Pain pattern: Sternocleidomastoid
Pain pattern: Posterior cervicals
Pain pattern: Splenius cervicis
Pain pattern: Masseter
Pain pattern: Temporalis
Pain pattern: Pterygoids
Eight cranial bones and fourteen facial bones form the structure of the skull. Suspended from the skull is the head’s only moveable bone, the mandible, known colloquially as the jawbone. Upon the bones of the skull lie the fifteen muscles through which we express most of our emotions, and the four muscles that move the lower jaw, allowing us to bite, grind, and chew food.
For most of us the face is the focal point of our sense of self. Rather than feeling our sense of self in the belly, chest, legs, or back, we identify ourselves with and in our face and head. This is one of the primary reasons that headache and facial pain can be so debilitating; pain in this region intrudes on our ability to function in ways that other bodily aches and pains do not. It interferes with our ability to think, to concentrate, and sometimes to see clearly. You can’t get away from head or face pain.
Head and facial pain often occurs as a function of injury or strain of the neck muscles, particularly when the head is held in extension (when it is dropped back slightly). Whiplash is often the source of injury, whether the whiplash has taken place as a result of an automobile accident or a fall. A fall secondary to being tackled from behind is the perfect example. Tackled from behind, the head flies backward before it is thrust forward. This is the recipe for sternocleidomastoid (SCM) injury—the trademark whiplash.
Straining the neck while holding it in extension is another source of injury. Think about it—the upper body bent forward over bent legs, head up, chin jutting forward. This head posture is common in football, tennis and other racket sports, in swimming the breaststroke, and in bicycling. Sitting in the front rows of a theater or painting your ceiling will place your head and neck in the same position. Consider what this position is doing to the neck muscles—the muscles in the front of the neck are lengthened and the muscles in the back of the neck are shortened. This posture inevitably leads to weakness of the neck musculature and the development of trigger points.
Keeping the head and neck bent forward in flexion for extended periods of time can be equally problematic. Lying in bed with your chin on your chest as you read a book or watch television is a prescription for restriction in the neck muscles. That muscular restriction may cause facial pain resembling sinus headache as well as phenomena that are generally considered to be completely unrelated to the musculature such as dizziness, imbalance, and tearing of the eye. Using a computer monitor that is positioned below your line of sight can do the same thing.
Head and facial pain may stem from a number of different disorders including, but not limited to, sinusitis, dental problems and infections, migraine or cluster headaches, neurologic disorders, and visual disorders. In many cases head and facial pain can be remedied through self-care. However, if pain is severe or debilitating, if it is accompanied by nausea, vomiting, extreme sensitivity to light and sound, facial swelling, loss of facial muscle control, visual disturbances, and/or difficulty speaking, chewing, swallowing or breathing, it is recommended that you seek professional evaluation prior to self-treatment.
Overuse or improper use of the muscles that are involved in chewing—the temporalis, masseter, and the pterygoids—will often lead to trigger points and resultant facial pain. Because of its location and associated symptoms, pain from trigger points in the head, neck, and facial muscles is often diagnosed as TMJ syndrome, a dysfunction of the temporomandibular joint. The temporomandibular joint connects your jawbone to your skull. The joint is located just in front of your ear. Place your index finger on the side of your face in front of the center of your ear, then open and close your mouth; you will feel the movement of the TMJ. You can also place your finger inside your ear and feel the movement of the joint as you open and close your mouth. Clenching a mouth guard or clenching onto a snorkel or regulator while diving produces overuse or improper use of those muscles, as will the automatic clenching of the teeth when lifting heavy weights, regardless of whether those weights are physical or emotional. Direct trauma to the jaw or habitually holding the head in a head-forward posture also places strain on these muscles and can lead to jaw dysfunction.
If you have head or facial pain, consider the symptoms that are associated with each of these muscles. Once you’ve identified the muscles that are involved, find and release their trigger points. But don’t stop there. Check out the rest of the muscles in this section—see if there are taut bands in those muscles as well. It’s highly likely that there will be. Release them all and stretch them all. You’ll be glad you did.
THE STERNOCLEIDOMASTOID MUSCLE, the SCM, is a large muscle that lies on the side and front of the neck. Its name describes where its attachments are—on the breastbone or sternum (sterno), the collarbone or clavicle (cleido), and the bump on the base of your skull behind your ear, the mastoid process (mastoid). The SCM acts in many different ways. When only one SCM is working, it turns and tilts your head to one side. When both muscles are working at the same time, the SCM flexes your neck, allowing your chin to drop down toward your chest, and it controls the backward motion of your head. Working with the trapezius, the SCM helps to stabilize the position of the head when your jaw moves, which is every time you speak or chew. Think about how hard this muscle has to work—the human head weighs as much as eight pounds!
Trigger points often develop in the SCM as a result of a whiplash injury. A whiplash is the forceful, unexpected, uncontrolled forward-then-backward motion of the head. Auto accidents are a well-known cause of whiplash injuries. So are falls, something that every athlete is at risk for. Keeping the head down for extended periods of time as well as extending it back for periods of time can create overuse injuries, another source of trigger points. Think of the position of the tennis player who is practicing receiving serves—the forward bend at the waist with head up is exactly one to strain the SCM. It is a familiar position for football players and skiers. Wrestlers practicing “bridges” are practically looking for trigger points in those positions!
Trigger points in the SCM don’t refer pain to the neck at all. The most common symptom of trigger points in the SCM is pain in the forehead, most of the time on the same side as the involved muscle; when trigger points are severe, pain can be felt across the entire forehead. Pain might also be experienced deep in the ear. Trigger points can produce pain in the cheek and temple and around the eye. There can be pain and scalp tenderness right at the top of your head. Symptoms unrelated to pain include dizziness and lack of balance, tearing and redness of your eye, visual disturbances, and increased mucus production in the sinuses. You might also develop a dry cough.
To identify the sternocleidomastoid, look in a mirror and turn your head slightly toward your left side, then tilt your right ear toward your right shoulder; you’ll see the bulge of the SCM on your right as it contracts to perform this action. You can easily grasp the muscle between your thumb and fingers and follow its course from the collarbone all the way up to the base of the skull.
Once you’re clear on where the muscle is, relax your neck and head and allow the muscle to relax. Grasp the muscle using a pincer technique, using both your thumb and your fingers. Massage the muscle through its length, feeling for tender spots. You can locate trigger points on both sides of the SCM. Once you’ve found a sore spot, hold it and massage: direct pressure followed by tiny circles directly on the trigger point works nicely. Leave the trigger point for a few seconds and then return to it.
Working on the SCM can be quite painful. Don’t live by the “no pain, no gain” formula with trigger points in this muscle. Pain that is bearable will produce results; pain that is unbearable will produce an irritated SCM.
Follow up working on the muscle with stretches.
Because the SCM is activated when you breathe up into your chest, it’s important to train yourself to breathe deeply into your lower abdomen. See page 173 for specifics on how to do this.
Stretch 2: Sternocleidomastoid, sternal head
Semispinalis Cervicis
THE POSTERIOR CERVICAL MUSCLES—the muscles in the back of the neck—work together to turn the neck and to extend the head and neck, allowing you to look up and back. These two muscles need to be examined together because of their close working relationship. Both muscles run vertically in the back of the neck. Semispinalis capitis attaches to the base of the skull; it acts to extend the head. Semispinalis cervicis attaches to the neck and its primary action is on the neck. Semispinalis cervicis is one of the most powerful muscles of the neck; for this reason it is sometimes called the “workhorse muscle.”
When trigger points are present in semispinalis capitis pain encircles the head, with its greatest intensity experienced at the temple and forehead over the eye. Think of a painful vice-like grip around your head that is focused over your eye. Semispinalis cervicis trigger points produce pain and soreness at the base of the skull and into the neck. When trigger points are present there will be difficulty dropping your head downward (flexing the head and neck) and looking up and back (extending the neck and head). You won’t be able to do either comfortably.
The posterior cervicals are deep, lying beneath several layers of muscle, but when there are areas of tightness and constriction they can be felt through the upper layers of muscle. Lie on your back with your head supported by a pillow that is thick enough to prevent your head from being forced forward or dropped back. Place your fingers at the base of the skull on either side of the spine. Move your fingers from the base of the skull to the upper back, within the muscle mass just beside the spine. Feel for thick bands of muscle. These will be the tight bands within the posterior cervicals. You might feel particular areas of thickness about 1 to 2 inches below the base of the skull and then again 1 to 2 inches below that. Once you find those areas, just hold your pressure gently into the muscle. Relax your head and neck and breathe slowly. With patience you’ll begin to feel the softening of the bands and the release of the muscle.
To stretch the posterior cervicals drop your head forward, aiming your chin for your chest. Allow the weight of your head to stretch these muscles. Hold this position for a count of ten to twenty. Repeat the stretch regularly throughout the day for a complete release.
Stretch: Posterior cervicals
SPLENIUS CAPITIS lies beneath the trapezius. It runs diagonally from the base of the skull, at the bump that can be felt behind the ear, to the vertebrae in the middle of the neck and the upper back. The muscle may be difficult to feel. Splenius capitis extends the head and neck and turns it to the side.
Thrusting the head forward is the action that most often is the precursor of trigger points. Tennis players anticipating the serve have their heads in that position. When there are trigger points in splenius capitis the pain will be felt directly at the top of the head.
To locate and treat splenius capitis, sit with your back resting against a chair. You’ll want to find the space between the upper trapezius (page 42) and the sternocleidomastoid (page 28). First, locate the bump at the base of your skull behind the ear. The sternocleidomastoid starts there. Press just behind the SCM and move your hand down the side of the neck. You’ll begin to feel the front border of the trapezius as you reach the middle of your neck. Just at that level, start to feel for a thin band of muscle in between the trapezius and the SCM. Gently press into that band. Hold it for several seconds to allow it to release. Work the trigger point in this way several times during the day. Follow it up with stretches.
To stretch splenius capitis, drop your head forward and down, turning the neck 20 to 30 degrees away from the painful side. Hold this position for a count of ten to twenty.
SPLENIUS CERVICIS attaches to the vertebrae of the neck and upper back. It extends the neck, turns the neck, and bends it to the side.
Thrusting the head forward is the action that most often is the source of trigger point development in this muscle: a tennis player anticipating receiving the serve has his or her head in this exact position. When there are trigger points in this muscle you may experience neck, head, and eye pain. Neck pain will be felt right at the angle of the neck, where the neck meets the shoulder, and it might include neck stiffness as well. There may even be some aching pain that goes through the head to the back of the eye. You might experience blurry vision in that eye as well.
Try to feel for splenius cervicis right at the angle of the neck. Sit with your back resting against a chair and bend your head, just a bit, to the side that the pain is on. You’ll be able to slide your fingers in between two layers of muscle to touch the deeper splenius. Once you’re able to feel the muscle, bend your head just a bit to the other side; you’ll feel splenius tightening under your fingers. Press gently into that band, holding it for several seconds. You’ll start to feel the muscle release slowly.
To stretch splenius cervicis, drop your head forward and down, turning the neck 30 to 40 degrees away from the painful side. Hold this position for a count of ten to twenty.
Stretch: Splenius cervicis
THE MASSETER is one of the strongest muscles of the face. It attaches to the part of the cheekbone that is close to the ear and to the jawbone, the mandible. It works when you chew and clench your teeth by raising the lower jaw. If you place your hand on your cheek, just by your lower jaw, and gently clench your teeth, you will feel the masseter move as it contracts. You may be able to see it contracting and releasing when a person is angry and automatically clenches and releases his or her jaw.
If you consider the action of this muscle you can figure out what causes its restriction—clenching on a mouth guard; clenching on a regulator or snorkel; clenching the teeth at night. Periods of any such activity can easily trigger the restriction of the masseter. Bodybuilders naturally clench their teeth when they are lifting heavy weights. Everyday actions—biting on something hard, chewing gum, biting the nails—or sustaining a trauma to the head that involves the jaw can also cause trigger points to develop in the masseter.
When the masseter develops taut bands and trigger points, it can become the source of facial pain. Sometimes the pain will be felt over the upper teeth and cheek and above the eyebrow. Trigger point pain might be described as sinus pain and it may even be misdiagnosed as a sinus infection. Sometimes the pain will be felt on the side of your cheek and deep in the ear, and it may cause ringing in the ears. When the masseter develops trigger points you may not be able to open your mouth as wide as you would like. Normally you can open your mouth comfortably to accommodate the knuckles of two stacked fingers. If you can’t do that, you have restriction in your jaw and you need to feel for trigger points in the masseter as well as in the other muscles involved in chewing: the temporalis and the pterygoids.
The masseter is covered by the parotid gland (the gland that swells when you get the mumps), so trigger points can sometimes be difficult to identify from the outside. You need to examine and treat the muscle from the inside of your cheek. Wash your hands well, then place your thumb on the inside of your mouth and your fingers on your cheek. Clench your teeth just a bit to identify the muscle. Use your thumb to work out any taut bands and sore spots in the muscle. It might be quite sore and painful; you may need to treat the muscle in this way several times during a day and over a period of days. Keep at it and it will release slowly. A good time to work on this muscle is when you’re in the shower. Your muscle will be warmed up and your hands will be clean.
After you’ve worked on the muscle you need to stretch it out. Place your hand under your chin to provide mild resistance to opening your mouth. Open your mouth gently against that resistance. Hold the position for a count of three to five. Repeat this stretch three times. Following this stretch cycle, open and close your mouth several times without resistance.
It’s important to avoid those activities that produce restriction in the jaw muscles—chewing gum, biting into hard foods, biting your nails, or clenching into a mouthpiece. Correcting a head-forward position is an important part of treating and retraining these muscles. Being mindful of the need to change is the first step toward lasting change.
You can begin to alter your head posture by trying to lengthen your spine, as if you were suspended from a string attached right at the top of your head. When seated you can place a small pillow or support at the small of your back in order to raise your chest. This will also allow your head to take on a more upright position.
Stretch: Masseter
THE TEMPORALIS is the strongest and most efficient of the chewing muscles. Temporalis is a large, flat muscle that lies on the temple, fanning the ear. Its lower attachment is to the jawbone, the mandible. Temporalis works with the masseter to close the jaw. If you place your fingers above your ears on your temples and lightly clench your back teeth you will be able to feel the contraction of temporalis.
Trigger points can develop in the temporalis much in the same way that they develop in the masseter—through clenching the teeth, grinding the teeth, and direct trauma caused by an impact or a fall. When trigger points do develop, pain is experienced as a headache in the temple region and it may extend as far as the eyebrow, the upper teeth, and to the area of the temporomandibular joint (TMJ). In addition to pain, your teeth might feel hypersensitive to heat, cold, or pressure. If your teeth are painful it’s important to see a dentist, but if the dentist is unable to identify anything wrong with the tooth it’s clearly worth your time and effort to try to find and release taut bands and trigger points in the temporalis muscle.
You can locate temporalis trigger points by spreading your fingertips in an arc about one inch above your ear and into the temple. Lightly clench your back teeth. You will feel the muscular contraction under your fingers. Gently move your fingers back and forth across the fibers of the muscle to locate taut bands within it. The trigger points will be the most sensitive points within those taut bands. Compress the points gently for several seconds to release them.
To stretch temporalis spread your fingers across the muscle, just behind the temples and above the ears. Open your mouth as wide as you can and inhale; as you exhale, press upward along the course of the fibers of the muscle. Hold for a count of five to ten. Repeat several times.
Just as with masseter, it’s important to avoid those actions that produce restriction in the muscles involved with chewing—chewing gum, biting into hard foods, biting your nails, or clenching a mouthpiece.
THE PTERYGOIDS suspend the lower jaw from their bony attachments within the skull. They work with the masseter and the temporalis to elevate the jaw, they produce the back-and-forth motion needed to grind food, and they draw the jawbone forward, a movement that’s necessary for opening the jaw wide.
The lateral pterygoid is the most common muscular source of TMJ dysfunction, yet the pterygoids are often overlooked because of the nature of the symptoms that are associated with trigger point development. Pain in the cheekbone and temporomandibular joint just in front of the ear, painful clicking of the jaw when opening and closing the mouth, difficulty in opening the mouth wide, and chewing difficulties send people to dentists and TMJ specialists, not myofascial therapists. Sinus pain with increased mucus production from the sinuses send patients to an ear, nose and throat doctor. In fact, all of these symptoms are associated with a muscular source of restriction.
The pterygoids are small muscles and their position is well back on the jaw, so they are difficult to feel. To find the lateral pterygoid, start at the cheekbone just in front of the ear. Press the underside of the cheekbone, following its course toward your nose. Open and close your jaw as you do this and you’ll feel the lateral pterygoid contract and release about an inch away from your ear. If there are trigger points you will feel a very tender, tight vertical band reaching up underneath your cheekbone. Press right into that band.
You can work on the lower end of the medial pterygoid by pressing up underneath the angle of the jaw about ½ inch. The upper fibers of medial pterygoid need to be reached inside your mouth. Wash your hands and then reach way into the back of your mouth, behind your last molar. You’ll feel the sharp, bony edge of the jawbone. Work on the muscle just behind that. Gently biting down on a small object such as a pencil or a cork will help you to identify the muscle clearly. If there are restrictions in the muscle it will undoubtedly be very sore. Work for brief periods of time several times throughout the day.
Follow up with a stretch. Place your hand under your chin to provide a mild resistance to opening your mouth. Open your mouth gently against that resistance. Hold the position for a count of three to five. Repeat this three times. Following this stretch cycle, open and close your mouth several times without resistance.
