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.