S3:Ep17 – Trigger Point Injections for Migraine
Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.
This episode is brought to you in part by our generous sponsors Amgen and Novartis.
Molly O’Brien: Hi there and welcome to Spotlight on Migraine. I’m your host Molly O’Brien. Today, we’re going to tackle the subject of trigger point injections and how you can use them for migraine. So to help us discuss this topic, I’d like to introduce our guest. She’s a board-certified neurologist and director of the Westport Headache Institute, Dr. Deena Kuruvilla. Thanks so much for joining us.
Dr. Deena Kuruvilla: Thank you for having me, Molly.
Molly: We’re super excited to have you, and I’m really interested in this topic. I’d also like to mention that Dr. Kuruvilla is an AMD executive board member, which we’re happy to have you on board in that way as well.
So let’s start off with the super basics. Before we get into trigger point injections, can you tell us a little bit about what trigger points are and where they are on our body?
Dr. Kuruvilla: Absolutely. So trigger points are areas of muscle that can feel like a taut band. Trigger points can exist basically wherever muscles exist, but the most common locations for trigger points in headache disorders are in the trapezius muscle. So the trapezius muscle is a huge muscle within the upper back that connects to the neck. That is the most common location for trigger point injections and one of the most commonly affected areas for headache disorders.
Other trigger point hotspots, I could say, are the neck muscle, the cervical paraspinal muscles; the neck muscles right in the front, the sternocleidomastoid muscles on both sides; the muscles within the temple, the temporalis muscle. These are the most common locations that we find these taut bands.
And the thought is that these taut bands form because there may be too much acetylcholine, one of the main chemicals within the body, within the muscle. Too much acetylcholine within the muscle can cause this sustained muscle contraction that can lead to loss of blood flow to that particular area of the muscle. It can lead to severe pain within that area of the muscle, which is what we see in our practice, is really severe pain in a specific area of muscle, a taut kind of band when you feel that area. That’s a trigger point.
Molly: OK, good to know. And I bet people at home are going, “Oh, yeah, I’ve got that right here. I know I [inaudible], here or right here.”
Dr. Kuruvilla: They’re very common.
Molly: I’m sure a lot of people can relate. So, again, we’re going to keep it super basic to start off with. What are trigger point injections?
Dr. Kuruvilla: Yeah. So, basically, it’s taking a really tiny needle and taking anesthetic medication, bupivacaine or lidocaine, and injecting it directly into that part of the muscle, that knot, if that’s a better term to describe it. The knot is that taut band.
Molly: OK, and I think a lot of people at home can relate to, “Oh, I’ve got a knot right here or in my back or my shoulder.” You explained a little bit about the medication used and how it happens. Can you walk us through a trigger point injection session or the actual therapy, what people can expect, what the establishment will do? Can people walk out 5 minutes later, 10 minutes later? How does it work?
Dr. Kuruvilla: The most important part of the whole procedure is finding those areas, finding those trigger points. And so your doctor or your provider doing a physical exam is probably the most important part.
So, once a physical exam is done within the different muscles of the head and neck and the provider has found the hotspot, basically, what I do is I pinch the area to stabilize that area of muscle, to stabilize that trigger point, so it doesn’t move while I’m injecting it. I try to elicit a twitch. Sometimes we can see some twitching of the muscle in a trigger point. And then I am directly injecting that trigger point and injecting the medication, that anesthetic medication, bupivacaine or lidocaine.
I sometimes do repeated injections within the same trigger point to break up that taut band, to break up that knot, and people see results immediately. The anesthetic medication works immediately. You go to the dentist’s office and get an anesthetic medication in your tooth, like novocaine, and it works right away — same thing. You’re going feel this right away, and you should feel that numbness for a couple of hours after you have the injection.
No one usually stays in the office to be observed or has any limitations after the procedure. After the procedure is done, if you’re feeling okay, you’re basically ready to go back to your regular life and regular activities.
Molly: Sounds amazing. Sign me up for a lot.
Molly: They sound very relieving, and the fact that you can find some relief immediately is incredible.
Dr. Kuruvilla: Absolutely.
Molly: So, Dr. Kuruvilla, can you tell us a little bit about how getting a trigger point injection can help in relation to migraine?
Dr. Kuruvilla: So it’s really interesting. Trigger point injections have been done across the spectrum in headache disorders, but with migraine specifically, what I found is — and research has shown — the vast majority of people have neck pain and they have upper back and shoulder pain. And we know that migraine is an inflammatory disease. We know that there’s CGRP, neurokinin, substance P being released in migraine, and the same is true for trigger points.
So research has shown that active trigger points have high levels of those same inflammatory factors, like CGRP, substance P, neurokinins. And so by treating those trigger points, we may be disrupting that process. We may be disrupting inflammation and disrupting that pain process by kind of blocking that inflammation.
Molly: It’s so cool to learn about this, and I hope people at home are learning a lot too. What do we know about the safety and efficacy about getting trigger point injections and also the actual medication injected?
Dr. Kuruvilla: Sure. So the injection itself is a very safe injection. It’s done outpatient in a clinic. And there are not enough randomized clinical trials specifically looking at trigger point injections for headache disorders. With that said, I was a part of a kind of consensus statement on using trigger point injections specifically for headache disorders, because, clinically, we see that people get so much benefit from it.
It’s usually best as an additive therapy. We’re not just using trigger point injections alone for the treatment of migraine, but we use it to add in based on our physical exam and based on the existence of pain within those muscles. And so, clinically, we see that it can be extremely helpful for releasing those really tight areas as an additive treatment to what we’re already doing, but we need more clinical trials in order to see that on a larger landscape.
The injections themselves are extremely safe. We use a really tiny needle. There have been rare cases of damage to the lung pneumothorax in very specific locations for the injections. For example, injections that are done too forward in the neck can disrupt the blood vessels of the neck or result in damage to the lung. And so we have to be really careful as providers when we’re doing these injections to pinch and locate the muscle and isolate any blood vessels or anything else before we do these injections.
The medications themselves, bupivacaine and lidocaine, are very safe. Lidocaine is the preferred anesthetic in pregnancy, and so we tend to use lidocaine as the safer option in pregnancy. But, otherwise, we’re using bupivacaine for pretty much everyone else.
Molly: You brought up a couple really great points in there that I wanted to address. You said that there could be some damage to blood vessels and lung. It’s very rare, but you want to have a provider who knows what they’re doing. I mean, that sounds real important. So what can someone look for or what should they look for in a provider if they are interested in trying trigger point injections?
Dr. Kuruvilla: Absolutely. So I would say most headache board-certified physicians are very comfortable with trigger point injections. Most pain-medicine board-certified physicians are very comfortable with trigger point injections. So those might be the two areas to pursue if you’re considering trigger point injections.
It’s always OK to ask, “How frequently are you doing trigger point injections?” or, “Have you done a lot of these injections?” just to feel comfortable with the person that’s doing the injections. But I think headache — if you’re going for headache board-certified or pain-medicine board-certified, you should be safe. Because we’re always taught to look out for things such as the patient’s individual anatomy, and if any anatomy is off, we might consider using an ultrasound, for example. I think most headache board-certified physicians and pain-medicine board-certified physicians are very comfortable with deciding those things, so that might be where to go.
Molly: OK. That’s great advice there. You also mentioned “very small needle” a few times, which is always good to hear “small” when you’re talking about injections. But I’m sure a lot of folks out there want to know if this is a painful experience, and I think classifying that it’s a small needle helps for people who might not be so comfortable around needles.
Dr. Kuruvilla: Absolutely. So the injections can be painful because the area that we’re injecting in the trigger point is an area that’s usually very inflamed and the muscle in that area has contracted so much that it produces pain for the patient. And so when we do inject, especially the first time, it can be painful. We may inject the same trigger point multiple times to break up that band, and so that can end up being painful. But that’s why we use an anesthetic to help numb that area.
There is another technique called dry needling, which a lot of my pain-management physicians use, where they only needle the area and do not use anesthetic. In my experience, for patients, that can be more painful because an anesthetic is not being used.
Molly: OK, and that’s good to know a little bit about the differences between them. They’re sort of similar, but not entirely, so it’s good to know.
I did want to ask you, kind of, if you go in, and you’ve had a massage, and someone’s working a knot out in your neck or your back, and they can say, “You might be sore for a couple of days before you find relief” — do you find that patients are sore at all after having a trigger point injection, or can an injection actually trigger a migraine for some people?
Dr. Kuruvilla: So I haven’t found that patients are sore after the injection, and I think that’s mainly because we’re injecting anesthetic with the treatment. I also haven’t found that patients have been triggered, specifically — it’s triggered a migraine for them.
This is a really great point that you make, Molly, because we know that with other types of injections — such as Botox, for example, or nerve blocks, for example — people may develop a migraine after the procedure. And, in my experience, that happens when the injection goes too deep and hits the periosteum. We are hitting bone, or we’re advancing the needle too much and manipulating the nerves around the head.
So, in trigger point injections, we are not in danger of hitting bone so much, which is really positive, and we’re not manipulating nerves like we are with nerve blocks and Botox. And so it’s less likely that we produce a migraine with trigger point injections.
Molly: Well, that is fascinating to know. I learned so many different things just in that one answer. I think some people are curious, too, on how often can you receive trigger point injections. Is this once in a couple of months? Is it every week?
Dr. Kuruvilla: So, as a very general outlook, most people, after they’ve received these injections, are OK with those painful areas for about a month. But I always give my patients the option to get in touch with me if they would like injections to be repeated sooner. Or, after a month, if they need the injections, we can push them to monthly. If they’re OK for six weeks, we push them to every six weeks or two months. It really depends on the individual person.
But, generally, I try to space them out a month apart, and I have had some rare cases where we’ve done them every two weeks. But, in this world, Molly, insurances kind of run all of our lives, and often if we do them sooner than two weeks, insurance companies opt not to cover it. So we have to be really careful about that.
Molly: OK, that’s great to know. And, of course, if you are interested, work with your doctor or healthcare provider to figure out a plan that can work best for you, it sounds like.
Dr. Kuruvilla: Yes.
Molly: So is there anyone that can benefit more from these trigger point injections? Is there an ideal person that can find a lot of relief? And then on the flip side of that, is there anyone who should avoid trigger point injections?
Dr. Kuruvilla: Yeah, that’s a great question. So I can say that people who should avoid trigger point injections are those with active infections. Anyone with an active infection, anyone with an infection within the skin at the site that we’re thinking about injecting, anyone with a skull defect. If you have a history of surgery where the skull has been removed for any reason, we should probably avoid trigger point injections in those cases. I think those would definitely be the big ones.
Another population that I’m super careful with is our patients who are on blood thinners. If they’re on blood thinners, I’m extremely cautious. Sometimes I’m checking blood work. I’m putting extra pressure to stop bleeding and monitoring them in my office for a little bit longer. So those are the people that I might certainly be more cautious in with these injections.
The people that might benefit from the injections is certainly variable. If someone is telling me they’re having a lot of upper back or neck pain, I am always doing a thorough exam to see if I can find these trigger points within the neck or the shoulders. I do check for trigger points in the temples also to make sure there’s not trigger points there. If I find them, I always end up offering trigger point injections.
Molly: OK, thank you for that. And you explained a little bit about how trigger point injections can differ from other types of injections, say, Botox and nerve blocks. But can you tell us just a little bit more about the mechanism of how it works? And, obviously, they go in different places and that kind of thing. Can you just explain a little bit more about that for us?
Dr. Kuruvilla: Of course. So I should start off by saying that Botox is the only FDA-approved preventive — one of the only FDA-approved preventive treatments for migraine, specifically for chronic migraine. And so with that protocol that’s been around for over 20 years now or so, we are injecting with Botox very specific areas, forehead, sides of the head, upper back, neck, and shoulders.
We’re injecting muscle, but we’re really, by injecting the muscle, trying to target the nerves, the superficial nerves of the forehead, the head, and the neck. And we’re trying to block calcitonin gene-related peptide, CGRP, and other inflammatory mediators. Botox lasts in the system for around 10 weeks or so, and then it starts to wear off. And so Botox is a treatment that needs to be done every 12 weeks to prevent chronic migraine. In Botox, we use acupuncture-like needles to inject the treatment directly under the skin, and then that kind of compares with nerve blocks.
Nerve blocks and trigger point injections can be used very similarly. Nerve blocks are basically when we take an anesthetic medication like lidocaine or bupivacaine and specifically inject nerves that we know are a part of the migraine circuit. We are injecting four areas in the forehead, one area on each side of the head, and two to four areas at the back of the head, specifically targeting nerves.
We use nerve blocks as an emergency treatment. For example, if someone’s had a severe headache for several days, we’ll say, “Come on in. We’ll give you a nerve block to try to break this headache cycle.”
We do also use it for prevention in rare cases. In our patients who are pregnant, we might do lidocaine nerve blocks every month to get them through their pregnancy. We also use nerve blocks for prevention in people with a lot of medical problems who can’t be on mainstream oral preventives or injectable preventives that we usually use. So nerve blocks have so many different utilities for migraine.
Trigger point injections are used very similarly to nerve block injections. I will even go as far as saying these trigger point injections complement nerve blocks. I often add in trapezius muscle trigger-point injections with nerve blocks to target the muscle specifically while nerve blocks are targeting the nerves. And so they can work together to break a bad headache cycle, trigger point injections and nerve blocks. Or if I’m preventing with nerve blocks, I might add trigger point injections also as a preventative approach.
Molly: So it’s good to know that these therapies can be used in combination with each other. That’s always great to know, another question people are curious about. That’s great to hear.
Dr. Kuruvilla: Yeah, absolutely. There’s so many different combinations of treatments now for the preventive treatment of migraine and the rescue treatment of migraine that it’s really an art trying to narrow down what to put together that works for every individual person.
Molly: Yeah, and everyone’s so different that the same remedy doesn’t work for everyone. So it’s nice to know that there are continuously more options becoming available to us.
All right, and that wraps up this conversation all about trigger point injections and migraine. I hope you learned a lot. I know I did. And I’d like to thank our guest today, Dr. Deena Kuruvilla. She is an AMD executive board member and also the director of the Westport Headache Institute. Dr. Kuruvilla, thank you so much for joining us today.
Dr. Kuruvilla: Thank you so much for having me, Molly. I look forward to chatting again soon.
Molly: Me too. You’ve been excellent and answered so many questions. We really appreciate it.
Dr. Kuruvilla: My pleasure.
Molly: And that wraps up this episode of Spotlight on Migraine. I appreciate you watching. Again, I hope you learned a lot. My name is Molly O’Brien, with the Association of Migraine Disorders, and we’ll see you next time.
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