DiagnosticTree/Temporal
{
"tree_id": "temporal-headache", "region": "Temporal Headache", "start": "agg-1",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Thunderclap headache",
"question": "Did the headache reach maximum intensity within seconds to a minute — described as the worst headache of the patient's life, or like a blow to the head?",
"rationale": "Subarachnoid haemorrhage presents as thunderclap headache. Any instantaneous-onset severe headache is an emergency until proven otherwise.",
"action": "Call emergency services immediately. Do not proceed with musculoskeletal assessment."
},
{
"id": "rf-e2",
"label": "Signs of raised intracranial pressure",
"question": "Is the headache worse on waking, progressively worsening over days or weeks, or associated with vomiting, papilloedema, or altered consciousness?",
"rationale": "Progressive headache with morning predominance or vomiting may indicate raised ICP from intracranial mass, hydrocephalus, or venous sinus thrombosis.",
"action": "Emergency medical referral. CT head urgently required."
},
{
"id": "rf-e3",
"label": "Meningism",
"question": "Is there neck stiffness with fever, photophobia, or a non-blanching rash?",
"rationale": "Meningitis or encephalitis must be excluded immediately.",
"action": "Call emergency services immediately."
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Temporal arteritis",
"question": "Is the patient aged 50+ with jaw claudication (pain building during chewing then easing at rest), scalp tenderness, or a tender non-pulsatile temporal artery?",
"rationale": "Temporal arteritis can cause irreversible blindness if untreated. Jaw claudication is pathognomonic. The temporal artery runs through the temporalis muscle — palpate it specifically in any patient over 50 with temporal pain. Same-day ESR required.",
"action": "Same-day GP referral + ESR and CRP. Do not delay for musculoskeletal assessment."
},
{
"id": "rf-u2",
"label": "Cervical instability",
"question": "Is there a history of significant trauma to the head or neck combined with arm symptoms, gait disturbance, or headache worsened by neck loading?",
"rationale": "Odontoid fracture or cervical instability can produce temporal and occipital head pain. Manual therapy is contraindicated until cleared.",
"action": "Urgent spinal assessment — no manual therapy or cervical stretch until cleared."
},
{
"id": "rf-u3",
"label": "Acute angle-closure glaucoma",
"question": "Is there temporal or periorbital pain with sudden visual blurring, halos around lights, nausea, or a hard red eye?",
"rationale": "Acute angle-closure glaucoma is a sight-threatening emergency presenting as periorbital and temporal pain with visual symptoms.",
"action": "Emergency ophthalmology referral same day."
}
]
},
"nodes": {
"agg-1": {
"type": "choice",
"question": "What is the PRIMARY activity or circumstance that aggravates or reproduces the temporal headache?",
"clinical_rationale": "This first split separates the six contributing muscles into three mechanism groups. Jaw activity (chewing, clenching, bruxism) implicates the temporalis as the primary source. Neck and shoulder loading with autonomic phenomena (tearing, rhinitis) implicates the SCM sternal division. Neck and shoulder loading without autonomic phenomena covers the remaining four muscles — upper trapezius, semispinalis capitis, splenius cervicis, and suboccipital — which are separated in the next choice node. This three-way split avoids the false dichotomy of a binary yes/no for jaw vs neck involvement.",
"options": [
{
"label": "Jaw activity — chewing, clenching, biting, or bruxism",
"sublabel": "Pain is worsened or triggered by jaw use; may also have tooth sensitivity or TMJ symptoms",
"next": "jaw-screen-1"
},
{
"label": "Neck or shoulder loading — AND ipsilateral tearing, rhinitis, or apparent eyelid drooping",
"sublabel": "Neck posture or shoulder carry aggravates the temporal pain; autonomic phenomena present on the same side",
"next": "exam-scm-sternal-1"
},
{
"label": "Neck or shoulder loading — WITHOUT autonomic phenomena",
"sublabel": "Neck posture, rotation, shoulder elevation, or carrying load aggravates; no tearing or rhinitis",
"next": "neck-split-1"
}
]
},
"jaw-screen-1": {
"type": "symptom",
"question": "Is there hypersensitivity of the upper teeth to percussion, heat, cold, or biting pressure — without a recent dental cause?",
"symptom_name": "Upper tooth hypersensitivity — no dental cause",
"muscles_implicated": ["Temporalis (ATrP₁, ATrP₂, ATrP₃)"],
"clinical_rationale": "Tooth hypersensitivity from temporalis TrPs is a cardinal distinguishing feature and a common source of unnecessary dental treatment. The referred tenderness extends to the upper teeth in the reference zone of each TrP spoke. If the patient reports that a dentist could find no cause for the tooth pain or sensitivity, temporalis TrP referral is strongly implicated. Absence of tooth sensitivity does not exclude temporalis — CTrP₄ (posterior temporal belly) does not refer to teeth.",
"yes": "exam-temporalis-1",
"no": "exam-temporalis-1"
},
"exam-temporalis-1": {
"type": "examination",
"question": "Does systematic palpation of the temporal fossa — in three anterior-to-posterior zones across the fan of the temporalis muscle — reproduce the temporal headache or provoke tooth sensitivity?",
"exam_type": "palpation",
"landmark": "Palpate the temporalis in systematic vertical strips across the fan. ATrP₁ zone: anterior fibres, near the musculotendinous junction above the zygomatic arch — reproduction of supraorbital or incisor tooth pain. ATrP₂ zone: intermediate fibres, mid-temple — reproduction of temple or premolar pain. ATrP₃ zone: posterior intermediate fibres — reproduction of molar or maxillary pain. CTrP₄: above and slightly behind the ear, in the posterior belly midfibre region — posterior temporal pain without tooth referral; activated by retrusive bruxism. CAUTION: the temporal artery runs through the muscle — palpate for pulsation and avoid during injection.",
"positive_finding": "Focal taut band tenderness reproducing temporal headache and/or tooth hypersensitivity in the reference zone of that TrP spoke",
"muscles_implicated": ["Temporalis"],
"yes": "result-temporalis",
"no": "neck-split-1"
},
"exam-scm-sternal-1": {
"type": "examination",
"question": "Does pincer palpation of the SCM sternal head — grasping the full muscle belly from mastoid to sternum — reproduce the temporal or cheek pain? Does the SCM Compression Test (firmly gripping the belly during swallowing) resolve a concurrent sore throat?",
"exam_type": "palpation",
"landmark": "Patient supine, head rotated slightly toward the TrP side to relax the muscle. Grasp the full sternal belly in a pincer grip from the mastoid process down to the sternum, rolling it between thumb and forefinger to isolate taut bands. SCM Compression Test: firmly grip the belly and ask the patient to swallow — resolution of pharyngeal pain with compression is pathognomonic of a sternal central TrP. Note palpebral fissure width: narrowing on the TrP side (apparent ptosis without miosis) confirms sternal division involvement.",
"positive_finding": "Reproduces temporal, cheek, orbit, or vertex pain. SCM Compression Test may relieve concurrent sore throat on swallowing.",
"muscles_implicated": ["SCM (Sternal Division)"],
"yes": "result-scm-sternal",
"no": "neck-split-1"
},
"neck-split-1": {
"type": "choice",
"question": "Within the neck-aggravated group — which feature best characterises the temporal headache and its associated symptoms?",
"clinical_rationale": "Upper trapezius TrP₁ is the most common TrP in the body and the most common neck-aggravated source of temporal headache — it is distinguished by shoulder and neck loading, ipsilateral head tilt, and a TrP in the anterior border of the upper trapezius reproducing the temporal pain. Semispinalis capitis is distinguished by the encircling band quality that reaches the temple and sweeps forward over the eye, worsened by neck flexion. Splenius cervicis and the suboccipital group are distinguished by diffuse intracranial pain referred to the back of the eye, with splenius cervicis adding ipsilateral near-vision blurring — a highly specific feature.",
"options": [
{
"label": "Shoulder carrying, neck elevation, or ipsilateral head tilt aggravates — temple and back of orbit pain",
"sublabel": "Shoulder load on the same side worsens the headache; patient may hold head tilted toward the pain side; neck and posterior clavicle tender",
"next": "exam-trapezius-1"
},
{
"label": "Band-like headache encircling from the occiput through the temple and forward over the eye — worsened by neck flexion",
"sublabel": "Looking down, reading, or computing intensifies the temporal component; may begin as suboccipital pain that spreads forward",
"next": "exam-semispinalis-1"
},
{
"label": "Diffuse intracranial pain referred to the back of the eye — AND/OR blurring of near vision on the same side",
"sublabel": "Pain feels deep inside the head; near vision may blur transiently; neck rotation may be restricted or provoke the headache",
"next": "splenius-suboccipital-split-1"
}
]
},
"exam-trapezius-1": {
"type": "examination",
"question": "Does pincer palpation of the upper trapezius TrP₁ — grasping the anterior border of the upper trapezius between thumb and forefinger at its most vertical midportion — reproduce the temporal headache or orbital pain?",
"exam_type": "palpation",
"landmark": "TrP₁ is located in the midportion of the anterior border of the upper trapezius, in the most vertical fibres attaching toward the clavicle. This is the most frequently identified myofascial TrP location in the entire body. Grasp the anterior border with a firm pincer grip — the TrP will often produce a local twitch response. When active, it refers pain upward along the posterolateral neck to the mastoid, then over the temple and toward the back of the orbit. Also palpate TrP₂ (midfibre at the scapular spine level) and TrP₃ (more lateral, toward the acromion) which refer more toward the neck and occiput.",
"positive_finding": "Reproduction of ipsilateral temporal headache and/or orbital pain with pincer palpation of the anterior border TrP₁",
"muscles_implicated": ["Upper Trapezius (TrP₁)"],
"yes": "result-trapezius",
"no": "exam-semispinalis-1"
},
"exam-semispinalis-1": {
"type": "examination",
"question": "Does cervical flexion (chin toward chest) reproduce or intensify the temporal or band-like headache? And does flat palpation of the semispinalis capitis — from the nuchal line down through the midbelly at C₁–C₄ — reproduce the pattern?",
"exam_type": "palpation",
"landmark": "Cervical flexion screen first: ask the patient to lower the chin slowly toward the sternum — note reproduction of temporal or encircling pain and range restriction. Then palpate: Location 1 (enthesopathy zone) at 1–2 cm lateral to midline at the superior nuchal line — usually exquisitely tender. Location 2 (causal upper-third TrP) at or just above C₁ level, 1–3 cm lateral to midline — DO NOT inject here (vertebral artery proximity). Location 3 (middle-third TrP) at C₃–C₄ level, 2–3 cm lateral to midline.",
"positive_finding": "Cervical flexion reproduces the temporal or encircling headache. Midbelly palpation at Location 2 or 3 reproduces the band-like pattern.",
"muscles_implicated": ["Semispinalis Capitis"],
"yes": "result-semispinalis",
"no": "splenius-suboccipital-split-1"
},
"splenius-suboccipital-split-1": {
"type": "symptom",
"question": "Is there ipsilateral blurring of NEAR vision — transient difficulty focusing on close objects on the same side as the temporal or orbital pain?",
"symptom_name": "Ipsilateral near-vision blurring",
"muscles_implicated": ["Splenius Cervicis"],
"muscles_excluded": ["Suboccipital Group"],
"clinical_rationale": "Ipsilateral near-vision blurring is the cardinal distinguishing feature of splenius cervicis TrPs and is not produced by any other muscle in this region. It is a specific and diagnostically important sign. Its absence shifts probability toward the suboccipital group, which produces a similarly diffuse and poorly localised deep head pain but without the visual component. Both muscles are nearly always satellites — treat the key posterior cervical muscles (semispinalis capitis, splenius capitis) first.",
"yes": "exam-splenius-1",
"no": "exam-suboccipital-1"
},
"exam-splenius-1": {
"type": "examination",
"question": "Does deep palpation at the upper attachment of the splenius cervicis — at the posterior tubercles of C₁–C₃ transverse processes, approached from posterior to anterior through the trapezius — reproduce the orbital or intracranial pain and near-vision blurring?",
"exam_type": "palpation",
"landmark": "The splenius cervicis lies beneath the trapezius and levator scapulae and is not directly accessible from behind. Upper TrP: approach from behind by pressing through the trapezius at the C₁–C₃ level, approximately 3–4 cm lateral to the midline — reproduce the diffuse orbital or intracranial pain. Lower TrP: approximately at the cervicothoracic junction at the T₃–T₆ spinous process level, lateral to the midline — produces pain at the angle of the neck. Active cervical rotation restriction is a consistent finding — ask the patient to rotate toward the involved side and note end-range restriction or pain.",
"positive_finding": "Deep palpation through the trapezius reproduces the diffuse orbital or intracranial pain and/or provokes near-vision blurring",
"muscles_implicated": ["Splenius Cervicis"],
"yes": "result-splenius-cervicis",
"no": "exam-suboccipital-1"
},
"exam-suboccipital-1": {
"type": "examination",
"question": "Does deep suboccipital palpation — pressing firmly just below the nuchal line between the mastoid and the midline — reproduce a diffuse, poorly localised deep head pain that seems to penetrate the skull? Is atlantoaxial rotation restricted?",
"exam_type": "palpation",
"landmark": "The suboccipital muscles lie beneath the semispinalis capitis and are not individually distinguishable by palpation. Palpate firmly in the suboccipital triangle, just inferior to the nuchal line between the midline and the mastoid process. The characteristic pain reproduction is a diffuse, deep, poorly localised ache that patients describe as hurting 'all over inside.' Atlantoaxial (AA) rotation test: patient supine, examiner rotates the head with the neck in slight flexion (chin slightly tucked) — restriction of pure C₁/C₂ rotation suggests AA dysfunction associated with suboccipital TrPs.",
"positive_finding": "Deep suboccipital palpation reproduces diffuse, poorly localised head pain described as penetrating or 'all over inside.' AA rotation may be restricted.",
"muscles_implicated": ["Suboccipital Group"],
"yes": "result-suboccipital",
"no": "result-overlap"
},
"result-temporalis": {
"type": "result",
"diagnosis": "Temporalis Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Temporalis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.9 Temporalis",
"notes": "Temporalis TrPs produce spoke-like referral patterns from the temporal fossa to the temple, supraorbital ridge, and upper teeth. ATrP₁–₃ are attachment TrPs at the musculotendinous junctions and each refer to a specific tooth group — unaware clinicians may needlessly extract perfectly healthy teeth or extirpate pulps. CTrP₄ (posterior belly midfibre, above and behind the ear) produces posterior temporal pain without tooth referral and is activated by retrusive bruxism. Temporalis TrPs are found in one-third to two-thirds of TMD patients. The temporal artery runs through the muscle — identify it before injection. Treatment is not complete until upper trapezius and SCM key TrPs have been inactivated.",
"treatment_hint": "Spray and stretch with jaw opened to stretch limit. Ischemic compression. Treat upper trapezius and SCM key TrPs first — temporalis is frequently their satellite. Address bruxism, clenching, and forward head posture. Prolonged jaw immobilisation during cervical traction without an occlusal splint is an iatrogenic activating factor — note this if the patient has had recent neck traction.",
"also_consider": ["Upper Trapezius (key TrP)", "SCM Sternal (key TrP)", "Masseter", "Medial Pterygoid"],
"less_likely": [
{ "muscle": "Upper Trapezius", "reason": "Jaw aggravation is the primary mechanism; upper trapezius is the key TrP to treat first but not the direct pain source here" },
{ "muscle": "SCM Sternal", "reason": "No autonomic phenomena; jaw activity — not neck load — is the primary aggravator" },
{ "muscle": "Semispinalis Capitis", "reason": "No encircling band quality; jaw aggravation and tooth sensitivity are specific to temporalis" }
],
"confirmatory": [
"Spoke-pattern TrP tenderness in the temporal fossa reproducing temporal headache — different TrPs refer to different tooth groups",
"Upper tooth hypersensitivity (percussion, heat, cold, biting pressure) without dental pathology — confirms ATrP₁–₃ referral",
"CTrP₄ above and slightly behind the ear — posterior temporal pain without tooth referral; activated by retrusive bruxism",
"Two-knuckle test: patient unable to fit two knuckles between incisor teeth (less than ~36 mm) — indicates elevator muscle TrP restriction",
"Temporal artery identified and confirmed pulsatile — not the pain source (non-pulsatile tender artery requires temporal arteritis exclusion)",
"Inactivating temporalis TrPs should immediately improve jaw opening if elevator muscle restriction is present"
],
"satellite_trps": ["Masseter", "Medial Pterygoid", "SCM", "Upper Trapezius (key TrP)"],
"landing_page_topics": [
"ATrP₁–₃ spoke patterns and tooth group referral — preventing unnecessary dental treatment",
"CTrP₄ posterior belly and retrusive bruxism",
"Temporal artery anatomy and injection caution",
"Prolonged jaw immobilisation as iatrogenic activating factor (cervical traction without splint)",
"Two-knuckle test and jaw opening measurement",
"Satellite relationship with upper trapezius and SCM"
],
"related_pages": [
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" },
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" },
{ "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
]
},
"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 refers to the cheek, supraorbital ridge, temple, occiput, and vertex. Temporal headache from this muscle is part of a wider facial pattern. The cardinal distinguishing features are ipsilateral autonomic phenomena: profuse tearing (often the most alarming symptom), rhinitis, and apparent ptosis via palpebral fissure narrowing without true miosis. Head tilts toward the TrP side due to pain on holding the head upright. The patient prefers to lie with a pillow so the sore face does not bear weight. A dry tingling cough may arise from a cough TrP near the sternal attachment.",
"treatment_hint": "Pincer palpation and spray and stretch, superior to inferior. SCM Compression Test confirms sternal central TrP. Correct forward head posture. Treating the sternal SCM often resolves zygomaticus major, orbicularis oculi, and temporalis satellite TrPs.",
"also_consider": ["SCM Clavicular Division", "Upper Trapezius", "Temporalis (satellite)"],
"less_likely": [
{ "muscle": "Upper Trapezius TrP₁", "reason": "Autonomic phenomena are present — these are specific to the SCM sternal division, not trapezius" },
{ "muscle": "Temporalis", "reason": "No jaw aggravation identified as primary mechanism; autonomic phenomena argue for SCM" },
{ "muscle": "Semispinalis Capitis", "reason": "No encircling band quality; autonomic phenomena do not arise from semispinalis" }
],
"confirmatory": [
"SCM Compression Test positive — pharyngeal pain on swallowing resolves when the sternal belly is firmly gripped; pathognomonic of sternal central TrP",
"Profuse ipsilateral tearing — often the most alarming symptom; specific to the sternal division",
"Rhinitis on the TrP side — ipsilateral nasal congestion or watering without infection",
"Apparent ptosis without miosis — palpebral fissure narrowing; confirm pupils equal and reactive to exclude true Horner syndrome",
"Head tilts toward the TrP side; patient prefers to lie on the sore side with pillow supporting the face",
"Visual disturbance with strongly contrasted vertical lines (venetian blinds, window frames) — not blurred or double vision"
],
"satellite_trps": ["Temporalis", "Zygomaticus Major", "Orbicularis Oculi", "Masseter"],
"landing_page_topics": [
"Sternal vs clavicular division — full symptom profiles and examination",
"Horner syndrome exclusion protocol",
"CN XI entrapment and trapezius weakness monitoring",
"Cough TrP near sternal attachment",
"Venetian blinds visual phenomenon",
"Satellite TrP treatment sequence"
],
"related_pages": [
{ "label": "Temporalis TrP →", "page": "Muscle:Temporalis" },
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" }
]
},
"result-trapezius": {
"type": "result",
"diagnosis": "Upper Trapezius TrP₁ — Temporal and Orbital Referral",
"confidence": "high",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "TrP₁ in the anterior border of the upper trapezius is the most frequently identified myofascial TrP location in the entire body. It refers pain upward along the posterolateral neck to the mastoid process, then over the temple and toward the back of the orbit. At higher intensity the pain extends to the angle of the jaw and may include the pinna of the ear (not deep inside). The temporal headache from upper trapezius TrP₁ is a major source of tension-type neckache and headache. Ipsilateral head tilt — the patient tends to hold the head tilted toward the pain side — is a consistent postural finding. Upper trapezius is also a key TrP that drives temporalis and SCM as satellites.",
"treatment_hint": "Pincer palpation and spray and stretch with ipsilateral side-bending away and contralateral rotation. Correct shoulder elevation posture — bags and heavy purses carried on the ipsilateral shoulder are the most common perpetuating factor. Treat levator scapulae if it co-activates. Treating upper trapezius often resolves temporalis and SCM satellite TrPs.",
"also_consider": ["Levator Scapulae", "SCM", "Temporalis (satellite)", "Semispinalis Capitis (satellite)"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena — absent tearing, rhinitis, palpebral narrowing" },
{ "muscle": "Temporalis", "reason": "Shoulder and neck loading is the primary aggravator, not jaw activity" },
{ "muscle": "Semispinalis Capitis", "reason": "No encircling band quality; shoulder loading distinguishes trapezius from semispinalis" }
],
"confirmatory": [
"TrP₁ tenderness at the anterior border of the upper trapezius midportion — most common TrP location in the body; local twitch response often elicited",
"Temporal and orbital pain reproduced by pincer palpation — the familiar headache, not just local tenderness",
"Ipsilateral head tilt — the patient holds the head tilted toward the TrP side to shorten the upper trapezius and reduce pain",
"Shoulder elevation with bag or purse on the same side reproduces or worsens the temporal headache",
"Cervical rotation and side-bending away from the TrP side are restricted"
],
"satellite_trps": ["Temporalis", "SCM", "Semispinalis Capitis", "Levator Scapulae"],
"landing_page_topics": [
"TrP₁ through TrP₇ — full referral pattern catalogue",
"Autonomic phenomena from TrP₁ — tearing and pinna ear pain",
"Shoulder carry posture and workstation correction",
"Cervical accessory nerve (CN XI) and trapezius inhibition from SCM TrPs",
"Satellite relationship with temporalis and SCM"
],
"related_pages": [
{ "label": "Temporalis TrP →", "page": "Muscle:Temporalis" },
{ "label": "Levator Scapulae TrP →", "page": "Muscle:Levator_Scapulae" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-semispinalis": {
"type": "result",
"diagnosis": "Semispinalis Capitis Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Semispinalis_Capitis",
"chapter_ref": "Travell & Simons Vol.1 — Ch.16 Semispinalis Capitis",
"notes": "The temporal component of semispinalis capitis referral is part of a band-like headache that encircles the head halfway, beginning at the occiput, reaching maximum intensity in the temporal region, and continuing forward over the eye. The muscle acts as a checkrein during even slight neck flexion — sustained forward head posture from reading, computing, or sewing chronically activates TrPs. The nuchal line tenderness (Location 1) is enthesopathy from taut bands of TrPs lower in the muscle. Greater occipital nerve entrapment by these taut bands may add a superficial tingling or hot prickling component to the deep aching headache.",
"treatment_hint": "Spray and stretch with neck extension. Moist heat. Do NOT inject Location 2 (vertebral artery proximity at C₁). Treat upper trapezius and splenius capitis key TrPs first — semispinalis capitis is frequently their satellite.",
"also_consider": ["Upper Trapezius (key TrP)", "Splenius Capitis (key TrP)", "Suboccipital Group", "Semispinalis Cervicis"],
"less_likely": [
{ "muscle": "Upper Trapezius TrP₁", "reason": "Encircling band with neck flexion aggravation is specific to semispinalis; no shoulder loading as primary aggravator" },
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena; band quality is specific to semispinalis" },
{ "muscle": "Temporalis", "reason": "No jaw aggravation and no tooth sensitivity; the encircling pattern does not arise from temporalis" }
],
"confirmatory": [
"Band-like headache encircling from occiput through temple to over the eye — the defining pattern",
"Cervical flexion reproduces or intensifies the temporal or band headache — the checkrein mechanism",
"Enthesopathy at the nuchal line (Location 1) — 1–2 cm lateral to midline at the superior nuchal line",
"Midbelly TrP at Location 2 or 3 reproduces the band headache — this is the causal TrP",
"Greater occipital nerve entrapment: additional superficial tingling or hot prickling in the scalp — distinct from the deep aching referral"
],
"satellite_trps": ["Suboccipital Group", "Semispinalis Cervicis", "Multifidi", "Upper Trapezius"],
"landing_page_topics": [
"Three TrP location zones — palpation technique, injection caution at Location 2",
"Greater occipital nerve entrapment — deep aching vs superficial tingling distinction",
"Checkrein mechanism and forward head posture",
"Satellite relationship with upper trapezius and splenius capitis"
],
"related_pages": [
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" },
{ "label": "Suboccipital Group →", "page": "Muscle:Suboccipital" }
]
},
"result-splenius-cervicis": {
"type": "result",
"diagnosis": "Splenius Cervicis Trigger Point",
"confidence": "moderate",
"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 that distinguishes it from other muscles in this region. The associated ipsilateral near-vision blurring is highly specific and clinically important: the mechanism is not fully established but is consistently reported. The lower TrP produces pain at the angle of the neck and upper shoulder rather than temporal pain. The muscle lies almost entirely beneath the trapezius and is not readily palpable — its involvement often only becomes apparent after TrPs in the levator scapulae and upper trapezius have been inactivated. Cervical rotation restriction toward the involved side is a consistent examination finding.",
"treatment_hint": "Treat levator scapulae and upper trapezius first — splenius cervicis is often their satellite and may resolve without direct treatment. Spray and stretch with contralateral rotation and slight flexion. Correct sustained ipsilateral rotation postures (e.g. working monitor positioned to one side).",
"also_consider": ["Upper Trapezius (key TrP)", "Levator Scapulae (key TrP)", "Splenius Capitis", "Suboccipital Group"],
"less_likely": [
{ "muscle": "Suboccipital Group", "reason": "Ipsilateral near-vision blurring is specific to splenius cervicis; suboccipital pain is more diffuse and described as ghostly or all-over" },
{ "muscle": "Upper Trapezius TrP₁", "reason": "Orbital and intracranial quality with vision blur argues for splenius cervicis; trapezius temporal pain does not produce near-vision blurring" },
{ "muscle": "Semispinalis Capitis", "reason": "No encircling band quality; intracranial and orbital referral with vision blur distinguishes splenius cervicis" }
],
"confirmatory": [
"Ipsilateral near-vision blurring — transient difficulty focusing on close objects on the same side; highly specific for splenius cervicis upper TrP",
"Diffuse intracranial pain referred to the back of the eye — deep inside the head quality",
"Cervical rotation restricted toward the involved side — consistent examination finding",
"Deep palpation through the trapezius at C₁–C₃ reproduces the orbital or intracranial pain",
"Becomes apparent after levator scapulae and upper trapezius TrPs have been treated"
],
"satellite_trps": ["Suboccipital Group", "Splenius Capitis", "Levator Scapulae (key TrP)"],
"landing_page_topics": [
"Near-vision blurring mechanism — splenius cervicis as the primary source",
"Upper vs lower TrP — intracranial referral vs angle-of-neck pain",
"Palpation technique — approaching through the trapezius",
"Cervical rotation restriction — examination and interpretation",
"Satellite relationship with levator scapulae and upper trapezius"
],
"related_pages": [
{ "label": "Levator Scapulae TrP →", "page": "Muscle:Levator_Scapulae" },
{ "label": "Splenius Capitis TrP →", "page": "Muscle:Splenius_Capitis" },
{ "label": "Suboccipital Group →", "page": "Muscle:Suboccipital" }
]
},
"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": "The suboccipital TrP referral pattern is characteristically diffuse and poorly localised — described as a deep, ghostly head pain that seems to penetrate the skull, often reported as hurting 'all over inside.' Pain radiates from the occiput toward the eye and forehead, contributing to temporal pain in the context of widespread posterior head involvement. These muscles cannot be individually identified by palpation alone — involvement is inferred from movement restrictions. It is rare for these muscles to develop TrPs in isolation — they nearly always develop as satellites of semispinalis capitis, splenius capitis, or as a consequence of forward head posture. Treating the key muscles first is the correct approach.",
"treatment_hint": "Treat semispinalis capitis and splenius capitis key TrPs first — suboccipital TrPs frequently resolve without direct treatment. If direct treatment is needed: suboccipital decompression technique (occipital hold), gentle sustained traction with slight chin tuck. Keep the suboccipital region warm. CAUTION on injection — the vertebral artery traverses the suboccipital triangle; injection should only be performed by practitioners highly familiar with the anatomy.",
"also_consider": ["Semispinalis Capitis (key TrP)", "Splenius Capitis (key TrP)", "Upper Trapezius", "Splenius Cervicis"],
"less_likely": [
{ "muscle": "Splenius Cervicis", "reason": "No ipsilateral near-vision blurring; suboccipital pain is more diffuse and described as penetrating or all-over" },
{ "muscle": "Upper Trapezius TrP₁", "reason": "Diffuse ghostly quality and AA rotation restriction distinguish suboccipital from the more localised trapezius referral" },
{ "muscle": "Temporalis", "reason": "No jaw aggravation; suboccipital pain is posterior and diffuse, not a spoke pattern from the temporal fossa" }
],
"confirmatory": [
"Diffuse, poorly localised deep head pain described as penetrating or 'all over inside the skull' — the characteristic ghostly quality",
"Deep suboccipital palpation just below the nuchal line reproduces the diffuse head pain",
"Atlantoaxial rotation restricted — inability to rotate C₁/C₂ in pure rotation with neck slightly flexed",
"Occipitoatlantal extension restricted — inability to fully extend the OA joint without the whole neck extending",
"Nearly always satellite TrPs — confirm semispinalis capitis and splenius capitis TrPs as the likely key TrPs driving suboccipital activation"
],
"satellite_trps": ["Semispinalis Cervicis", "Multifidi", "Upper Trapezius (key TrP)", "Splenius Capitis (key TrP)"],
"landing_page_topics": [
"Atlantoaxial and occipitoatlantal examination technique",
"Suboccipital decompression technique — occipital hold",
"Vertebral artery anatomy and injection caution",
"Satellite relationship with semispinalis and splenius capitis",
"Forward head posture correction and neck warmth"
],
"related_pages": [
{ "label": "Semispinalis Capitis →", "page": "Muscle:Semispinalis_Capitis" },
{ "label": "Splenius Capitis TrP →", "page": "Muscle:Splenius_Capitis" }
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings are inconclusive. Multi-muscle involvement is common in temporal headache — upper trapezius is frequently the key TrP activating temporalis, SCM, and posterior cervical muscles as satellites. Perform a systematic screen in order of clinical priority.",
"screen_these": [
"Upper Trapezius TrP₁ — pincer palpation of the anterior border at the most vertical midportion; note ipsilateral head tilt and shoulder loading as aggravators",
"Temporalis — systematic palpation of the temporal fossa in three zones (ATrP₁–₃ and CTrP₄); check for tooth hypersensitivity without dental cause",
"SCM sternal division — pincer palpation full length; SCM Compression Test; note autonomic phenomena",
"Semispinalis capitis — palpation at the nuchal line and midbelly; cervical flexion reproduction test",
"Splenius cervicis — deep palpation through trapezius at C₁–C₃; assess near-vision blurring and cervical rotation",
"Suboccipital group — deep palpation just below the nuchal line; assess AA rotation and OA extension"
],
"wiki_page": "Differential:Temporal_Headache"
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "Temporal Arteritis (Giant Cell Arteritis)",
"confidence": "uncommon — critical in over-50s",
"mimics": "Unilateral temporal pain — overlaps directly with temporalis and upper trapezius referral patterns",
"distinguishing_feature": "Jaw claudication (pain building with chewing, easing at rest) is pathognomonic. Age over 50. Tender non-pulsatile temporal artery. ESR typically >50 mm/hr, often >100. Scalp tenderness. The temporal artery runs through the temporalis muscle — always palpate it specifically when examining this region in any patient over 50.",
"action": "Same-day GP referral + ESR and CRP in any patient over 50 with new temporal pain. Do not delay for musculoskeletal assessment."
},
{
"id": "bd-2",
"condition": "Tension-type Headache",
"confidence": "uncommon",
"mimics": "Bilateral pressing or tightening temporal pain — overlaps with bilateral upper trapezius and semispinalis capitis TrP patterns",
"distinguishing_feature": "Very high probability of myofascial TrP involvement (Ch.5, Table 5.1). The pressing quality of tension headache matches the steady deep aching of myofascial TrP pain. Pericranial muscle tenderness consistent with TrPs is the consistent finding. EMG activity is not elevated.",
"action": "Systematic TrP examination of pericranial and cervical muscles. All six muscles in this algorithm should be screened. Myofascial treatment with perpetuating factor correction is first-line."
},
{
"id": "bd-3",
"condition": "Migraine Without Aura",
"confidence": "uncommon",
"mimics": "Unilateral temporal or temporal-orbital headache — overlapping referral from upper trapezius TrP₁, SCM sternal, and temporalis produces a typical migraine picture",
"distinguishing_feature": "Pericranial TrP tenderness present even between attacks and increasing with headache intensity. Injection of these sites produces complete relief in 60% of patients. The myofascial and vascular components coexist.",
"action": "Screen for TrPs in all migraine patients. Treat active TrPs alongside standard migraine management."
},
{
"id": "bd-4",
"condition": "Temporomandibular Joint Disorder",
"confidence": "common",
"mimics": "Temporal and preauricular pain with jaw movement — overlaps directly with temporalis TrP pattern",
"distinguishing_feature": "True TMJ disorder: capsulitis produces periarticular aching pain specifically tender on joint palpation (lateral pole anterior to tragus) and aggravated by all jaw movements. Temporalis TrPs are present in one-third to two-thirds of TMD patients — both can coexist. Myofascial TrP pain was the primary diagnosis in 55% of patients in the Minnesota TMJ study, vs 21% with primary joint disorder.",
"action": "Palpate the TMJ lateral pole and retrodiscal tissues. If acute joint inflammation present, refer before masticatory muscle stretching. Treat temporalis TrPs concurrently with palliative joint care."
},
{
"id": "bd-5",
"condition": "Toothache — Dental Pulpitis or Abscess",
"confidence": "uncommon",
"mimics": "Upper tooth pain and sensitivity — directly overlaps with temporalis ATrP₁–₃ referral to the upper teeth",
"distinguishing_feature": "True dental pathology: radiographic changes, percussion sensitivity localised to one tooth (not distributed across a zone), response to cold test, and reproduction of pain from the tooth itself rather than from the muscle. Temporalis TrP referral: percussion sensitivity distributed across a zone of upper teeth, normal radiographs, pain reproduced by palpating the temporalis TrP, not by direct dental stimulation.",
"action": "Request periapical radiograph. If normal, palpate temporalis before any irreversible dental treatment. Inactivating the TrP should resolve the tooth sensitivity."
},
{
"id": "bd-6",
"condition": "Cluster Headache",
"confidence": "rare",
"mimics": "Severe unilateral temporal or orbital headache with autonomic features — overlaps with SCM sternal division tearing and rhinitis in the temporal region",
"distinguishing_feature": "Classic cluster: periorbital and temporal, 15–180 minutes, ipsilateral tearing, rhinitis, ptosis, clustered in bouts. Ch.5 case: chronic cluster with SCM TrP as a contributing factor producing suboccipital and facial referral mimicking cluster features. Treating the SCM TrP significantly reduced frequency.",
"action": "Examine for SCM and upper trapezius TrPs in all cluster headache patients. Myofascial treatment may reduce frequency without replacing cluster prophylaxis."
},
{
"id": "bd-7",
"condition": "Post-traumatic Headache",
"confidence": "uncommon",
"mimics": "Temporal and occipital headache following whiplash or closed head injury — semispinalis capitis and splenius capitis most commonly activated",
"distinguishing_feature": "History of trauma. Clinically indistinguishable from tension-type headache. Semispinalis capitis and splenius capitis are the most commonly activated muscles regardless of impact direction. The temporal referral from these muscles predominates in many post-traumatic cases.",
"action": "Systematic TrP screen with priority on semispinalis capitis, SCM, upper trapezius, and splenius capitis. Address perpetuating factors. Refer if neurological symptoms suggest brainstem or vestibular involvement."
},
{
"id": "bd-8",
"condition": "Occipital Neuralgia",
"confidence": "rare",
"mimics": "Occipital and temporal pain with shooting or burning quality — overlaps with semispinalis capitis and suboccipital referral",
"distinguishing_feature": "Paroxysmal stabbing with aching between attacks; radiation to temporal and frontal regions. Greater occipital nerve entrapped by semispinalis capitis taut bands — produces both neuritic pain and myofascial TrP aching simultaneously. Always treat TrPs first before any neuroablative procedure.",
"action": "Treat semispinalis capitis TrPs first. If neuritic component persists after adequate TrP treatment, refer to neurology."
}
]
}