Tuesday, September 27, 2011

Retinal Migraine-another of my DX's

  • drcareers: CMA's career centre for physicians
CMAJ December 6, 2005 vol. 173 no. 12
  • Practice

Transient monocular visual loss and retinal migraine

  1. Kenman D. Gan*,
  2. Mikael S. Mouradian*,
  3. Ezekiel Weis,
  4. James R. Lewis
+ Author Affiliations
  1. *Division of Neurology, Department of Internal Medicine; †Department of Ophthalmology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.
The Case: A 40-year-old man was referred because of multiple events of transient monocular visual loss since adolescence. He described the events as small, translucent, grey-coloured spots similar to those seen after looking at a bright light. These visual defects affected both of his eyes equally in frequency but never simultaneously (i.e., each episode was monocular). Episodes lasted about 5–10 minutes, occurred 2–3 times a day on average and were often associated with migrainous headaches, which began within 30 minutes after the onset of the visual symptoms. The headaches were described as unilateral, pounding, lasting up to 4 hours, and sometimes associated with nausea, vomiting, photophobia and phonophobia. On 1 or 2 occasions the headaches also coincided with unilateral jaw and arm numbness, and scintillating scotoma. Although the headaches responded well to ibuprofen, the visual symptoms did not.
On examination, the patient's visual acuity was 20/20 (6/6) in both eyes, and the intraocular eye pressure was 14 mm Hg bilaterally (normal pressure 10–20 mm Hg). Gross examination of the visual fields by confrontation yielded normal findings, as did the rest of the ophthalmologic and the neurologic examinations. Comprehensive blood work revealed only mild hyperlipidemia. Electrocardiography demonstrated sinus rhythm, and neither carotid duplex Doppler ultrasonography nor transthoracic echocardiography revealed any abnormalities. Retinal migraine was diagnosed, and daily therapy with ASA and verapamil was started. The frequency of events of transient visual loss decreased from 2–3 attacks per day to 2–3 attacks per week.
Retinal migraines are transient monocular visual disturbances (scintillations, scotomas or blindness) that can occur simultaneously with migraine headaches or in a patient with a prior history of migraines. They occur because of hypoperfusion of either the eye or the optic nerve. This is in contrast to typical migraine with aura (previously known as classic migraine), which involves the cerebral cortex and is therefore associated with binocular visual phenomena. The International Headache Society's definition of retinal migraine is given in Box 1.1 The society's definition is limited because it does not account for patients who have visual symptoms without headaches or who have permanent visual scotomas; although rare, both of these presentations have been well documented in the literature.
Retinal migraine affects about 1 of every 200 patients who have migraines. At the time of diagnosis, most patients are less than 40 years old. Nearly 30% have a past history of nonretinal migraine with or without aura, and 25% have a relative with retinal migraines.
Clinically, retinal migraine has a highly variable presentation. Some patients describe primarily negative symptoms (visual loss) consisting of black, grey, white or shaded areas of varying size that may appear instantaneously or gradually progress inward from the peripheral visual field. Others describe positive symptoms such as flashing lights or scintillating scotomas. Symptoms are always monocular. Most events are transient, lasting from 5–20 minutes, and may occur several times a day. When headaches occur in association with the visual changes, they may occur either during or after the visual disturbances.
Specific precipitants for attacks are often unclear. Although the natural history of retinal migraine has not been well studied, the prognosis appears to be similar to that of typical migraine with aura. Symptoms may go into permanent remission after several months or years, they may go into remission but recur at a future date, or they may persist lifelong.
The diagnosis of retinal migraine is by exclusion. The differential diagnosis of transient monocular visual loss is given in Box 2. A careful history and physical examination are required, often in conjunction with appropriate investigations, including a complete blood count, erythrocyte sedimentation rate, prothrombin and partial thromboplastin times, electrocardiography, carotid duplex Doppler ultrasonography, transthoracic echocardiography and, if an arrhythmia is suspected, a Holter monitor. A work-up for hypercoagulable states is often indicated if the personal or family history is suggestive. Signs that should raise clinical suspicion of retinal migraine are listed in Box 3.
Management is often done in collaboration with a neurologist or an ophthalmologist. Formal baseline visual field testing is advisable; abnormalities may indicate a need for additional investigation or closer follow-up. If the episodes of transient visual loss have been infrequent, management is often conservative, with reassurance and simple follow-up. Although no guidelines are available, we recommend prophylactic therapy if the episodes are disabling or occur more than twice per week. Low-dose daily ASA therapy is well tolerated and has been reported anecdotally to be effective. Although randomized trials of therapies are lacking, anecdotal reports have suggested that calcium-channel blockers such as verapamil and nifedipine,2 β-blockers3 and inhaled amyl nitrate therapy4 may be effective for prophylaxis.


  • This article has been peer reviewed.


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Monday, September 26, 2011


» Vitreous Detachment and Floaters

Vitreous Detachment & Floaters

The center of the eye is filled with a jelly-like substance called "vitreous". At a young age, this substance is very thick with a consistency somewhat like "Jell-o". As a natural process of aging, the vitreous becomes more liquefied as one gets older. The vitreous is usually completely attached to the retina, which is the seeing membrane in the back of the eye.
The vitreous jelly has pulled away from the retina in the back of the eye.
As the vitreous becomes progressively liquefied, it begins to move around inside the eye. Eventually, the vitreous becomes so loose that it "pulls away" from the retina behind it. This is called a "vitreous detachment" and is a result of a natural process of life. Some people get this in their 30's and 40's but usually the process occurs after age 50.
As the vitreous pulls away from the back of the eye, sometimes small pieces of the vitreous "break away" and float inside the liquefying jelly. These are "floaters" and appear as black spots or specks in your vision that often move around, especially with eye movement. As the vitreous continues to detach, these floaters usually settle to the bottom of the eye and become less bothersome. Sometimes, it takes several months for the symptoms to improve. There is no medication, glasses, or surgery that will make these symptoms improve faster.
A retinal detachment can occur by creating a tear in the retina shown by the arrow. The tear occurs as the vitreous jelly pulls the retina while detaching from the retina. Fluid inside the eye goes through the newly created hole (see arrow) and the fluid pulls the rest of the retina off the back of the eye (Retinal Detachment)
Rarely, the retina behind the vitreous can be pulled as the vitreous detaches producing a "retinal detachment" or a tear in the retina. This could require laser or other surgical treatment to prevent the tear from enlarging and pulling the retina away from the back of the eye, which would require more extensive treatment. Your retina should be examined if you have any of the following symptoms:
  1. Onset of floaters or increase in number of floaters.
  2. Any association with flashing lights in your peripheral or "side" vision, or an increase in flashing lights.
  3. A black curtain covering your peripheral vision and coming from above, below, or from the side. You can check each eye by covering one eye at a time.
Sometimes tears in the retina are treated with laser surgery. At the left, a retinal tear is present shaped like a horseshoe! At the right, laser application surrounding the tear seals down the tear preventing it from getting bigger and allowing for resorption of fluid beneath the retina.
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Saturday, September 24, 2011


Myelomalacia is a pathological term refering the softening of the spinal cord.[1]Hemorrhagic infarction (bleeding) of the spinal cord that can occur as a sequel to acute injury, such as that caused by intervertebral disc extrusion (being forced or pressed out) is the cause of myelomalacia. [2] The disorder causes flaccid paraplegia (impairment of motor function in lower extremities), total areflexia (below normal or absence of reflexes) of the pelvic limbs and anus, loss of deep pain perception caudal (in the coccyx) to the site of spinal cord injury, muscular atrophy (wasting away of muscle tissue), depressed mental state, and respiratory difficulty due to intercostal (muscles that run between the ribs) and diaphragmatic paralysis. [3] Gradual cranial migration of the neurological deficits (problems relating to the nervous system), is known as ascending syndrome and is said to be a typical feature of diffuse myelomalacia. Although clinical signs of myelomalacia are observed within the onset (start) of paraplegia, sometimes they may become evident only in the post-operative period, or even days after the onset of paraplegia. Death from myelomalacia may occur as a result of respiratory paralysis when the ascending lesion (abnormal damaged tissue) reaches the motor nuclei of the phrenic nerves (nerves between the C3-C5 region of the spine) in the cervical (neck) region.



Travis Jackson
Her hair was up in a pony tail, Her favorite dress tied with a bow. Today was Daddy's Day at school, And she couldn't wait to go. But her mommy tried to tell her, That she probably should stay home. Why the kids might not understand, If she went to school alone. But she was not afraid; She knew just what to say. What to tell her classmates Of why he wasn't there today. But still her mother worried, For her to face this day alone. And that was why once again, She tried to keep her daughter home. But the little girl went to school Eager to tell them all. About a dad she never sees A dad who never calls. There were daddies along the wall in back, For everyone to meet. Children squirming impatiently, Anxious in their seats One by one the teacher called A student from the class. To introduce their daddy, As seconds slowly passed. At last the teacher called her name, Every child turned to stare. Each of them was searching, A man who wasn't there. 'Where's her daddy at?' She heard a boy call out. 'She probably doesn't have one,' Another student dared to shout. And from somewhere near the back, She heard a daddy say, 'Looks like another deadbeat dad, Too busy to waste his day.' The words did not offend her, As she smiled up at her Mom. And looked back at her teacher, Who told her to go on. And with hands behind her back, Slowly she began to speak. And out from the mouth of a child, Came words incredibly unique. 'My Daddy couldn't be here, Because he lives so far away. But I know he wishes he could be, Since this is such a special day. And though you cannot meet him, I wanted you to know. All about my daddy, And how much he loves me so. He loved to tell me stories He taught me to ride my bike. He surprised me with pink roses, And taught me to fly a kite. We used to share fudge sundaes, And ice cream in a cone. And though you cannot see him. I'm not standing here alone. 'Cause my daddy's al ways with me, Even though we are apart I know because he told me, He'll forever be in my heart' With that, her little hand reached up, And lay across her chest. Feeling her own heartbeat, Beneath her favorite dress. And from somewhere here in the crowd of dads, Her mother stood in tears. Proudly watching her daughter, Who was wise beyond her years. For she stood up for the love Of a man not in her life. Doing what was best for her, Doing what was right. And when she dropped her hand back down, Staring straight into the crowd. She finished with a voice so soft, But its message clear and loud. 'I love my daddy very much, he's my shining star. And if he could, he'd be here, But heaven's just too far. You see he is a Brittish soldier And died just this past year When a roadside bomb hit his convoy And taught Britians to fear. But sometimes when I close my eyes, it's like he never went away.' And then she closed her eyes, And saw him there that day. And to her mothers amazement, She witnessed with surprise. A room full of daddies and children, All starting to close their eyes. Who knows what they saw before them, Who knows what they felt inside. Perhaps for merely a second, They saw him at her side. 'I know you're with me Daddy,' To the silence she called out. And what happened next made believers, Of those once filled with doubt. Not one in that room could explain it, For each of their eyes had been closed. But there on the desk beside her, Was a fragrant long-stemmed rose. And a child was blessed, if only for a moment, By the love of her shining star. And given the gift of believing, That heaven is never too far. Send this to the people you'll never forget and Remember to send it also to the person that sent It to you. It's a short message to let them know That you'll never forget them. If you don't send it to anyone, it means you're in a hurry and that you've forgotten your friends. Take the time...to live and love. Until eternity.......God Bless!!

Saturday, September 17, 2011


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See also shoulder pain patterns and the muscles behind "frozen shoulder".
Neck and Head Pain is the most common expression of myofascial dysfunction yet chronic headache sufferers respond badly to diagnoses of muscle tension headache. The labels of "vascular" headache or "neurological disease" seem more respectable, more likely to be taken seriously. But "vascular" doesn't stop at the head; "neurological" isn't restricted to the brain or spine. Tight muscles and fascia press, shear, block, and strangle both blood vessels and nerves throughout the body. “Muscle tension headache” can mean very simply “headache due to tight muscles” but from there it has been a short trip to “You’re just tense” and . . . “Have you considered psychiatric counseling?” with the clear implication that...
The pain is not real. YOU are just crazy.

Many pains do indeed have psychiatric components, but the psychogenic diagnosis is woefully overdone. Strangely, it is rarely applied to knee pain, big toe pain, or shoulder pain, but is used all too often by the physician, who, when asked for the underlying cause of head pain, cannot bring himself to say “I don’t know.” And there's a lot to know. Over 20 muscles (primarily of the neck) refer pain to the head. Several refer pain specifically to the eye. At least three refer pain directly to the teeth for reasons that will never be relieved by fillings or repeated root canals.

Of particular concern is strain or compression of the trigeminal nerve and its branches which mediate tissue inflammation, vasodilation and vascular permeability -- all issues in migraine. Over the last few years, plastic surgeons have verified the muscle-migraine connection beginning with the odd observation that Botox injections in the frontalis and corrugator muscles of the brow also eliminated migraines.

If irritated muscles and nerves fire off an inflammatory response and vasodilation, is the resulting headache "muscular," "neurological," or "vascular"? Perhaps the only real answer is "all of the above" because amazingly enough, it all functions together -- or dysfunctions together.

For patient or physician, the following pain patterns may look surprisingly familiar and will, we hope, point the user in the direction of truly effective treatment.

In the following illustrations, black dots indicate common trigger point locations; red areas indicate the pain referred by the trigger point. You can evaluate these muscles with the Cervical and Masticatory Tests excerpted and adapted from our Range-of-Motion Testing Charts.
  1. Upper Trapezius > Tension headache and "bursitis". The trapezius muscle of the back and neck is the single muscle most likely to have trigger points in both adults and children. Upper Trapezius Pain The upper trapezius refers a "fish-hook" pain pattern up the back side of the neck to the head, and around the temple to the eye. There may be goosebumps to upper arm and thigh possibly with nausea and visual disturbances. Problems often begin with heavy bags or purses, balancing phones between head and shoulder, or imbalances and strain by tight SCM or scalene muscles.
    The nauseating pain of a one-sided trapezius headache is commonly diagnosed as "migraine" although migraine medications often fail to relieve the pain. ("Bursitis" and backpain may arise from the upper and lower fibers of the same muscle; see Introduction to Shoulder Pain.)

  2. Sternocleidomastoid (SCM) > SCM-Pain Dizziness, nausea, "migraine" and "sinus". Because of its intimate involvement with brain stem and the vagus nerve, the SCM muscle of the neck produces a long list of neurological and pain symptoms which appear primarily in the head and face but which may also appear as nausea, motion sickness, and balance problems. These are commonly mistaken for migraine, sinus headache, inner-ear problems, trigeminal neuralgia -- and so on. SCM has one of the most extensive patterns of pain and dysfunction, yet is one of the easiest muscles to self-treat. Click the link to see an info page on this muscle.

  3. Scalenes > "Thoracic outlet" and "carpal tunnel" syndromes; chest, arm, and upper back pain. Scalenes contribute to severe tension headache and are one of the leading causes of "carpal tunnel syndrome." On the list of a half-dozen possible causes, the carpal tunnel itself is dead last. This is one of the reasons why carpal tunnel surgery is so ineffective. Check before you cut! Scalene-Pain
    Notice also the fingerlike projections of pain extending down the chest. This is easily confused with angina. If you think you are having heart problems, get to a doctor immediately!
    If, however, no cardiac problems are found, consider other muscles, especially if the chest pain was accompanied by a tingly thumb or index finger. Scalene pain typically extends down the upper arm, skipping the elbow. There may also be severe pain at the vertebral border of the scapula.
    All of these patterns may be painfully familiar to wrestlers and Aikidoists who have suffered too many "neck-a-nage's." In Aikido, students who don't understand kokyu-nage techniques (based on balance and timing) tend to interpret what they think they see as: "Swing your partner around by the neck then drop him on his head," a painful variation on the game of “Hangman.”
    In professional football, doing the same thing to a large, padded, extremely fit refrigerator-sized opponent by grabbing his face-guard will get you an instant 15-yard penalty, for very good reason.
    The consequences of “neck-a-nage” can be extremely painful or disabling. The the electrical supply for arm and fingers comes from the brachial plexus, the “wiring harness” originating in the neck. If the source of finger pain is diagnosed as entrapment of the median nerve, the patient may be referred for carpal tunnel surgery. If the problem is identified as scalene entrapment of the brachial plexus, the current treatment is surgical removal ("scalenectomy") of the anterior scalene and the first rib to which the muscle is attached. Unfortunately, this barbaric surgery usually causes more problems than it cures. Where care, consideration, and technical skill on the mat have failed, know this pain pattern and how to treat it -- by treating the muscle and its trigger points.

  4. Masseter > TMJ, tinnitus, "sinus", and toothache. For its size and weight, the masseter is the strongest muscle in the body and its effects are not trivial. Masseter-Pain-Composite It refers pain to both upper and lower molar teeth, causes TMJ dysfunction, earache and a "sinus" pain over the eyebrow. Prozac and related anti-depressants such as Paxil specifically cause tightness in this muscle. If you're grinding your teeth at night and waking with a headache, ask your doctor about taking the medication during the daytime when you can be more aware of clenching and tooth-grinding which tense the masseter but also strain the temporalis . . .

  5. Temporalis > "Tension / sinus" headache, TMJ and toothache in upper teeth. Temporalis-Pain Combine a head-forward position with a pipe and long hours of playing the violin (see the scalene pain pattern, above) and what do you get? "Elementary!" cries Dr. Watson. "Head pain, tooth pain, and extreme tooth sensitivity to heat/cold and vibration."
    You may wisely eschew "The Seven Percent Solution" in favor of directions to massage the temples to relieve tension headaches. But to make it more effective, notice the location of the trigger points and their specific areas of pain. Temporalis is remarkable for spoke-like lines of pain up into the temple and down into the upper teeth. Follow these lines and you will feel distinct taut bands. Massaging them may provide temporary relief. But the best approach is to follow the taut bands down to their trigger points located as shown near the cheekbones and adjacent to the ears.

  6. Pterygoids > TMJ and "sinus" pain. The lateral pterygoids (at right) help to open and protrude the jaw. These relatively weak muscles are easily strained in opposing the powerful masseter and temporalis muscles that close the jaw.
    The pterygoids commonly develop trigger points which in turn cause pain and/or clicking in the TMJ joint. They may block drainage from the maxillary sinus causing more still more pain. They are also linked to tinnitis, and cause lateral deviation on opening the jaw. There may be entrapment of the buccal nerve causing numbness / tingling in the cheek (see buccinator, below). The masseter muscle and medial pterygoid support the jaw like a sling. Masseter is on the outside, medial pterygoid inside; together they close the jaw. Pterygoid-pain Medial pterygoids produce diffuse pain in the mouth involving the floor of the nose, tongue, throat and hard palate; pain below and behind the TMJ joint, pain and/or stuffiness of the ear, difficulty swallowing, lateral deviation and possibly pain on opening the jaw. They can also entrap the lingual nerve producing the odd symptom of a bitter, metallic taste in the mouth (which the patient may not connect with other symptoms and may not report for fear of being thought "crazy.")

  7. Buccinator > Cheek pain. This muscle forms the wall of cheek and mouth. It's Buccinator-pain the part of the cheek that puffs out when playing the trumpet (for which it is named), blowing up balloons or stuffing one's mouth too full. Buccinator pain may appear suddenly following dental/orthotic work. There are no entrapments by the buccinator itself, but the lateral pterygoid can entrap the buccal nerve which supplies the skin and mucous membrane in this area. The muscle itself can cause local pain deep in the cheek while chewing, commonly misdiagnosed as TMJ dysfunction.

  8. Digastric > Neck pain and and toothache in the lower incisors. The digastric assists the lateral pterygoid in opening the jaw against the counterforce of the far more powerful temporalis and masseter muscles. The upper portion can entrap the external carotid artery and auricular artery decreasing blood flow to the brain. Digastric-pain Strained by retrusion of the jaw (as in playing the clarinet or similar wind instruments) or by holding a violin in place with the chin. Commonly damaged in whiplash injuries in concert with other neck muscles such as trapezius and splenius. Trigger points in the anterior belly send pain to the four lower incisor teeth and the alveolar ridge. There may also be pain in the throat and tongue and difficulty swallowing because of the relationship to the hyoid bone.
    Trigger points in the posterior belly refer pain to the upper sternocleidomastoid muscle, pain to the throat possibly as far back as the occiput. There may also be difficulty swallowing and a bothersome feeling of a persistant "lump" in the throat. That "lump" may be the hyoid bone which, again, is not moving properly.

  9. Orbicularis > Nose and cheek pain (shown with zygomaticus, below). A trigger point in orbicularis refers pain along the eybrow, alongside the nose to the upper lip. There may be visual disturbances and problems with "jumpy print" in reading, along with droopy eyelid (ptosis).
  10. Zygomaticus > Nose, cheek, and forehead pain (shown with orbicularis, below). orbic-zygo
    Orbicularis and zygomaticus are the only two muscles that refer pain to the nose. Both patterns are commonly mistaken for "sinus" pain but may be due to a blow to the eye or simply smiling too long at the reception.
    Zygomaticus can entrap blood vessels that travel from cheek to nose and up to the forehead. The resulting pain is not "sinus," it's a muscle cramp due to reduced blood and oxygen supply -- but no less painful.

  11. Occipitofrontalis > Temporal and eye pain. OccFront-Pain
    Trauma to the scalp fascia or the occipitalis at the back of the skull can transmit pain through the head and into the eye. Trauma may include a blow to the back of the head, strain from a tight ponytail or bun, or the weight of long, heavy hair. In one case I know of, a man struck the top of his head on the corner of a cabinet. Result: a slight puncture wound in the scalp, a brutal pain in the eye.
    Frontalis helps open the eyes, raises the eyebrows, and wrinkles the forehead into "worry lines." It is commonly used by biofeedback practitioners to monitor muscle tension. Trauma to frontalis (whether a blow to the forehead or habitual frowning) can cause severe frontal headache often diagnosed as "migraine." Frontalis is one of the muscles that definitively proved the muscle-migraine connection.
    Botox injections paralyzed the frontalis, eliminating "worry lines" but they also had the surprising side effect of halting chronic "migraines". Or maybe not so surprising, as frontalis entraps the supraorbital nerve. The related corrugator supercilii (at the top of the nose between the eyebrows) compresses branches of the supraorbital nerve along with the supratrochlear nerve and branches of the supraorbital nerve. All of these are branches of the trigeminal nerve which is heavily involved in migraine. You can treat trigger points with great results -- or, avoid compressing those muscles. Your frown may be giving you a headache!

  12. Splenius Capitis > Occipital neuralgia and "word processor headache". Splenius capitis and splenius cervicis (below) are almost always injured in auto accidents, regardless of the direction of the blow. They are commonly injured in "head rolling" movements in exercise classes, always strained by head forward position and by computer use or other reasons for sitting with head held forward and turned to the side. Splenius capitis (shown below, right) typically causes a pain at the top lateral side of head. Splenius Capitis Pain Splenius Cervicis Pain

  13. Splenius Cervicis > Neck pain, eye pain, and blurred vision. Splenius cervicis (above, left) is strained in all the ways as splenius capitis (above, right) but the results are even more brutal. A trigger point high in the neck portion of the muscle sends pain through the head from the occiput and into the eye. Even without the pain, there may be blurred vision. The lower trigger point refers pain to the angle of the neck. Reading under a drafty air conditioner or riding a motorcycle with head forward with a cold wind whipping around the edge of the helmet is damaging to these muscles.
  14. Semispinalis Capitis > Head pain and occipital neuralgia. Injured in whiplash and involved in "tension" and "cervicogenic" headache.
    Semispinalis capitis is commonly injured in auto accidents. You can injure it more slowly but just as effectively with a chronic head-forward position.
    When tight, semispinalis may entrap the greater occipital nerve which in turn causes numbness, tingling and/or burning pain extending over the back of the head to the top (vertex) of the head. It may be difficult to touch chin to chest, and sufferers may be unable to bear the pain of laying the back of the head on a pillow.
    Relieve nerve pain with cold.
    Relieve muscle pain with moist heat.
    In either case, look for the origin of the pain, rarely the spot where it hurts.

  15. Semispinalis Cervicis > Even more head pain.
    This muscle typically produces a vague band of pain from occiput along side of head to just behind orbit (similar to suboccipital pain pattern).
  16. Longus Capitis, Longus Colli > Neck, ear, and eye pain. A pain in the neck, and surprisingly, pain in the eye and ear and possibly the forehead (more "sinus" pain!) as well. Almost always injured in whiplash.
  17. Multifidi and Rotatores > Basal skull pain, neck pain and scapular pain.
    This pain arises from the tiny muscles that run between the individual vertebrae of the spine.
  18. Levator scapula > The "wry" or "stiff neck" muscle.
    This muscle is the Number One cause of "stiff" or "wry" neck and the second most common shoulder girdle muscle (trapezius is Number One) to have trigger points. Working with trapezius, levator shrugs the shoulders and helps prevent forward flexion of the neck, hence it is also damaged in whiplash injuries. In daily life, it is commonly strained when shoulder (or shoulders) are chronically hunched, either in stress, or by attempting to keep a strap from sliding off the shoulder, especially when the muscle is cold or fatigued. Pain in the angle of the neck and along the vertebral border of the scapula may be so severe that patient cannot move the neck at all.
  19. Suboccipitals > Temporal and eye pain. Suboccipitals-Pain The four pairs of suboccipital muscles cause deep aching pain running in a band from the back of the head to the orbit of the eye, possibly with balance problems and dizziness. One of these (the rectus capitis superior minor) attaches directly to the dura mater of the spinal cord. When traumatized it can produce odd visual and neurological symptoms to the point of seizures.
    Suboccipitals are commonly strained or hypertrophied in persons who wear bifocals, children who watch TV lying with chin propped on hands, and anyone who habitually holds the head in position with chin up and neck flexed backward.

  20. Omohyoid > Head, neck, shoulder, and back pain. This small muscle (actually missing from many anatomy books)can cause disabling pain and dysfunction. It's just one of the several muscles that attaches to the hyoid bone. The other end attaches to the scapula at the back of the shoulder. Aside from the severe pain in shoulder, neck, and jaw (which often appears after a bout of coughing or vomiting) there may also be weakness and tingling down arm and fingers and symptoms of thoracic outlet syndrome. Pain patterns may be confused with that of the scalenes or levator scapula. An excellent article on The Omohyoideus Syndrome is available online.
  21. Soleus > Heel and calf pain, sacral pain and cheek (facial) pain. One of the outstanding examples of long-distance pain referral from muscles. This muscle of the calf sends pain to the calf and heel (commonly known "jogger's heel") -- but there's more. Soleus PainPain from this muscle also appears in the sacrum at the sacro-iliac joint and then reappears in the face and jaw where it may fire off symptoms of TMJ and toothache. "But," you say, "migraine is vascular!"
    Indeed it is -- and the soleus is the other end of the cardio-vascular system. It is known as "The Second Heart" because its pumping action returns blood from the lower extremities to the heart. I have stopped many full-blown migraines by working adductor and calf muscles.
    "But," you say, "migraine is neurological!"
    Indeed it is -- and tightness and restriction in soleus and the adductor magnus can cause serious impingement of neurovascular structures including the femoral nerve, femoral artery, and femoral vein (at the adductor hiatus of the adductor magnus) and the posterior tibial nerve, vein, and artery by the soleus. (The plantaris, a slip of the soleus muscle, can also entrap the popliteal artery at the back of the knee.) Entrapment by these muscles can be so severe that the patient may lose deep tendon reflexes. Short of that, it's no surprise that a sufferer might have cold feet.
    Upstream, entrapment by the adductors can be brought on by failing to stretch out after using the thigh machines at the gym and very commonly, by footwear. It may be difficult to believe that shoes (whether you call them "cowboy boots" or "high heels") may be causing your jaw and head pain, but it is often true. Knee-high stockings with tight, constricting bands will do the job and I have also seen a man who never had headaches in his life until he caught some shrapnel in the calf. Even worse can happen, however.
    When the soleus can no longer work as "the second heart" due to inactivity or constriction, there can be side effects far worse than migraine. Pooling and subsequent clotting of blood in the lower extremities is involved in deep vein thrombosis, also known as "airline thrombosis" due to the consequences of a cramped seat and long periods of inactivity. The condition is very real, but sadly mis-named. The condition arises far more commonly from long hours of sitting at a desk than from (relatively rare) airline travel.

For more information on myofascial pain, see these books and resources.

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Monday, September 12, 2011



Submitted 185 days ago...
New User (4)

Why do I hurt so much on my left temple,some right temple and all over my body?

Hello,I am having temple pressure,piercing stabs like an ice pick, but it seems like a vein that is swelling,have a fleshy lump on opposite side under my right ear,but doc said it was my tendons,I don't know what is going on,but hurting severely under my knees,I been sick for a long time. I had surgery back in '06(an ACD & F spinal discectomy) for a small herniated disk and hurt worse now than did b4 surgery.Why do they do surgeries that are unnecessary?I also have had surgery on my left jaw for a bone spur in '89.I have been told that I had a screw placed in an opening and put right on top of a nerve, doc said something @ it being brachial.I have to mention that I hurt severely all over my body with burning,aching,itching and lots of sharp, piercing pain that feels like a knife or an axe stinking in my back.I just need to know where the pain is starting or its primal destination.WHAT IS CAUSING ME TO HAVE ALL THIS MISERY?MY BODY IS TOO YOUNG(45)FOR ALL OF THIS.
I know this is a lot of info to process and I deal with it ever day and need HELP SO badly.I never hurt in my life like this and it started after surgery with just an arm ache and after the nerve block that hit me ALL OVER,but it is progressing and intensifying in intensity. I don't want to die and it sure feels like it sometimes. I just need to know which of these it is or could it even be where I had the surgery on my jaw for a bone spur since it is on the same side? Can u help me? <3 Karen,suff


Answer 1 / 2 - Submitted 185 days ago...

Brain (7,096)
Do you live near a major medical center or a teaching hospital? These larger hospitals usually have a pain management center, which brings together all kinds of specialists to help people manage their pain. At a pain center, you might have care that includes being seen by a physician specializing in pain management, a neurologist, physical therapist, orthopedist, physiatrist or others who work together as a team to figure out the cause of your pain and come up with a treatment plan.

Awarded Answer (What’s This?)
Answer 2 / 2 - Submitted 185 days ago...
Professor (1,221)
The pain in your temple sounds very much like the pain of migraine. For more information see: http://ww1.webanswers.com/health/how-do-you-know-if-you-have-a-migrain e-headache-e5ed9e

The burning, aching, and itching all over your body you describe are common complaints of people with fibromyalgia, which is neurologically mediated pain (pain that results from a problem in the nerves to the muscles). Fibromyalgia is a very painful condition that is not uncommon in young people. It is not uncommon for people with fibromyalgia to have associated migraines. Cymbalta is a medication that has recently been shown to be helpful in neurologically mediated pain such as in fibromyalgia, and this medication may be very helpful for you.

Another possible cause of your problems is temporal arteritis. Arteritis is inflammation and damage to blood vessels which most commonly affects the arteries in the head, especially the temporal arteries. The condition can affect your entire body. The cause of temporal arteritis is not known but is believed to be at least partially due to a problem in the immune system.

Symptoms of temporal arteritis can include:
? Throbbing pain on one side of the head
? Jaw pain
? Muscle aches
? Scalp sensitivity or tenderness
? Feel generally ill
? Weakness
? Excessive tiredness
? Excessive sweating
? Fever
? Loss of appetite
? Weight loss
? Vision difficulties (eg. blurred vision, double vision, or loss of vision)
? Joint pain and/or stiffness

You should see a doctor, as soon as possible, to be evaluated for the possibility of temporal arteritis. Although temporal arteritis generally resolves on its own and most people make a full recovery, resolution may take as long as 1 to 2 years, and proper treatment is required until it resolves. Without treatment tissue damage and other complications, including stroke, may occur.

I hope that you are feeling better soon.

This answer was edited by HelpDoctor 115 days ago.
Reason: grammical correction
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Comment 1 / 3 - Submitted 185 days ago...

New User (4)
Dear Help Doctor,
I have to say I was thinking @ that, but also trigeminal neuralgia. I don't think I could match 13 out of 13 on that one, but mabye. It seems, it could be something else. Did u read @ where I had had surgery on the left jaw up through the ear to remove a bone spur. I had got to 98 and eating through a straw, but the op. wasn't bad at all. I got to eat pizza after surgery. Easiest surgery I ever had.
In ur list I did get all of them. I have every symptom, but the stiffness is always in my neck, regardless of what I take for the pain and right now, I think a Fentany patch of 75mcg every 3 days is a lot, not counting the Norco for breathrough,4x day..IS that normal? IS that a lot? I don't know, all I know is that I still have pain and don't understand. It is always pressure and like someone has a vice grip on sometimes right at the back of my neck and with a VA(venous Angioma,that they said might have been there since birth-they could be wrong, for I never hurt there b4 in my whole life, never had headaches. With that being in that same area,and on my MRI said my Occitipal something(sorry, I don't have exact phrase, but Occipital is lower region of the back of neck,right?..and it hurts there A LOT. I just hope I don't or haven't developed a AVM(arteriovenous malfomations) or a CCM(Cerebral Cavernous malformations)ohhh, I read it wrong maybe, it starts with a VA in which, is aka for DVA(developemental venous anomaly).
Sometimes, my jawbone will pull all the way down to my clavical and that scares me..a lot scares me with the intensity and amount of pain that I feel. I am so afraid that I have 2 out of 2 things..the surgery I had went wrong and when they hit me with that ESI..that did me in prob. 4 Arachnoiditis or Dystonia?
Thank YOU ever so much 4 the information and care that u have given some one that is definately in dire need of help.. THANKS DOC.. Karen

 Comment 2 / 3 - Submitted 185 days ago...

Professor (1,221)
You are welcome skeet65. I do agree that you need an evaluation for the pain in your temple and need your medications adjusted. A chronic pain clinic is a good idea. Be sure and ask about Cymbalta, and also, Neuronin (gabapentin) if you have not tried this medication. You need something other than narcotics for your pain. Good luck!

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