DiagnosticTree/Vertex
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{
"tree_id": "head-neck",
"region": "Head and Neck Pain \u2014 Myofascial",
"start": "rom-1",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Subarachnoid Haemorrhage",
"question": "Sudden-onset thunderclap headache \u2014 the worst headache of the patient\u2019s life, reaching maximal intensity within seconds to a minute; may be accompanied by neck stiffness, vomiting, photophobia, or brief loss of consciousness?",
"rationale": "The classic \u2018thunderclap\u2019 headache is a neurosurgical emergency until proven otherwise. Myofascial headache is never of sudden thunderclap onset.",
"action": "Call emergency services immediately. Do not proceed with myofascial assessment."
},
{
"id": "rf-e2",
"label": "Vertebral or Carotid Artery Dissection",
"question": "New severe unilateral neck pain or occipital headache, especially following recent neck manipulation, trauma, or sudden neck movement; associated with ipsilateral face or neck pain, Horner syndrome, or new neurological symptoms (dysarthria, dysphagia, limb weakness, diplopia)?",
"rationale": "Arterial dissection can present identically to posterior cervical muscle pain. Any new focal neurological sign in this context requires immediate vascular imaging.",
"action": "Call emergency services immediately. Note: SCM TrPs produce autonomic phenomena resembling Horner syndrome \u2014 exclude true Horner before attributing to TrPs."
},
{
"id": "rf-e3",
"label": "Meningitis / Encephalitis",
"question": "Headache with fever, photophobia, phonophobia, and neck stiffness (Kernig\u2019s or Brudzinski\u2019s sign positive); non-blanching petechial or purpuric rash; altered consciousness or seizure?",
"rationale": "Neck stiffness from meningism is fundamentally different from myofascial restriction \u2014 meningism resists passive neck flexion in all planes whereas myofascial restriction has a directional pattern.",
"action": "Call emergency services immediately."
},
{
"id": "rf-e4",
"label": "Cervical Epidural Abscess / Cord Compression",
"question": "Severe progressive neck pain with fever and exquisite midline spinal tenderness; new upper or lower limb weakness, sensory level, or bladder / bowel dysfunction?",
"rationale": "Spinal cord or cauda equina compromise requires emergency decompression.",
"action": "Call emergency services immediately."
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Temporal Arteritis (Giant Cell Arteritis)",
"question": "New temporal headache in a patient aged over 50; scalp tenderness, jaw claudication, visual disturbance, or loss of vision; elevated ESR or CRP; tender, thickened, or pulseless temporal artery?",
"rationale": "Visual loss from temporal arteritis is irreversible. A tender temporal artery in a patient over 50 is temporal arteritis until proven otherwise. Temporalis muscle TrPs do not cause scalp tenderness or jaw claudication.",
"action": "Same-day GP or emergency referral. High-dose corticosteroids must not be delayed. Do not proceed with myofascial assessment."
},
{
"id": "rf-u2",
"label": "Cervical Fracture or Instability",
"question": "Neck pain following significant trauma (fall, motor vehicle accident, axial load injury, diving); midline cervical tenderness; any neurological sign; known osteoporosis, rheumatoid arthritis with atlantoaxial involvement, or Down syndrome?",
"rationale": "Cervical spine must be cleared radiologically before any manual assessment or treatment. Whiplash TrPs are common but require fracture and instability to be excluded first.",
"action": "Urgent same-day referral for cervical imaging. Do not proceed with myofascial examination."
},
{
"id": "rf-u3",
"label": "Space-Occupying Lesion / Raised Intracranial Pressure",
"question": "Headache that is progressively worsening over weeks, worse on waking, worse on Valsalva, coughing, or bending forward; associated with personality change, focal neurological signs, papilloedema, or unexplained weight loss?",
"rationale": "Progressive morning headache with postural or Valsalva aggravation is a cardinal feature of raised ICP. Myofascial headache does not worsen consistently on waking or with Valsalva.",
"action": "Urgent same-day GP referral for CT or MRI. Do not proceed with myofascial assessment."
},
{
"id": "rf-u4",
"label": "New Headache in Immunocompromised Patient",
"question": "New or changing headache pattern in a patient who is HIV-positive, on immunosuppressants, or has had a recent systemic infection; any fever, night sweats, or neck stiffness?",
"rationale": "Cryptococcal meningitis, CNS lymphoma, and toxoplasmosis must be excluded in immunocompromised patients before attributing headache to myofascial causes.",
"action": "Urgent same-day GP or infectious diseases referral."
}
]
},
"nodes": {
"rom-1": {
"type": "rom",
"question": "Is the head or neck pain aggravated by active rotation of the head and neck to the same side as the pain \u2014 turning to look over the shoulder?",
"movement": "Active cervical rotation \u2014 ipsilateral",
"direction": "aggravating",
"muscles_implicated": [
"Splenius Capitis",
"Splenius Cervicis",
"Levator Scapulae"
],
"muscles_excluded": [
"SCM (sternal division) \u2014 rotation toward affected side relieves SCM stretch",
"SCM (clavicular division)"
],
"clinical_rationale": "Painful restriction of active rotation to the same side is the cardinal ROM finding for splenius capitis and splenius cervicis TrPs. The SCM is an antagonist to this movement and is not typically painful with ipsilateral rotation.",
"yes": "rom-2",
"no": "rom-3"
},
"rom-2": {
"type": "rom",
"question": "Is passive rotation and flexion of the head and neck toward the OPPOSITE side also restricted or uncomfortable \u2014 i.e., is there restriction in both directions, forming a bilateral pattern of limited mobility?",
"movement": "Passive cervical rotation and flexion \u2014 contralateral",
"direction": "aggravating",
"muscles_implicated": [
"Splenius Capitis",
"Splenius Cervicis"
],
"muscles_excluded": [
"Levator Scapulae \u2014 typically restricts rotation more toward the ipsilateral side only"
],
"clinical_rationale": "Splenius TrPs characteristically produce moderate restriction of passive rotation and flexion toward the opposite side alongside the painful active restriction to the same side. This bidirectional pattern distinguishes splenius involvement from pure levator scapulae restriction.",
"yes": "symptom-1",
"no": "rom-4"
},
"rom-3": {
"type": "rom",
"question": "Is the pain aggravated by sustained or repeated rotation of the head away from the painful side \u2014 such as when driving, working at a screen placed to one side, or looking over the contralateral shoulder for prolonged periods?",
"movement": "Sustained cervical rotation \u2014 contralateral (postural loading)",
"direction": "aggravating",
"muscles_implicated": [
"SCM (sternal division)",
"SCM (clavicular division)"
],
"muscles_excluded": [
"Splenius Capitis",
"Splenius Cervicis"
],
"clinical_rationale": "SCM TrPs are aggravated by sustained loading in the lengthened position \u2014 i.e., rotation away from the affected SCM. This is the opposite direction to splenius aggravation. Forward head posture is the dominant perpetuating factor.",
"yes": "symptom-3",
"no": "rom-5"
},
"rom-4": {
"type": "rom",
"question": "Is ipsilateral shoulder elevation painful or restricted \u2014 such that shrugging the shoulder on the same side as the neck pain reproduces or worsens the pain?",
"movement": "Shoulder elevation \u2014 ipsilateral",
"direction": "aggravating",
"muscles_implicated": [
"Levator Scapulae"
],
"muscles_excluded": [
"Splenius Capitis",
"Splenius Cervicis \u2014 neither contracts with shoulder elevation"
],
"clinical_rationale": "The levator scapulae contracts with shoulder elevation but not with neck extension. The splenius cervicis contracts with neck extension but not with shoulder elevation. This distinguishes the two muscles during the examination when ipsilateral active rotation is painful but the bidirectional restriction pattern is absent.",
"yes": "exam-levator-1",
"no": "symptom-3"
},
"rom-5": {
"type": "rom",
"question": "Is the pain located in the anterior neck, face, or head \u2014 rather than posterior neck or occiput \u2014 and associated with any of: dizziness, imbalance, ear symptoms, tearing, or autonomic phenomena on the same side as the pain?",
"movement": "Symptom distribution and autonomic screen",
"direction": "present",
"muscles_implicated": [
"SCM (sternal division)",
"SCM (clavicular division)"
],
"muscles_excluded": [
"Splenius Capitis",
"Splenius Cervicis",
"Levator Scapulae"
],
"clinical_rationale": "SCM TrPs are among the most clinically complex in the body. Dizziness and disequilibrium (clavicular division), profuse ipsilateral tearing, apparent ptosis, rhinitis, and ear symptoms (sternal division) are autonomic phenomena not produced by the posterior cervical muscles.",
"yes": "symptom-3",
"no": "exam-palpation-screen"
},
"symptom-1": {
"type": "symptom",
"question": "Is the head pain located specifically at the VERTEX \u2014 the very top of the skull \u2014 on the same side as the restricted rotation, described as a sharply localised ache that the patient can point to with a single finger?",
"symptom_name": "Vertex headache \u2014 ipsilateral, sharply localised",
"muscles_implicated": [
"Splenius Capitis"
],
"muscles_excluded": [
"Splenius Cervicis \u2014 upper TrP refers through the inside of the head to the back of the eye, not to the vertex",
"SCM sternal division \u2014 refers to the vertex only rarely and diffusely",
"Levator Scapulae \u2014 does not refer to the vertex"
],
"clinical_rationale": "Sharply localised vertex pain on the same side as the painful rotation restriction is the defining, must-have feature of splenius capitis TrP involvement. No other cervical muscle reliably produces this pattern. SCM sternal division can refer to the vertex but does so diffusely and as part of a wider pattern that includes cheek, temple, and supraorbital referral.",
"yes": "symptom-2",
"no": "symptom-4"
},
"symptom-2": {
"type": "symptom",
"question": "Is there also an \u2018ache inside the skull\u2019 \u2014 pain that seems to radiate through the inside of the head toward the back of the ipsilateral eye or orbit \u2014 in addition to or instead of the vertex pain?",
"symptom_name": "Intracranial ache with orbital projection \u2014 ipsilateral",
"muscles_implicated": [
"Splenius Capitis (craniad TrP near C\u2082)",
"Splenius Cervicis (upper TrP)"
],
"muscles_excluded": [
"Splenius Capitis (typical mid-muscle TrP) \u2014 refers to vertex without orbital component",
"Levator Scapulae"
],
"clinical_rationale": "An unusually craniad splenius capitis TrP (near the level of C\u2082, just caudad to the exposed vertebral artery) adds an intracranial quality with orbital projection to the vertex pattern. The upper splenius cervicis TrP produces the same orbital / intracranial quality but without the vertex localisation. If both vertex AND orbital referral are present simultaneously, both muscles are likely involved.",
"yes": "symptom-2b",
"no": "exam-splenius-cap-1"
},
"symptom-2b": {
"type": "symptom",
"question": "Is there also blurring of NEAR vision in the eye on the same side \u2014 not dizziness, not double vision, not conjunctivitis \u2014 that may improve immediately when the neck is repositioned or the muscle is released?",
"symptom_name": "Ipsilateral near-vision blurring \u2014 without dizziness or conjunctivitis",
"muscles_implicated": [
"Splenius Cervicis (upper TrP)"
],
"muscles_excluded": [
"Splenius Capitis \u2014 does not produce near-vision blurring",
"SCM \u2014 visual disturbance is a different quality (contrast sensitivity, venetian blind effect), not near-vision blur"
],
"clinical_rationale": "Blurring of near vision in the homolateral eye without dizziness or conjunctivitis is a clinically decisive marker of upper splenius cervicis TrP involvement. It sometimes resolves immediately and completely on TrP inactivation. This symptom is not produced by splenius capitis or SCM.",
"yes": "exam-splenius-cerv-1",
"no": "exam-splenius-cap-1"
},
"symptom-3": {
"type": "symptom",
"question": "Is there a dry, tingling cough \u2014 not explained by respiratory illness \u2014 OR a sensation of sore throat or pharyngeal pain on swallowing, without pharyngeal infection?",
"symptom_name": "Dry tingling cough / pharyngeal sore throat",
"muscles_implicated": [
"SCM (sternal division)"
],
"muscles_excluded": [
"SCM (clavicular division)",
"Splenius Capitis",
"Splenius Cervicis"
],
"clinical_rationale": "A dry tingling cough TrP and referred pharyngeal sore throat that resolves with SCM pincer compression are pathognomonic features of the SCM sternal division. They are not produced by any posterior cervical muscle.",
"yes": "exam-scm-sternal-1",
"no": "symptom-5"
},
"symptom-4": {
"type": "symptom",
"question": "Is the pain located at the ANGLE OF THE NECK on the same side \u2014 the posterior lateral triangle where the neck meets the shoulder \u2014 with pain referring upward toward the base of the skull and medially toward the upper cervical spine?",
"symptom_name": "Angle-of-neck pain with upward and medial referral",
"muscles_implicated": [
"Splenius Cervicis (lower / central TrP)"
],
"muscles_excluded": [
"Splenius Capitis \u2014 does not refer to the angle of the neck",
"Levator Scapulae \u2014 refers to the angle of the neck but also to the posterior shoulder; pattern lies more laterally"
],
"clinical_rationale": "The lower splenius cervicis TrP refers pain to the angle of the neck with spread upward to the base of the skull and some spread medially \u2014 lying in the upper part of the levator scapulae pain pattern but with medial spread. Splenius capitis does not produce this pattern.",
"yes": "exam-splenius-cerv-1",
"no": "exam-palpation-screen"
},
"symptom-5": {
"type": "symptom",
"question": "Is there postural dizziness or imbalance \u2014 a sense of unsteadiness or veering when walking or turning \u2014 that is worse on changing head position, lying without a pillow, or quick head rotation, but WITHOUT Romberg\u2019s sign or nystagmus?",
"symptom_name": "Postural dizziness / disequilibrium \u2014 without Romberg or nystagmus",
"muscles_implicated": [
"SCM (clavicular division)"
],
"muscles_excluded": [
"SCM (sternal division)",
"Splenius Capitis",
"Splenius Cervicis"
],
"clinical_rationale": "Postural dizziness and disequilibrium caused by clavicular SCM TrPs has a characteristic profile: Romberg negative, nystagmus absent, straight-line walking veers toward the active TrP side. True vestibular pathology produces a positive Romberg (worse with eyes closed) and nystagmus. This distinction is clinically critical.",
"yes": "exam-scm-clav-1",
"no": "exam-palpation-screen"
},
"exam-splenius-cap-1": {
"type": "examination",
"question": "Does flat palpation in the muscular triangle posterior and medial to the sternocleidomastoid \u2014 below the occiput, at approximately the level of the C\u2082 spinous process \u2014 reproduce the vertex pain or produce a localised taut band with exquisite tenderness?",
"exam_type": "palpation",
"landmark": "Muscular triangle bounded anteriorly by the SCM, posteriorly by the upper trapezius, caudad by the levator scapulae. Patient turns face TOWARD the side being examined and extends the head against light resistance to contract the diagonal splenius capitis fibres. Palpate across the fibre direction for taut bands. The TrP is typically mid-muscle near the level of C\u2082.",
"positive_finding": "Reproduces vertex pain on the same side; OR localised taut band with jump sign in the muscular triangle",
"clinical_rationale": "Splenius capitis is palpable in the muscular triangle. Contraction against resistance identifies fibre direction and location. Tenderness near the mastoid insertion indicates enthesopathy secondary to a mid-muscle TrP, not a primary insertion TrP.",
"muscles_implicated": [
"Splenius Capitis"
],
"yes": "result-splenius-cap",
"no": "exam-splenius-cerv-1"
},
"exam-splenius-cerv-1": {
"type": "examination",
"question": "Does pressure applied from the SIDE \u2014 sliding the palpating finger anterior to the free border of the upper trapezius at approximately the level of C\u2087, then directing pressure medially toward the spine \u2014 reproduce the patient\u2019s neck, occipital, or orbital pain?",
"exam_type": "palpation",
"landmark": "Patient sidelying or seated. Operator\u2019s finger slides anterior to the free border of upper trapezius at approximately C\u2087 spinous process level, past the levator scapulae if non-tender, directing pressure medially toward the spine. Alternatively: posterior approach, approximately 2 cm lateral to the spine at C\u2087, just above the angle of the neck. Splenius cervicis contracts with neck extension \u2014 distinguish from levator scapulae which contracts with shoulder elevation.",
"positive_finding": "Medially directed pressure reproduces orbital, occipital, or angle-of-neck pain; OR diagonal taut bands palpable running caudad from lateral to medial in patients with mobile connective tissue",
"clinical_rationale": "The splenius cervicis is not palpable from directly behind (entirely covered by trapezius). The only approach with reliable access is from the side, through or around the levator scapulae. Neck extension (not shoulder elevation) confirms the contracting muscle is splenius cervicis.",
"muscles_implicated": [
"Splenius Cervicis"
],
"yes": "result-splenius-cerv",
"no": "exam-levator-1"
},
"exam-scm-sternal-1": {
"type": "examination",
"question": "Does pincer palpation of the SCM sternal division reproduce familiar head, face, or chest pain \u2014 AND does sustained pincer compression of the sternal head relieve the sore throat or cough when present?",
"exam_type": "palpation",
"landmark": "Patient seated or supine, ear tilted toward the shoulder to slack the muscle. Grasp the entire sternal division between thumb and forefinger from mastoid to sternal attachment. Snapping a taut band may cause a reflexive head jerk. SCM Compression Test: pincer grip steadily compresses the muscle belly; ask the patient to swallow. Positive result: pharyngeal pain resolves with compression.",
"positive_finding": "Reproduces familiar head, face, ear, or upper sternal pain; OR pincer compression relieves sore throat / cough on swallowing",
"clinical_rationale": "The SCM Compression Test is pathognomonic \u2014 pharyngeal pain that resolves with muscle compression cannot arise from true pharyngeal pathology. Profuse ipsilateral tearing, apparent ptosis, conjunctival redness, and rhinitis are autonomic phenomena confirming sternal division TrP activation.",
"muscles_implicated": [
"SCM (sternal division)"
],
"yes": "result-scm-sternal",
"no": "exam-scm-clav-1"
},
"exam-scm-clav-1": {
"type": "examination",
"question": "Does flat palpation of the clavicular division of the SCM \u2014 along the medial clavicle upward toward the mastoid, posterior to the sternal head \u2014 reproduce frontal headache, dizziness, or ear symptoms? Perform the straight-line walking test: does the patient veer toward the side of the suspected TrP when walking toward a fixed point across the room?",
"exam_type": "palpation",
"landmark": "Clavicular division: flat palpation from medial clavicle upward, posterior and deep to the sternal head. Straight-line walking test: patient walks toward a fixed point while fixing their gaze on it \u2014 veering toward the TrP side indicates clavicular division involvement. Romberg test: negative (normal sway with eyes closed) confirms myofascial rather than vestibular origin.",
"positive_finding": "Reproduces frontal headache or dizziness on palpation; OR straight-line walking test veers toward the TrP side; OR Romberg negative with dizziness present",
"clinical_rationale": "The straight-line walking test and Romberg negative combination is the clinical hallmark of clavicular division SCM TrP dizziness, distinguishing it from vestibular pathology. Weight perception dysmetria (same object feels heavier on the unaffected side) further confirms clavicular division involvement.",
"muscles_implicated": [
"SCM (clavicular division)"
],
"yes": "result-scm-clav",
"no": "exam-levator-1"
},
"exam-levator-1": {
"type": "examination",
"question": "Does flat palpation of the levator scapulae \u2014 at the angle of the neck where the muscle emerges from beneath the trapezius, and along the posterior border of the SCM \u2014 reproduce ipsilateral neck pain or posterior shoulder pain? Is shoulder elevation on the same side painful or does it provoke neck pain?",
"exam_type": "palpation",
"landmark": "Levator scapulae: palpate at the angle of the neck (posterior to SCM, anterior to trapezius) and along the medial scapular border. Levator scapulae contracts with shoulder elevation \u2014 use this to confirm muscle identity. Distinguish from splenius cervicis (contracts with neck extension, not shoulder elevation).",
"positive_finding": "Reproduces posterior neck pain or posterior shoulder pain; shoulder elevation provokes or reproduces the pain; taut band palpable at the angle of the neck",
"clinical_rationale": "Levator scapulae and splenius cervicis share an attachment at the transverse processes of the upper cervical vertebrae and frequently co-activate. Levator scapulae TrPs often mask coexisting splenius cervicis TrPs \u2014 the latter only become apparent after the levator is inactivated. Shoulder elevation activates levator but not splenius cervicis.",
"muscles_implicated": [
"Levator Scapulae"
],
"yes": "result-levator",
"no": "exam-palpation-screen"
},
"exam-palpation-screen": {
"type": "examination",
"question": "Systematic palpation screen: does palpation of any of the following reproduce the patient\u2019s familiar pain? (a) Upper trapezius \u2014 flat palpation across the crest of the shoulder; (b) Semispinalis capitis \u2014 just lateral to midline from occiput to C\u2084; (c) Suboccipital muscles \u2014 between the occiput and C\u2082, in the suboccipital triangle; (d) Temporalis \u2014 flat palpation over the temporal fossa in three zones?",
"exam_type": "palpation",
"landmark": "(a) Upper trapezius: pinch the muscle crest between thumb and forefinger across the shoulder to neck. (b) Semispinalis capitis: flat palpation just lateral to midline, occiput to C\u2084. (c) Suboccipital: pressure in the suboccipital triangle between occiput and C\u2082 spinous process. (d) Temporalis: flat palpation in anterior, middle, and posterior zones of the temporal fossa.",
"positive_finding": "Any muscle reproduces the patient\u2019s familiar pain pattern on palpation",
"clinical_rationale": "Head and neck pain is almost always multi-muscle in origin. When the primary splenius and SCM screens are negative or equivocal, systematic palpation of the remaining major head and neck muscles is required before concluding the examination.",
"muscles_implicated": [
"Upper Trapezius",
"Semispinalis Capitis",
"Suboccipital Muscles",
"Temporalis"
],
"yes": "result-overlap",
"no": "result-no-trp"
},
"result-splenius-cap": {
"type": "result",
"diagnosis": "Splenius Capitis Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Splenius_Capitis",
"chapter_ref": "Travell & Simons Vol.1 \u2014 Ch.15 Splenius Capitis and Splenius Cervicis",
"notes": "The defining feature is sharply localised vertex pain on the same side \u2014 the patient points to the crown with a single finger. An unusually craniad TrP near C\u2082 adds an intracranial ache projecting to the back of the eye. Splenius capitis was the second most frequently injured muscle in systematic whiplash studies (present in 94% of frontal impacts). Active TrPs rarely appear in the splenii alone \u2014 levator scapulae and posterior cervical muscles are almost always co-involved.",
"confirmatory": [
"Vertex pain \u2014 ipsilateral, sharply localised, single-finger location \u2014 pathognomonic",
"Painful restriction of ACTIVE rotation to the same side",
"Moderate restriction of PASSIVE rotation and flexion to the opposite side",
"Taut band with jump sign in the muscular triangle posterior and medial to the SCM, approximately at C\u2082 level",
"Only the splenius capitis (not splenius cervicis) is further elongated by flexion of the HEAD on the cervical spine beyond neck flexion alone \u2014 use this to distinguish the two muscles"
],
"treatment_hint": "Release together with splenius cervicis and levator scapulae as one functional unit. Spray and stretch: up-stroke vapocoolant pattern, head rotated 20\u201330\u00b0 away and gently flexed toward the opposite side, upward traction. INJECTION CAUTION: needle aimed caudad, below C\u2081\u2013C\u2082 junction; craniad musculotendinous junction injection is not recommended. Hot pack after stretch. See Muscle:Splenius_Capitis for full protocol.",
"less_likely": [
{
"muscle": "Splenius Cervicis",
"reason": "Upper splenius cervicis refers through the inside of the head to the back of the eye, not to the vertex; lower TrP refers to the angle of the neck, not the vertex"
},
{
"muscle": "SCM sternal division",
"reason": "SCM vertex referral is rare and diffuse, part of a wider pattern including cheek, temple, and supraorbital pain; autonomic phenomena (tearing, rhinitis) distinguish SCM"
},
{
"muscle": "Semispinalis Capitis",
"reason": "Semispinalis capitis refers to the occiput and posterior head, not specifically to the vertex"
}
]
},
"result-splenius-cerv": {
"type": "result",
"diagnosis": "Splenius Cervicis Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Splenius_Cervicis",
"chapter_ref": "Travell & Simons Vol.1 \u2014 Ch.15 Splenius Capitis and Splenius Cervicis",
"notes": "The upper TrP produces a diffuse intracranial ache that focuses strongly behind the ipsilateral eye \u2014 an \u2018ache inside the skull.\u2019 The lower (central) TrP refers to the angle of the neck. Near-vision blurring in the homolateral eye without dizziness or conjunctivitis is a clinically decisive marker. Splenius cervicis involvement is frequently masked by levator scapulae TrPs and only becomes apparent after the levator is inactivated. Trifocal eyeglasses are a named perpetuating factor specific to this muscle.",
"confirmatory": [
"Intracranial ache projecting to the back of the ipsilateral eye \u2014 distinguishes upper TrP from splenius capitis vertex referral",
"Near-vision blurring in the homolateral eye without dizziness or conjunctivitis \u2014 sometimes resolves immediately on TrP inactivation",
"Pain at the angle of the neck (lower TrP) with spread upward and medially",
"Painful restriction of active rotation to the same side with moderate contralateral passive restriction",
"TrP only accessible from the side, through or around the levator scapulae \u2014 medially directed pressure at C\u2087 level reproduces pain",
"Neck extension (not shoulder elevation) contracts splenius cervicis \u2014 distinguishes from levator scapulae",
"Involvement often only apparent AFTER levator scapulae TrPs are inactivated"
],
"treatment_hint": "Release together with splenius capitis and levator scapulae. Spray and stretch: up-stroke pattern with spray also covering the angle of the shoulder and lateral head to the eye (protect eye from spray). Injection: needle directed lateral to medial, superficial to ribs posterior to transverse processes; CAUTION \u2014 some patients faint with autonomic response on needle contact. Do not wear trifocal eyeglasses. See Muscle:Splenius_Cervicis for full protocol.",
"less_likely": [
{
"muscle": "Splenius Capitis",
"reason": "Splenius capitis refers to the vertex, not through the inside of the head to the eye; capitis is further elongated by head-on-cervical-spine flexion, cervicis is not"
},
{
"muscle": "Levator Scapulae",
"reason": "Levator scapulae contracts with shoulder elevation, not neck extension; levator TrPs often co-exist and must be inactivated first to unmask splenius cervicis"
},
{
"muscle": "Suboccipital muscles",
"reason": "Suboccipitals refer to the occiput and posterior head; they do not produce near-vision blurring or orbital intracranial quality"
}
]
},
"result-scm-sternal": {
"type": "result",
"diagnosis": "SCM Trigger Point \u2014 Sternal Division",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 \u2014 Ch.7 Sternocleidomastoid",
"notes": "The sternal division refers ipsilaterally to cheek, temple, supraorbital ridge, occiput, and vertex, and downward to the upper sternal region. The dry tingling cough TrP and pharyngeal sore throat that resolves with SCM compression are pathognomonic. Autonomic phenomena \u2014 profuse ipsilateral tearing, apparent ptosis, conjunctival redness, rhinitis \u2014 are frequently the patient\u2019s most alarming symptoms. SCM TrPs activate masseter, temporalis, and other head muscles as satellites \u2014 treat SCM first.",
"confirmatory": [
"Dry tingling cough TrP \u2014 not explained by respiratory illness \u2014 pathognomonic for SCM sternal division",
"SCM Compression Test positive \u2014 pincer grip compression relieves pharyngeal pain and/or cough on swallowing",
"Profuse ipsilateral tearing, conjunctival redness, or apparent ptosis (palpebral fissure narrowing, not true ptosis)",
"Head tilts toward the affected side with strongly activated TrPs \u2014 pain on holding the head upright",
"Cheek, temple, supraorbital, and occipital pain in the same referral pattern",
"Forward head posture \u2014 the single most important perpetuating factor"
],
"treatment_hint": "Spray and stretch in superior-to-inferior direction over the muscle belly and referred pain zone. Passive stretch into contralateral rotation and lateral flexion. Correct forward head posture with axial extension exercise. Address satellite TrPs (masseter, temporalis) only AFTER SCM is inactivated. See Muscle:Sternocleidomastoid for full protocol including neurological screen.",
"less_likely": [
{
"muscle": "Splenius Capitis",
"reason": "Splenius capitis refers to the vertex only, without the autonomic phenomena, cough, or sore throat of SCM sternal division"
},
{
"muscle": "Temporalis",
"reason": "Temporalis refers to the teeth and temporal region; it is frequently a satellite of SCM and should be treated after SCM"
},
{
"muscle": "Sinusitis / Rhinitis",
"reason": "SCM sternal division TrPs produce ipsilateral rhinitis and apparent sinus symptoms without true sinus infection; fever, purulent discharge, and radiographic changes absent"
}
]
},
"result-scm-clav": {
"type": "result",
"diagnosis": "SCM Trigger Point \u2014 Clavicular Division",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 \u2014 Ch.7 Sternocleidomastoid",
"notes": "The clavicular division produces three dominant presentations \u2014 frontal headache, postural dizziness and disequilibrium, and dysmetria \u2014 any one of which may predominate. Dizziness is postural and worsens on changing head load, rolling over in bed, or quick head rotation. Hearing may rarely be impaired on the same side. Straight-line walking veers toward the active TrP side \u2014 pathognomonic when Romberg is negative.",
"confirmatory": [
"Frontal headache \u2014 ipsilateral, often mistaken for tension or sinus headache",
"Postural dizziness and disequilibrium: Romberg NEGATIVE, nystagmus ABSENT, straight-line walking veers toward the TrP side",
"Dysmetria: the same object feels heavier when held on the UNAFFECTED side (no bilateral TrP present)",
"Dizziness worsens on changing head load, lying without a pillow, rolling over in bed, or quick head rotation",
"Hearing restoration manoeuvre positive: rotating toward the affected side with chin down temporarily restores hearing",
"Forward head posture \u2014 the single most important perpetuating factor"
],
"treatment_hint": "Spray and stretch clavicular head separately from sternal. Ischemic compression on clavicular division taut bands. Postural correction essential \u2014 axial extension exercise. Advise patient to roll the head on the pillow rather than lifting it when turning in bed. See Muscle:Sternocleidomastoid for full neurological screen protocol (Romberg, nystagmus, postural BP, carotid auscultation) before attributing dizziness to myofascial cause.",
"less_likely": [
{
"muscle": "M\u00e9ni\u00e8re\u2019s Disease",
"reason": "M\u00e9ni\u00e8re\u2019s produces episodic rotational vertigo with fluctuating unilateral hearing loss and nystagmus \u2014 nystagmus is absent in SCM TrP dizziness"
},
{
"muscle": "Benign Paroxysmal Positional Vertigo (BPPV)",
"reason": "BPPV produces brief rotational vertigo (seconds) with a positive Dix-Hallpike; SCM TrP dizziness is a sustained postural unsteadiness without rotational vertigo"
},
{
"muscle": "Splenius Capitis / Cervicis",
"reason": "Posterior cervical muscles do not produce dizziness, disequilibrium, or dysmetria"
}
]
},
"result-levator": {
"type": "result",
"diagnosis": "Levator Scapulae Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Levator_Scapulae",
"chapter_ref": "Travell & Simons Vol.1 \u2014 Ch.19 Levator Scapulae",
"notes": "Levator scapulae TrPs refer pain to the angle of the neck and posterior shoulder. Ipsilateral shoulder elevation reproduces or provokes the pain. Active TrPs rarely appear in the splenii alone \u2014 levator scapulae is almost always co-active and frequently masks coexisting splenius cervicis TrPs. Inactivating levator TrPs first is essential before the splenius cervicis can be properly assessed.",
"confirmatory": [
"Pain at the angle of the neck and posterior shoulder \u2014 characteristic referral zone",
"Shoulder elevation on the same side reproduces or provokes the neck pain",
"Levator scapulae contracts with shoulder elevation (not neck extension) \u2014 distinguishes from splenius cervicis",
"Taut band palpable at the angle of the neck, posterior to the SCM and anterior to the trapezius",
"Often reveals splenius cervicis TrPs after inactivation"
],
"treatment_hint": "Inactivate levator scapulae TrPs BEFORE assessing splenius cervicis. Spray and stretch of levator scapulae. Re-assess splenius cervicis after levator treatment. See Muscle:Levator_Scapulae for full protocol.",
"less_likely": [
{
"muscle": "Splenius Cervicis",
"reason": "Splenius cervicis contracts with neck extension, not shoulder elevation; splenius cervicis TrPs are frequently unmasked AFTER levator scapulae is inactivated"
},
{
"muscle": "Upper Trapezius",
"reason": "Upper trapezius refers to the lateral neck and temple; it does not produce the specific angle-of-neck pattern with shoulder elevation provocation"
}
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings suggest multi-muscle involvement \u2014 common in head and neck pain. Perform a systematic palpation screen of all primary head and neck pain muscles. Note: active TrPs rarely appear in the splenii alone; levator scapulae and other posterior cervical muscles are almost always co-involved.",
"screen_these": [
"Splenius Capitis \u2014 flat palpation in the muscular triangle posterior and medial to the SCM, with head rotation against resistance to identify fibre direction",
"Splenius Cervicis \u2014 approach from the side, anterior to the free border of upper trapezius at C\u2087; medially directed pressure toward the spine",
"SCM sternal division \u2014 pincer palpation full length; SCM Compression Test for pharyngeal symptoms",
"SCM clavicular division \u2014 flat palpation from medial clavicle upward; Romberg test and straight-line walking test if dizziness present",
"Levator scapulae \u2014 palpate at the angle of the neck; shoulder elevation provocation test",
"Upper trapezius \u2014 pincer palpation across the crest of the shoulder",
"Semispinalis capitis \u2014 flat palpation just lateral to midline from occiput to C\u2084",
"Suboccipital muscles \u2014 pressure in the suboccipital triangle",
"Temporalis \u2014 flat palpation in anterior, middle, and posterior zones of the temporal fossa"
],
"wiki_page": "Pain:Head_and_Neck"
},
"result-no-trp": {
"type": "overlap",
"text": "Systematic palpation screen negative for reproducible TrP tenderness. Myofascial trigger point involvement is not confirmed by this assessment. Consider: (1) red flag conditions not yet excluded; (2) primary headache disorders (migraine, tension-type, cluster); (3) cervicogenic headache from cervical articular dysfunction; (4) referred pain from visceral structures; (5) neuralgias (occipital, trigeminal). Re-examine if symptoms change or persist.",
"screen_these": [
"Confirm all red flag conditions excluded",
"Cervical articular dysfunction assessment \u2014 C\u2082 dysfunction most commonly associated with splenius capitis TrPs",
"Primary headache disorder classification \u2014 refer to GP or neurology if indicated",
"Occipital neuralgia \u2014 lancinating quality, positive Tinel\u2019s at the greater occipital nerve"
],
"wiki_page": "Pain:Head_and_Neck"
},
"refer-neuro": {
"type": "neuro_referral",
"urgency": "emergency",
"title": "Serious Pathology NOT Excluded \u2014 Do Not Proceed",
"body": "One or more red flag groups have not been screened or cleared. Myofascial head and neck pain can closely mimic subarachnoid haemorrhage, vertebral artery dissection, meningitis, temporal arteritis, and cervical cord compression. A positive myofascial TrP examination does NOT exclude coexisting serious pathology. SCM TrPs produce autonomic phenomena that superficially resemble Horner syndrome \u2014 true Horner must be excluded before attributing to TrPs.",
"action": "Return to the red flag screen. Act on any positive group per that group\u2019s action before proceeding. For any uncleared doubt about intracranial or vascular origin: refer to Emergency Department immediately."
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "Migraine \u2014 without aura",
"confidence": "common",
"mimics": "Unilateral throbbing headache overlapping with splenius capitis and SCM sternal division TrP patterns",
"distinguishing_feature": "Migraine: pulsating quality, moderate to severe intensity, nausea/vomiting, photophobia or phonophobia, lasts 4\u201372 hours untreated. Myofascial headache: dull ache, reproduced by TrP palpation, no consistent pulsating quality. Note: active SCM and posterior cervical TrPs are a common trigger for migraine episodes \u2014 both may coexist.",
"action": "Palpate for active TrPs in SCM, splenius capitis, and upper trapezius \u2014 TrP inactivation may reduce migraine frequency. Refer to GP or neurology for migraine classification and prophylaxis."
},
{
"id": "bd-2",
"condition": "Tension-Type Headache",
"confidence": "very common",
"mimics": "Bilateral pressing or tightening headache overlapping with bilateral splenius capitis, SCM, and upper trapezius TrP patterns",
"distinguishing_feature": "Tension headache: bilateral pressing quality, mild to moderate, not aggravated by routine activity. Myofascial headache: reproduced by TrP palpation with direction-specific ROM restriction. Many patients diagnosed with tension headache have unrecognised active TrPs in the cervical muscles as the primary source.",
"action": "Systematic TrP palpation of all head and neck muscles. Active TrP inactivation is first-line treatment before prophylactic medication."
},
{
"id": "bd-3",
"condition": "Cervicogenic Headache",
"confidence": "common",
"mimics": "Unilateral posterior to anterior headache from cervical articular dysfunction \u2014 overlaps extensively with splenius capitis and SCM referral patterns",
"distinguishing_feature": "Cervicogenic headache: pain provoked by cervical movements or sustained postures, ipsilateral neck/shoulder arm pain, reduced cervical ROM, joint tenderness on examination. Note: C\u2082 dysfunction is the most common articular dysfunction associated with splenius capitis TrPs \u2014 both muscle and joint sources frequently coexist and require treatment.",
"action": "Assess for cervical articular dysfunction (C\u2081\u2013C\u2082 occipitoatlantal, C\u2082\u2013C\u2083) alongside TrP examination. Inactivate TrPs and mobilise the joint \u2014 either intervention alone is often insufficient."
},
{
"id": "bd-4",
"condition": "Benign Paroxysmal Positional Vertigo (BPPV)",
"confidence": "common",
"mimics": "Postural dizziness overlapping with SCM clavicular division TrP dizziness",
"distinguishing_feature": "BPPV: brief (seconds) rotational vertigo with a positive Dix-Hallpike test; nystagmus present. SCM clavicular TrP dizziness: sustained postural unsteadiness, no rotational vertigo, Romberg negative, nystagmus absent, straight-line walking veers toward the TrP side.",
"action": "Dix-Hallpike test to screen for BPPV. Romberg and nystagmus screen to confirm myofascial origin before attributing dizziness to SCM TrPs."
},
{
"id": "bd-5",
"condition": "Occipital Neuralgia",
"confidence": "uncommon",
"mimics": "Posterior head and occipital pain overlapping with splenius capitis, semispinalis capitis, and suboccipital TrP patterns",
"distinguishing_feature": "Occipital neuralgia: lancinating, electric-shock quality in the greater or lesser occipital nerve distribution; positive Tinel\u2019s sign at the nerve emergence; may have hypersensitivity of the scalp. Myofascial pain: dull aching quality, reproduced by muscle palpation. Note: splenius capitis TrP pain has previously been misdiagnosed as occipital neuralgia.",
"action": "Palpate for TrPs in splenius capitis and semispinalis capitis before attributing pain to occipital neuralgia. Tinel\u2019s sign at the greater occipital nerve confirms neuralgic component."
},
{
"id": "bd-6",
"condition": "Spasmodic Torticollis (Cervical Dystonia)",
"confidence": "rare",
"mimics": "Involuntary head rotation and cervical muscle tautness overlapping with unilateral splenius capitis and SCM TrP-driven head posture",
"distinguishing_feature": "Spasmodic torticollis: paroxysmal or clonic contractions, muscle hypertrophy with fibrotic change, geste antagoniste (touch of the jaw reduces rotation), dystonic movement ceases completely during sleep. Myofascial tautness: steady resistance without paroxysmal contractions, no hypertrophy, no geste antagoniste.",
"action": "Geste antagoniste test and sleep cessation observation. If positive: refer to neurology \u2014 botulinum toxin is first-line. Myofascial TrPs may coexist and can be treated alongside neurological management."
},
{
"id": "bd-7",
"condition": "Whiplash-Associated Disorder",
"confidence": "common",
"mimics": "Multi-muscle head and neck pain with restricted ROM following acceleration-deceleration injury \u2014 splenius capitis is the second most commonly injured muscle in MVA studies",
"distinguishing_feature": "Whiplash: history of acceleration-deceleration mechanism; splenius capitis present in 94% of frontal impacts; multiple anterior and posterior muscles injured simultaneously. Recovery requires inactivation of TrPs in BOTH posterior muscles (splenius capitis, semispinalis capitis) AND anterior muscles (SCM, pectoralis minor). Focusing only on posterior muscles is a common treatment error.",
"action": "Examine all anterior and posterior neck muscles. Baker\u2019s study: splenius capitis and semispinalis capitis are the most commonly active TrPs following MVA; however, anterior muscle involvement (SCM, pectoralis minor) is the most commonly overlooked. Neurological screen required before manual treatment."
},
{
"id": "bd-8",
"condition": "TMJ Internal Derangement / Bruxism",
"confidence": "common",
"mimics": "Facial, temple, and preauricular pain overlapping with SCM sternal division and masseter TrP patterns",
"distinguishing_feature": "TMJ derangement: click or crepitus on jaw opening, mandibular deviation on opening. SCM and masseter TrPs activated by forward head posture and parafunctional habits may drive TMJ symptoms as satellite patterns. SCM is a key TrP that activates masseter, temporalis, and other masticatory muscles as satellites.",
"action": "Treat SCM TrPs first \u2014 satellite resolution in masseter and temporalis often follows. Full TMJ screening examination if joint symptoms persist after SCM inactivation. See Pain:TMJ_Screening_Examination."
}
]
}