title: Referred pain elicited by manual exploration of the lateral rectus muscle in chronic tension-type headache.
abstract: OBJECTIVE
  To analyze the presence of referred pain elicited by manual examination of the lateral rectus muscle in patients with chronic tension-type headache (CTTH).
  
  
  METHODS
  A case-control blinded study.
  
  
  METHODS
  It has been found previously that the manual examination of the superior oblique muscle can elicit referred pain to the head in some patients with migraine or tension-type headache. However, a referred pain from other extraocular muscles has not been investigated.
  
  
  METHODS
  Fifteen patients with CTTH and 15 healthy subjects without headache history were included. A blinded assessor performed a manual examination focused on the search for myofascial trigger points (TrPs) in the right and left lateral rectus muscles. TrP diagnosis was made when there was referred pain evoked by maintained pressure on the lateral corner of the orbit (anatomical projection of the lateral rectus muscle) for 20 seconds, and increased referred pain while the subject maintained a medial gaze on the corresponding side (active stretching of the muscle) for 15 seconds. On each side, a 10-point numerical pain rate scale was used to assess the intensity of referred pain at both stages of the examination.
  
  
  RESULTS
  Ten patients with CTTH (66.6%) had referred pain that satisfied TrPs diagnostic criteria, while only one healthy control (0.07%) reported referred pain upon the examination of the lateral rectus muscles (P < 0.001). The elicited referred pain was perceived as a deep ache located at the supraorbital region or the homolateral forehead. Pain was evoked on both sides in all subjects with TrPs, with no difference in pain intensity between the right and the left. The average pain intensity was significantly greater in the patient group (P < 0.001). All CTTH patients with referred pain recognized it as the frontal pain that they usually experienced during their headache attacks, which was consistent with active TrPs.
  
  
  CONCLUSIONS
  In some patients with CTTH, the manual examination of lateral rectus muscle TrPs elicits a referred pain that extends to the supraorbital region or the homolateral forehead. Nociceptive inputs from the extraocular muscles may sustain the activation of trigeminal neuron, thus sensitizing central pain pathways and exacerbating headache.
authors.affiliation: Department of Physical Therapy, Universidad Rey Juan Carlos, Alcorcón, Madrid.
authors.forename: César
authors.initials: C
authors.lastname: Fernández-de-Las-Peñas
authors.forename: Maria Luz
authors.initials: ML
authors.lastname: Cuadrado
authors.forename: Robert D
authors.initials: RD
authors.lastname: Gerwin
authors.forename: Juan A
authors.initials: JA
authors.lastname: Pareja
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009209:Myofascial Pain Syndromes; D009801:Oculomotor Muscles / Q000502:physiology*; D010147:Pain Measurement; D053591:Referred Pain / Q000503:physiopathology*; D018781:Tension-Type Headache / Q000503:physiopathology*; D055815:Young Adult