Topical Migraine Trigger Point Treatment as Effective as Injection

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The use of trigger point topical treatment with a nonsteroidal anti-inflammatory drug may be as effective as trigger point anesthetic injection to relieve migraine pain.
The use of trigger point topical treatment with a nonsteroidal anti-inflammatory drug may be as effective as trigger point anesthetic injection to relieve migraine pain.

In patients with frequent migraine attacks, cervical myofascial trigger points, and target areas coinciding with the site of migraine pain, the combination of standard migraine prophylaxis with topical trigger point treatments may be effective in reducing migraine severity and frequency, according to a study published in The Journal of Headache and Pain.

The study authors conducted a retrospective analysis, specifically studying patients with migraine who also had cervical myofascial trigger points and whose target areas coincided with migraine sites. These patients were divided into 3 groups (25 participants per group) and received flunarizine 5 mg per day and on-demand treatments. All participants received monthly evaluations and a headache diary. Evaluations included migraine attack frequency, rescue medication use, and migraine intensity. 

Pain thresholds to skin electrical stimulation and muscle pressure stimulation at trigger points and targets were evaluated at baseline, days 30, 60, and 180. Researchers used analysis of variance for recurring measures and 1-way analysis of variance to assess sequential trends and for group comparisons. They set the significance level at <.05.

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Group 1 inclusion criteria included a diagnosis of migraine without aura, ≥7 migraine attacks within the prior 2 months, ≥1 myofascial trigger points in the cervical muscles that coincided with migraine pain site, and a history of allergy to or intolerance of nonsteroidal anti-inflammatory drugs (NSAIDs) or local anesthetics and/or needle phobia. 

Participants in this group did not receive trigger point treatment. Individuals in group 2 met the same inclusion criteria but did not have a history of needle phobias. Participants in this group received trigger point injection with bupivacaine 5 mg/mL in basal conditions and on days 3, 10, 30, and 60. The individuals in group 3, with similar inclusion criteria to group 1, received daily trigger point topical treatment with 1.5 grams of 3% nimesulide gel for 15 days, followed by a 15-day interruption, and another 15 days of treatment.

The study results for individuals in group 1 indicated that the number and intensity of migraine attacks progressively decreased during the treatment period, but not significantly until 60 and 180 days from baseline (.01 < < .001). Drug consumption also progressively decreased with noteworthy effects at 60 and 180 days (<.001). The study results for individuals in group 2 indicated a significant reduction in the number and intensity of migraine attacks and drug consumption. This reduction was significant as early as day 30 and continued over the study period (<.001 for all internal comparisons). 

The study results for patients in group 3 showed a substantial reduction in migraine attack frequency, intensity, and in drug consumption as early as day 30 (<.05 for number of attacks and drug consumption; <.01 for intensity), and the trend progressed over the evaluation period (<.001 at 60 and 180 days). 

There were no significant differences among individuals in the 2 trigger point groups regarding migraine parameters, skin electrical stimulation, and muscle pressure stimulation. In these same 2 groups, some patients reported improvement of a concurrent cervicalgia/cervicobrachialgia.

Researchers acknowledged the retrospective nature of the study, short duration of follow-up, and lack of a comparison group as limitations of this study.

Study results indicate that trigger point topical treatment with an NSAID may be as effective as trigger point anesthetic injection. "These results, though preliminary, are of relevance in routine medical practice, suggesting use of this topical treatment in addition to the standard migraine prevention measures, to help enhance the therapeutic outcome," the researchers concluded.

Multiple authors declare associations with the pharmaceutical industry. Please see the original reference for a full list of authors' disclosures.

Reference

Affaitati G, Costantini R, Tana C, et al. Effects of topical vs injection treatment of cervical myofascial trigger points on headache symptoms in migraine patients: a retrospective analysisJ Headache Pain. 2018;19(104):1-10.

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