CONCLUSION
Myofascial trigger points and sensitive entheses associated with the
levator scapulae muscle may reproduce headache symptoms in individuals
with CTTH. Particular areas of interest for both diagnosis and treatment
are the region medial and cephalad to the superior angle of the scapula
and also the distal teno-osseus attachment site over the medial aspect
of the superior angle of the scapula. These two pathoanatomic lesions
appeared to respond favorably to a multimodal treatment approach that
included DN targeting MTrPs, periosteal DN targeting the enthesis,
education, and strength training. A future randomized clinical trial
with an active comparison group would be a useful next step to ascertain
whether the changes seen in this single case study are apparent in a
two-arm trial and not attributable to natural history.