Co-occurrence of pain syndromes

Stimulated by Affaitati et al 2019.[1]

Photo by Aiony Haust on Unsplash.

This paper popped up on a very recent search, but not because it mentions acupuncture, in fact it doesn’t. I also search every day for the latest research in myofascial pain.

I had a look at this one because of the last author – Maria Adele Giamberardino. I can type this name without checking my spelling because I invited her to speak at a BMAS meeting that we held in the Royal Institution – yes the place set up by Michael Faraday. I was practicing her name over and over so I could introduce her without getting my tongue in a knot, and then I realised that her long surname is neatly chopped into easy 2 or 3 letter syllables, and if you use an Italian accent it all runs off the tongue quite easily… Maria Adele Gi-am-ber-ar-dino.

Anyway, she is a highly respected physician and researcher in the pain world who does great experimental and clinical research and acknowledges the importance of myofascial pain syndromes (MPS) as well as the importance of segmental relationships in pain phenomena. One of my favourite papers of hers was an experimental trial in patients with 2 painful visceral complaints, such as coronary heart disease (CHD) and gallstones. She showed that if the conditions overlapped segmentally, then adequately treating one of them improved the symptoms from the other. This did not occur is there was no segmental overlap eg gallstones and left urinary calculosis. This paper also examined somatic thresholds and demonstrated how these changed in line with symptom improvement.[2]

So this is a huge review paper with over 6 pages of references, one of which I was surprised to find was mine.[3] For a moment I almost felt important, then I woke up and remembered that I’d become a blogger.

…then I woke up and remembered that I’d become a blogger.

It is a tough read, so I recommend one section at a time. There’s a lot of choice from viscero-visceral hypersensitivity (VVH) to MPS and migraine. I am going to bring out some details from the latter section.

I cannot fault the vast majority of this paper, just as I would expect, but I must address the issue of MPS and migraine, in particular the suggestion that trigger points might trigger migraine. This is a controversial topic, and I recall inviting the neurologist from NICE’s CG150 on headache to speak at our first BMAS Headache Day. He was clear that muscle was not a cause of headache, and certainly not migraine headache. I should note though that he admitted later to self-treating his own migraine by needling GB20.

So what do they say (Maria and her colleagues) about trigger points (TrPs) triggering migraine? Well they imply that TrPs that refer pain into the same areas as the headache can make symptoms worse, which seems logical, but their evidence is somewhat lacking rigor. It derives from an uncontrolled cohort (n=52) of injecting TrPs associated with improvement of symptoms,[4] and a non-randomised controlled trial (n=54, 24 & 12) where the placebo-like TrP treatment (penetration of a needle in the vicinity of a TrP; n=12) was associated with no change in migraine symptoms.[5] The latter result does seem strange when we look at the effect of sham acupuncture in large RCTs of migraine prophylaxis, where the RR50 (responder rate defined by a 50% reduction in days with headache) is typically around 50%. Having said that a single session of sham injection with a hypodermic needle is quite different from say 12 sessions of gentle (sham) needling within the context of acupuncture treatment.

Now to something related but different. I was pleased to find the review paper by Maria’s team, but I was unfamiliar with the journal – the Journal of Neural Transmission. I could access it via the RSM library online resources. So as I had access I thought I would see if they had any papers on acupuncture. The only one with acupuncture in the title was from 1975.[6] I recognised one of the authors – Johannes Bischko. He was one of the grandfathers of medical acupuncture in Austria. The paper describes an experiment measuring urinary and serum catecholamines and their derivatives before and after acupuncture treatment.

I was interested to note a quite prescient line in the introduction:

…the neurophysiological view does not explain clinically manifest therapeutic success following treatment with acupuncture.

They went on to suggest that the observed effects of treatment that might last months or years could only be explained as follows:

With the aid of acupuncture, regulation mechanisms are influenced in such a way as to lead to a long lasting homeostasis.

This is very similar to the way I explain the length of action of acupuncture beyond what is measurable physiologically. Physiological effects can only be measured for 2 to 3 days, but symptom relief in chronic pain can last weeks. I explain this by suggesting that in the 2 to 3 days of physiological alteration the natural amplification of nociception is reduced to normal, and whilst the acupuncture effect on the physiology wears off in days, it may take weeks for the amplification to ramp up again to the point of perception of symptoms. The 1975 authors use of homeostasis here equates to my amplification system being set back to the normal baseline level. Their suggestion was particularly prescient because the whole mechanism of amplification had yet to be discovered when they wrote their paper.

Whilst we are on the subject of homeostasis, I cannot finish without mentioning my current read: The Strange Order of Things: Life, Feeling and the making of Culture, by Antonio Damasio.[7] It is a fascinating read, but quite intense – I cannot even chop garlic and listen to the audiobook without having to go back and relisten. Damasio contends that the most sophisticated feelings and the roots of human culture are simply an extension of the homeostatic principles of living organisms that first began in single cell life without genomes some 3.8 billion years ago.


1         Affaitati G, Costantini R, Tana C, et al. Co-occurrence of pain syndromes. J Neural Transm 2019;1:3. doi:10.1007/s00702-019-02107-8

2         Giamberardino MA, Costantini R, Affaitati G, et al. Viscero-visceral hyperalgesia: characterization in different clinical models. Pain 2010;151:307–22. doi:10.1016/j.pain.2010.06.023

3         Cummings M, Baldry P. Regional myofascial pain: diagnosis and management. Best Pract Res Clin Rheumatol 2007;21:367–87. doi:10.1016/j.berh.2006.12.006

4         García-Leiva JM, Hidalgo J, Rico-Villademoros F, et al. Effectiveness of Ropivacaine Trigger Points Inactivation in the Prophylactic Management of Patients with Severe Migraine. Pain Med 2007;8:65–70. doi:10.1111/j.1526-4637.2007.00251.x

5         Giamberardino MA, Tafuri E, Savini A, et al. Contribution of myofascial trigger points to migraine symptoms. J Pain 2007;8:869–78. doi:10.1016/j.jpain.2007.06.002

6         Riederer P, Tenk H, Werner H, et al. Manipulation of neurotransmitters by acupuncture (?). J Neural Transm 1975;37:81–94. doi:10.1007/BF01249768

7         Damasio A. The Strange Order of Things: Life, Feeling, and the Making of Cultures. Reprint ed. Random House Inc 2019.

Declaration of interests MC