strong autonomic stimulus — have patient supine and monitor throughout.",
"also_consider": ["SCM Sternal", "Suboccipital Group", "Semispinalis Capitis"],
"less_likely": [
{ "muscle": "SCM Sternal", "reason": "No autonomic features (tearing, rhinitis); near-vision blurring rather than lacrimation" },
{ "muscle": "Suboccipital Group", "reason": "Splenius cervicis has a straight-through-the-head quality; suboccipital pain is diffuse and poorly-bordered without this quality" },
{ "muscle": "Temporalis", "reason": "No jaw movement aggravation; neck movement/posture is the primary aggravator" }
],
"confirmatory": [
"Pain quality: 'straight through the head to the back of the eye' — intracranial quality distinguishes from suboccipital diffuse pattern",
"Ipsilateral near-vision blurring without dizziness or conjunctivitis — resolves with TrP inactivation",
"Active rotation to the SAME side is restricted and painful (mid-cervical level) — unlike SCM where contralateral rotation is restricted",
"Neck flexion increases sensitivity of the palpation tenderness — stretches splenius cervicis specifically",
"Trifocal eyeglasses use: a strong perpetuating factor — advise change in eyewear"
],
"satellite_trps": ["Levator Scapulae", "Splenius Capitis", "Semispinalis Capitis", "SCM"],
"landing_page_topics": [
"Vision blurring — mechanism and resolution with TrP treatment",
"Palpation approach: lateral vs posterior technique",
"Levator scapulae differentiation — splenius involvement often revealed after levator treated",
"Injection syncope precaution"
],
"related_pages": [
{ "label": "Levator Scapulae TrP →", "page": "Muscle:Levator_Scapulae" },
{ "label": "Splenius Capitis TrP →", "page": "Muscle:Splenius_Capitis" }
]
},
"result-trapezius": {
"type": "result",
"diagnosis": "Upper Trapezius — TrP₁",
"confidence": "high",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "TrP₁ in the upper trapezius is the most frequently identified myofascial TrP in the entire body. It refers unilaterally upward along the posterolateral neck to the mastoid, temple, and — when intense — to the back of the orbit. The orbital referral from TrP₁ is the component relevant to this region. Pain is constant and severe; it is aggravated by arm loading (carrying a bag, elevated keyboard), by sidebending the neck away from the involved side, and by shoulder strap pressure. The patient often cradles the chin in one hand and keeps moving the head as if trying to stretch the muscle.",
"treatment_hint": "Pincer grasp of the anterior free border, lifting the muscle off the underlying supraspinatus. Spray and stretch with head tilted toward opposite side; always spray bilaterally. Postisometric relaxation is an effective adjunct. Always check and address lower trapezius TrP₃ — it is commonly the 'joker' key TrP driving TrP₁ as a satellite.",
"also_consider": ["SCM Sternal", "Splenius Cervicis", "Lower Trapezius TrP₃"],
"less_likely": [
{ "muscle": "SCM Sternal", "reason": "No autonomic features; shoulder loading is the primary aggravator rather than neck rotation" },
{ "muscle": "Splenius Cervicis", "reason": "No intracranial quality; no near-vision blurring; shoulder loading aggravates" },
{ "muscle": "Temporalis", "reason": "No jaw movement aggravation" },
{ "muscle": "Suboccipital Group", "reason": "No pillow intolerance; shoulder loading is the primary aggravator" }
],
"confirmatory": [
"Pain reproduced by pincer compression of the anterior border of the upper trapezius in the most vertical fibres",
"Intolerance to shoulder strap, heavy coat, or bra strap on the affected side",
"Lateral neck flexion AWAY from the involved side is the most restricted movement (not rotation)",
"No autonomic features — distinguishes from SCM sternal division",
"No near-vision blurring — distinguishes from splenius cervicis",
"Check lower trapezius TrP₃ — often the key TrP driving persistent upper trap satellite activity"
],
"satellite_trps": ["Temporalis", "Masseter", "Splenius Capitis", "Semispinalis Capitis", "Levator Scapulae"],
"landing_page_topics": [
"TrP₁ vs TrP₂ — location and clinical distinction",
"Lower trapezius TrP₃ as the joker key TrP",
"Bilateral treatment protocol",
"Postural correction — arm support, keyboard height, shoulder strap redistribution"
],
"related_pages": [
{ "label": "Lower Trapezius TrP₃ →", "page": "Muscle:Trapezius" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-occipitalis": {
"type": "result",
"diagnosis": "Occipitalis Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Occipitofrontalis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.14 Cutaneous II: Occipitofrontalis",
"notes": "Active TrPs in the occipitalis belly refer pain diffusely over the back of the head and through the cranium, causing intense pain deep in the orbit — pain referred 'behind the eye' and 'in the eyeball.' The patient cannot bear the weight of the back of the head on the pillow and must lie on the side. Occipitalis tenderness was found in 42% of patients with ipsilateral face and head pain in the myofascial pain-dysfunction syndrome. The TrP lies in a small hollow just above the superior nuchal line, approximately 4 cm lateral to the midline. Importantly: deep aching TrP referral (patient prefers moist heat) must be distinguished from the more superficial hot prickling of greater occipital nerve entrapment by posterior cervical TrPs (patient prefers ice pack and cannot tolerate heat).",
"treatment_hint": "Spray and stretch is unsatisfactory — muscle is very difficult to stretch. TrP pressure release and deep massage are the treatments of choice. Injection: 3.7 cm (1.5 inch) needle; considerable probing may be needed to locate the TrP in the small hollow. Inactivate key TrPs in posterior cervical muscles (posterior digastric, semispinalis cervicis) that refer to the occiput.",
"also_consider": ["Semispinalis Capitis", "Posterior Digastric", "Semispinalis Cervicis", "Suboccipital Group"],
"less_likely": [
{ "muscle": "Suboccipital Group", "reason": "Focal TrP tenderness present — suboccipital pain is diffuse and poorly bordered without a single focal intolerant spot" },
{ "muscle": "SCM Sternal", "reason": "No autonomic features; pillow intolerance is the distinguishing feature" },
{ "muscle": "Splenius Cervicis", "reason": "No straight-through-the-head intracranial quality; focal occipital tenderness present" }
],
"confirmatory": [
"Patient cannot bear weight of back of head on firm pillow at night — must lie on side",
"Deep aching quality — patient prefers moist heat (distinguishes from nerve entrapment which prefers ice pack)",
"Focal TrP in small hollow just above superior nuchal line, 4 cm lateral to midline",
"Occipitalis TrPs likely activated by decreased visual acuity, glaucoma, or as satellites of posterior cervical TrPs — check and inactivate these key muscles"
],
"satellite_trps": ["Semispinalis Cervicis", "Posterior Digastric", "Suboccipital Group"],
"landing_page_topics": [
"Deep aching TrP referral vs greater occipital nerve entrapment — heat/cold preference test",
"Pillow intolerance as clinical marker",
"Injection technique — probing the small hollow",
"Visual acuity and glaucoma as perpetuating factors"
],
"related_pages": [
{ "label": "Frontalis TrP →", "page": "Muscle:Occipitofrontalis" },
{ "label": "Suboccipital TrP →", "page": "Muscle:Suboccipital" }
]
},
"result-suboccipital": {
"type": "result",
"diagnosis": "Suboccipital Group Trigger Points",
"confidence": "high",
"wiki_page": "Muscle:Suboccipital",
"chapter_ref": "Travell & Simons Vol.1 — Ch.17 Suboccipital Muscles",
"notes": "The suboccipital TrP headache is characteristically diffuse and poorly localised — a 'ghostly' deep head pain that patients describe as hurting 'all over.' On careful questioning, most describe it extending unilaterally forward from the occiput toward the eye and forehead, without clearly definable limits. This pain does NOT have the straight-through-the-head quality of splenius cervicis. TrPs in these muscles are nearly always satellites of key TrPs in semispinalis capitis, splenius capitis, or trapezius — inactivating the key muscles often resolves the suboccipitals without direct treatment. Injection carries serious risk of vertebral artery injury and is generally not recommended.",
"treatment_hint": "Priority: treat key TrPs in trapezius, semispinalis capitis, and splenius capitis first. Manual release: patient supine, operator flexes head gently; patient looks up/inhales (operator resists extension), then slowly exhales/looks down and allows flexion — take up slack with each breath cycle. Suboccipital decompression technique. CAUTION: do not inject — vertebral artery traverses the suboccipital triangle at C₁ level.",
"also_consider": ["Semispinalis Capitis", "Splenius Capitis", "Occipitalis"],
"less_likely": [
{ "muscle": "Occipitalis", "reason": "No focal exquisitely tender spot at nuchal line; suboccipital pain is diffuse without single pressure-intolerant point" },
{ "muscle": "Splenius Cervicis", "reason": "Suboccipital pain lacks the straight-through-the-head quality of splenius cervicis; no near-vision blurring" },
{ "muscle": "SCM Sternal", "reason": "No autonomic features; no neck movement as primary aggravator in this branch" }
],
"confirmatory": [
"Pain is diffuse, 'ghostly,' poorly-bordered — contrasts with the focal, well-defined TrP of the occipitalis",
"Patient can identify the approximate region (base of skull) but not a single tender spot they cannot touch",
"Atlantoaxial rotation test: head in full flexion — soft end-feel of restricted rotation toward opposite side = muscular (suboccipital); hard end-feel = articular",
"Suboccipital decompression manoeuvre reduces headache temporarily — useful for confirmation",
"INJECTION WARNING: vertebral artery traverses the suboccipital triangle — injection not recommended; noninvasive treatment first"
],
"satellite_trps": ["Semispinalis Capitis", "Splenius Capitis", "Trapezius (Upper)", "SCM"],
"landing_page_topics": [
"Individual muscle differentiation by movement restriction (rectus vs obliquus)",
"Atlantoaxial rotation test — soft vs hard end-feel",
"Suboccipital decompression technique",
"Injection risk — vertebral artery anatomy",
"Articular co-dysfunction at OA, AA, C₂ on C₃"
],
"related_pages": [
{ "label": "Semispinalis Capitis TrP →", "page": "Muscle:Semispinalis_Capitis" },
{ "label": "Occipitalis TrP →", "page": "Muscle:Occipitofrontalis" }
]
},
"result-orbicularis": {
"type": "result",
"diagnosis": "Orbicularis Oculi Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Orbicularis_Oculi",
"chapter_ref": "Travell & Simons Vol.1 — Ch.13 Cutaneous I: Facial Muscles",
"notes": "The orbicularis oculi is one of the very few muscles that refers pain to the nose. Its TrPs also refer to the cheek close to the nose and over the upper lip, homolaterally. Active TrPs may produce unilateral palpebral fissure narrowing resembling Horner's syndrome — exclude by confirming normal pupillary reactivity (no miosis). The 'jumpy print' symptom (letters appear to jump when reading high-contrast text) is pathognomonic of orbicularis oculi TrP involvement and resolves with TrP inactivation. TrPs are activated by habitual squinting, photophobia, astigmatism, or as satellites of SCM sternal division TrPs — which refer to the orbit and activate the overlying orbicularis as a satellite.",
"treatment_hint": "Spray and stretch is unsatisfactory — cannot adequately stretch a circular muscle and must keep spray away from the eye. TrP pressure release is the treatment of choice: roll and progressively squeeze the TrP between the fingers as tension releases. Injection: 16 mm (5/8 inch), 25–26 gauge needle, 0.5% procaine; warn patient that ecchymosis may produce a 'black eye.' Inactivate SCM sternal division TrPs first — orbicularis TrPs are often satellites.",
"also_consider": ["SCM Sternal", "Zygomaticus Major", "Masseter (Superficial)"],
"less_likely": [
{ "muscle": "SCM Sternal", "reason": "No autonomic features (tearing, rhinitis); local eye/periorbital pain without neck movement aggravation" },
{ "muscle": "Temporalis", "reason": "No jaw movement aggravation; no tooth hypersensitivity" },
{ "muscle": "Suboccipital Group", "reason": "No posterior head component; no pillow intolerance; pain is periorbital and nasal, not diffuse and intracranial" }
],
"confirmatory": [
"'Jumpy print' symptom — letters jump when reading high-contrast text; pathognomonic of orbicularis oculi TrP; resolves with TrP inactivation",
"Unilateral palpebral fissure narrowing — exclude Horner syndrome: pupils equal and reactive, no miosis, no enophthalmos",
"On testing upward gaze, patient tilts head backward because they cannot raise the upper eyelid sufficiently to look up",
"TrP located in upper arc of orbital portion — above eyelid, beneath eyebrow, against orbital bone",
"SCM sternal division TrPs active on same side — confirms satellite relationship; treat SCM first"
],
"satellite_trps": ["SCM Sternal (as key TrP)", "Zygomaticus Major", "Frontalis"],
"landing_page_topics": [
"Jumpy print symptom — diagnosis and resolution",
"Palpebral fissure narrowing — Horner exclusion protocol",
"Satellite relationship with SCM sternal division",
"Injection technique — black eye warning"
],
"related_pages": [
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Zygomaticus Major TrP →", "page": "Muscle:Zygomaticus_Major" }
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings are inconclusive. Multi-muscle involvement or atypical presentation is likely. Perform a full palpation screen of all muscles in this region.",
"screen_these": [
"Temporalis — jaws partly open; anterior musculotendinous junction palpation",
"Masseter superficial — gonial angle flat palpation and pincer palpation",
"SCM sternal head — pincer palpation full length; SCM Compression Test",
"Splenius cervicis — lateral approach anterior to trapezius free border; neck flexion sensitivity test",
"Upper trapezius TrP₁ — pincer grasp of anterior free border",
"Occipitalis — flat palpation 4 cm lateral to midline just above nuchal line",
"Suboccipital group — bilateral suboccipital recess pressure, patient supine",
"Orbicularis oculi — flat crosswise palpation above eyelid against orbital bone"
],
"wiki_page": "Differential:EyeEyebrow"
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "Acute angle-closure glaucoma",
"confidence": "rare — but emergency",
"mimics": "Severe unilateral eye and orbital pain",
"distinguishing_feature": "Fixed mid-dilated pupil, decreased visual acuity, nausea, halos around lights. Onset often in dim light or after emotional stress.",
"action": "Emergency ophthalmology referral. Examine pupils in all severe unilateral eye pain presentations."
},
{
"id": "bd-2",
"condition": "Temporal arteritis (Giant cell arteritis)",
"confidence": "uncommon — but critical in over-50s",
"mimics": "Temporal and orbital pain from upper trapezius TrP₁ or temporalis TrPs",
"distinguishing_feature": "Age >50; non-pulsatile tender temporal artery; jaw claudication; ESR typically >50 mm/hr, often >100. Transient visual loss is a pre-blindness emergency.",
"action": "Same-day GP referral + ESR and CRP for any patient over 50 with new eye or temporal pain."
},
{
"id": "bd-3",
"condition": "Migraine with aura",
"confidence": "common",
"mimics": "Unilateral orbital and supraorbital pain from SCM sternal or temporalis TrPs — especially with autonomic accompaniments",
"distinguishing_feature": "Prodrome, photophobia, phonophobia, nausea in combination. Myofascial headache is postural and reproduced by palpation. Note: SCM TrPs can trigger genuine migraines in susceptible individuals.",
"action": "Examine SCM in all headache patients. Migraine and myofascial pain frequently coexist."
},
{
"id": "bd-4",
"condition": "Cluster headache",
"confidence": "uncommon",
"mimics": "Severe unilateral orbital/periorbital pain with ipsilateral autonomic features — closely resembles SCM sternal TrP autonomic phenomena",
"distinguishing_feature": "Cluster headache: strictly unilateral, periorbital, 15 min–3 hours duration, occurs in clusters of weeks/months with complete remission periods. Ipsilateral Horner syndrome, conjunctival injection, lacrimation, rhinorrhoea, facial sweating. Extreme restlessness during attack. Nocturnal attacks common.",
"action": "Refer to neurology. Examine SCM for TrPs — both may coexist."
},
{
"id": "bd-5",
"condition": "Uveitis / iritis",
"confidence": "uncommon",
"mimics": "Deep aching eye pain referral from SCM sternal or occipitalis",
"distinguishing_feature": "Photophobia, ciliary flush (ring of redness around the iris), decreased visual acuity, flare and cells in anterior chamber on slit lamp.",
"action": "Ophthalmology referral. Slit lamp examination required."
},
{
"id": "bd-6",
"condition": "Trigeminal neuralgia (V1 — ophthalmic branch)",
"confidence": "rare",
"mimics": "Supraorbital pain from temporalis ATrP₁ or SCM sternal",
"distinguishing_feature": "Lancinating, electric shock quality — seconds to minutes. Trigger zones on forehead/scalp. Ceases completely between attacks. No autonomic features.",
"action": "Refer to neurology. MRI to exclude vascular compression. Carbamazepine first-line."
},
{
"id": "bd-7",
"condition": "Sinusitis (frontal / ethmoid)",
"confidence": "common misdiagnosis",
"mimics": "Supraorbital and periorbital pain from SCM sternal and temporalis TrPs",
"distinguishing_feature": "True sinusitis has fever, purulent nasal discharge, and radiographic sinus opacification. Myofascial orbital pain occurs without these features. Antibiotics for recurring orbital/sinus pain without these findings should prompt TrP examination.",
"action": "Examine SCM sternal and temporalis before prescribing antibiotics for recurrent periorbital/sinus pain."
},
{
"id": "bd-8",
"condition": "Cervicogenic headache with orbital referral",
"confidence": "common",
"mimics": "Orbital and periorbital pain referred from upper cervical joints (C0–C2) — overlaps with suboccipital and splenius cervicis TrP patterns",
"distinguishing_feature": "Unilateral, non-throbbing, with ipsilateral neck stiffness and restricted cervical ROM. Diagnostic cervical nerve block produces temporary relief. Myofascial and cervicogenic components frequently coexist.",
"action": "Examine cervical ROM and upper cervical joint tenderness alongside TrP palpation."
},
{
"id": "bd-9",
"condition": "Dental pathology referred to orbit",
"confidence": "uncommon",
"mimics": "Upper tooth and supraorbital pain from temporalis ATrP₁",
"distinguishing_feature": "A non-restorable carious upper premolar or molar can produce referred pain over the temporalis and to the orbit — confirm dental pathology radiographically before attributing to TrPs.",
"action": "Periapical radiograph of upper teeth on the affected side before TrP injection in the temporalis."
}
]
}