Proposal of a migraine with associated myofascial pain phenotype: Bridging corpalgia,fibromyalgia and chronic migraine

We want to draw attention to a commonly under-recognized clinical presentation observed in many patients with chronic migraine: persistent or recurrent cervicoscapular discomfort, often described as aching or burning pain in the neck, upper back and shoulder region, particularly over the trapezius muscle and surrounding fascia. In our outpatient clinical practice, this complaint emerges frequently in migraineurs, particularly women, and seems to correlate with migraine frequency, chronicity and overall disability.

Fernández-de-las-Peñas et al. (1) previously evaluated pressure pain sensitivity maps of the trapezius muscle in patients with chronic tension-type headache (CTTH), unilateral migraine, and healthy controls. Using a pressure algometer at 11 standardized points across the trapezius and adjacent muscles, Fernández-de-las-Peñas et al. (1) found that both CTTH and migraine patients exhibited significantly lower pressure pain thresholds compared to controls, indicating widespread muscle hyperalgesia. Notably, the upper trapezius, located near the neck, was the most pain-sensitive region in all groups. While CTTH patients showed generalized hypersensitivity, unilateral migraine patients exhibited side-to-side differences in pressure pain thresholds, with lower thresholds on the symptomatic side. These findings suggest that central sensitization and muscle hyperalgesia extend beyond the head in migraine (1,2), affecting neck and shoulder muscles, particularly the trapezius, and may contribute to overall headache burden.

This specific distribution of pain, which often satisfies the diagnostic criteria for myofascial pain syndrome, is frequently neglected in both diagnostic classifications and clinical trials of migraine (3). Although not part of the core migraine symptomatology, we argue that this pericranial and cervicothoracic myofascial pain represents a meaningful comorbidity – or even a clinical phenotype – within the spectrum of chronic migraine.

Proposed diagnostic features

Based on clinical observations, we propose the term “migraine with associated myofascial pain” (MAMP) to describe this syndrome. Preliminary exploratory criteria may include:

Presence of migraine (episodic or chronic) according to ICHD-3 criteria.

Persistent or recurrent pain involving the neck, upper shoulders, or upper back, especially overlying the trapezius, rhomboid, levator scapulae, or suboccipital muscles.

Pain aggravated by palpation, posture, movement, or during migraine attacks.

Clinical signs of myofascial dysfunction, including taut bands, trigger points and referred pain upon digital pressure.

Absence of other primary musculoskeletal disorders explaining the distribution of pain.

This pain is often symmetrical and bilateral, described as aching, tightening or pressure-like. It may precede, accompany or follow migraine attacks and is frequently associated with cutaneous allodynia, suggesting a shared pathophysiological mechanism involving central sensitization.

The term “corpalgia”, first introduced in chronic pain literature, refers to widespread bodily pain without clear inflammatory or structural pathology (4). In migraineurs, this type of body-wide discomfort – especially in females – may evolve, potentially overlapping with fibromyalgia syndrome.

There is growing evidence that migraine and fibromyalgia share pathophysiological pathways, including central sensitization, dysregulated descending pain modulation and heightened nociceptive gain (5). There is growing evidence of a strong comorbid relationship between fibromyalgia and chronic migraine, with fibromyalgia diagnosed in a considerable number of chronic migraine patients (6,7). However, while fibromyalgia is defined by widespread pain (above and below the waist, both sides and axial skeleton), MAMP may represent a localized, migraine-related expression of central sensitization preceding the development of full-blown fibromyalgia in some individuals.

Unlike classic fibromyalgia, MAMP is characterized by regional pain that is anatomically coherent and associated with the migraine cycle. It may thus serve as a clinical marker of transitional central sensitization, particularly in patients who are at risk for chronification of migraine or multisite pain syndromes.

Recognizing MAMP has significant implications for both treatment and research. Patients with MAMP may benefit from targeted therapies such as trigger point injections, physical therapy, posture correction and manual myofascial release in addition to standard migraine prophylaxis (8). Botulinum toxin type A, already used in the treatment of chronic migraine, may exert part of its benefit through muscle deactivation and reduction of peripheral nociceptive input (9).

Early identification of MAMP may help prevent central sensitization and the evolution into more disabling pain disorders, including fibromyalgia. Future clinical trials may stratify patients based on the presence of comorbid myofascial pain because it may influence treatment response, quality of life, and functional outcomes.

Our research group has previously investigated myofascial pain in the posterior cervical region and trapezius muscle in women with migraine, using magnetic resonance imaging (MRI) to explore potential anatomical and functional changes (10). In a cross-sectional study, we found that migraine patients exhibited a greater number of myofascial trigger points (MTrPs) in the descending fibers of the trapezius muscle and a significantly smaller muscle volume compared to non-migraine controls. Interestingly, the volume of the trapezius showed a strong negative correlation with migraine frequency, suggesting that muscular atrophy or disuse may be associated with increased headache burden. Although MRI was effective for quantifying muscle volume, it did not reveal signal alterations in MTrP regions, indicating that MRI may not be a suitable tool for identifying trigger points directly. These findings support the hypothesis that cervicoscapular myofascial dysfunction may play a relevant role in the pathophysiology or chronification of migraine.

We propose that MAMP be recognized as a typical but underdiagnosed clinical phenotype within the chronic migraine spectrum. Positioned between localized nociceptive dysfunction and widespread central sensitization, it may serve as a clinical bridge between migraine, corpalgia and fibromyalgia. Formal validation of diagnostic criteria through prospective studies is warranted. Still, in the interim, clinicians should be attentive to myofascial symptoms (11) in migraine patients, especially those with high attack frequency, medication overuse and widespread cutaneous allodynia.