Muscle:Occipitofrontalis

The occipitofrontalis (also called the epicranial muscle) is the major cutaneous muscle of the scalp. It has two muscle bellies — the frontalis anteriorly and the occipitalis posteriorly — connected above by a large flat tendinous sheet, the galea aponeurotica, which covers the vertex of the skull. The galea is firmly connected to the skin but slides freely over the periosteum.

Trigger points (TrPs) in these muscles are a commonly overlooked source of frontal and occipital headache. Because the pain tends to stay local to the muscle, it is nearly always misattributed to tension headache. The occipitalis belly is the more clinically significant of the two: its TrPs refer deep aching pain through the cranium to behind the eye, and the patient cannot bear the weight of the back of the head on a pillow at night. Both bellies most commonly develop TrPs as satellites of TrPs in the clavicular division of the sternocleidomastoid (SCM) or other posterior cervical muscles — making SCM the first muscle to check and treat.

Anatomy

The two bellies share the galea aponeurotica above:

Frontalis

Attaches below and anteriorly to the skin over the eyebrow, where it interdigitates with the orbicularis oculi muscle. Has no bony attachment anteriorly — it is a true cutaneous muscle. Fibres lie in the subcutaneous fascia of the forehead.

Occipitalis

Attaches below and posteriorly to the superior nuchal line of the occipital bone. Lies in the subcutaneous fascia over the occiput.

The galea aponeurotica connects both bellies above, covering the vertex. It is firmly attached to the overlying skin but slides freely over the periosteum of the skull.

Innervation

Both bellies are supplied by the facial nerve (cranial nerve VII).

Referred Pain Patterns

Frontalis

TrPs in the frontalis muscle belly evoke pain that spreads upward and over the forehead on the same side. The referred pain remains largely local — in the region of the muscle itself — similar in character to TrPs in the deltoid muscle. There is no referral to the eye or occiput from frontalis TrPs.

An active TrP in the medial half of the frontalis belly can also entrap the supraorbital nerve, producing a unilateral frontal headache with primarily neuritic rather than myofascial pain characteristics (see Entrapment below).

Occipitalis

Active TrPs in the occipitalis belly refer pain laterally and anteriorly, diffusely over the back of the head and through the cranium, causing intense pain deep in the orbit ("behind the eye"). This through-the-skull referral pattern is distinctive and clinically important.

Experimental injection of hypertonic saline into normal occipitalis muscle produced "earache." Injection into the galea aponeurotica between the two bellies referred pain homolaterally behind the eye, in the eyeball, and in the eyelids.

Occipitalis tenderness was found in 42% of 42 patients with ipsilateral face and head pain associated with the myofascial pain-dysfunction syndrome.

Referred pain summary — Occipitofrontalis

Belly	TrP location	Essential referred zone	Key distinguishing feature
Frontalis	Above medial end of eyebrow	Upward and over the forehead, ipsilateral; local to the muscle	Stays local — no eye or occipital referral. May produce supraorbital nerve entrapment (neuritic frontal headache).
Occipitalis	Small hollow just above the superior nuchal line, ~4 cm lateral to midline	Diffusely over the back of the head → through the cranium → deep in the orbit ("behind the eye")	Through-the-skull pattern. Cannot bear head weight on pillow at night. Responds to moist heat (distinguishes from nerve entrapment).

Activation and Perpetuating Factors

Frontalis

• Satellite TrPs from TrPs in the clavicular division of the SCM, which refer head pain to the frontal region — the most common driver
• Work overload in anxious or tense people with great mobility of facial expression
• Habitual use of the frontalis in an expression of attention with raised eyebrows and persistently wrinkled forehead
• Habitual frowning

Occipitalis

• Satellite TrPs from posterior cervical TrPs (semispinalis cervicis, posterior digastric) that refer pain and tenderness to the occipital region
• Decreased visual acuity and/or glaucoma — due to persistent, strong contraction of forehead and scalp muscles
• Satellite activation from clavicular division SCM TrPs

Clinical Examination

Patient Presentation

Frontalis: The patient has frontal headache and tends to frown habitually. Be suspicious of frontalis TrPs in any patient with frontal headache and a furrowed brow at rest.

Occipitalis: The patient cannot bear the weight of the back of the head on a pillow at night because of the pain induced by pressure on the TrP, and must lie on their side. The deep aching occipital pain caused by occipitalis TrPs must be distinguished from the more superficial scalp tingling and hot prickling pain due to entrapment of the greater occipital nerve by the posterior cervical muscles:

Occipital pain: myofascial vs nerve entrapment

Feature	Occipitalis TrPs (myofascial)	Greater occipital nerve entrapment
Pain quality	Deep aching, through-the-skull	Superficial tingling, hot prickling
Pain location	Occiput → through cranium → behind the eye	Scalp distribution along nerve path
Response to heat	Moist heat provides relief	Cannot tolerate heat; prefers ice pack
Pressure on occiput	Aggravated by lying on back (TrP compression)	Tenderness at nerve exit point

No other specific physical sign is present. Examination is otherwise unremarkable.

Trigger Point Examination

Both bellies are accessible by flat palpation — the muscle is pressed against the underlying skull and the examining fingertip is moved crosswise over the fibres.

Frontalis TrP

Located by flat palpation as spot tenderness above the medial end of the eyebrow. Local twitch responses are not observed in this muscle.

Occipitalis TrP

Located in a small hollow just above the superior nuchal line, approximately 4 cm (1.5 inches) lateral to the midline. Spot tenderness is found by flat palpation. Considerable probing of the area may be necessary to locate the TrP precisely. Local twitch responses may be visible and palpable given the superficial location of the muscle.

Differential Diagnosis

Pain caused by TrPs in the occipitofrontalis muscles is nearly always misdiagnosed as tension-type headache without recognition of the treatable muscular source. The following table helps distinguish the key mimics:

Differential diagnosis of frontal and occipital headache

Diagnosis	Key distinguishing features	How to differentiate from occipitofrontalis TrPs
Tension-type headache	Bilateral, band-like, featureless	Occipitofrontalis TrPs are unilateral, localised, and have palpable spot tenderness with referred pain; respond to TrP treatment
Clavicular SCM TrP (satellite source)	Frontal headache ipsilateral to the SCM TrP; dizziness and postural imbalance may be present	SCM TrP is the key TrP — palpate the clavicular head of SCM first; treating SCM may resolve frontalis TrP spontaneously
Occipital neuralgia (neurological)	Lancinating, electric, clearly localised along greater occipital nerve; scalp allodynia	TrP pain is deep and aching, not lancinating; moist heat relieves TrP pain but worsens neuralgic pain; ice pack preferred for neuralgia
Greater occipital nerve entrapment (myofascial)	Usually caused by posterior cervical TrPs (semispinalis capitis, trapezius) entrapping the nerve — treat those muscles first
Supraorbital neuralgia (frontalis entrapment)	Unilateral frontal "headache" with neuritic quality; no myofascial taut band	Relieved by inactivating the responsible frontalis TrPs — confirms myofascial origin
Glaucoma	Periorbital aching; intraocular pressure elevated on tonometry	Occipitalis TrPs may coexist — both must be addressed; check IOP
Posterior digastric / semispinalis cervicis TrPs	Occipital aching; referred tenderness to the occiput	Palpate these muscles; their TrPs may be the primary key TrPs driving occipitalis satellites

Key principle

Active TrPs in the frontalis are often found as satellites in association with long-standing TrPs in the clavicular division of the SCM on the same side. Lasting relief depends on inactivating the SCM TrPs first. Similarly, occipitalis TrPs frequently persist because of key TrPs in the posterior digastric and semispinalis cervicis — these must be specifically checked.

Entrapment

Active TrPs in the medial half of the frontalis belly can apparently entrap the supraorbital nerve. This entrapment produces a unilateral frontal headache with primarily neuritic rather than myofascial pain characteristics. The symptoms are relieved by inactivating the frontalis TrPs responsible — by digital pressure, massage, or injection.

No nerve entrapments have been identified from occipitalis TrPs.

Treatment

Trigger Point Release

Frontalis: Spray and stretch is unsatisfactory because the muscle is so difficult to stretch adequately. The frontalis responds well to massage and TrP pressure release — progressively squeezing and rolling the TrP between the fingers as the tension releases. Digital pressure release of the TrPs is also recommended as the primary patient self-treatment.

Occipitalis: The same approach applies — spray and stretch is unsatisfactory, but TrP pressure release and deep massage are effective and have been recommended consistently. The muscle lies in a small hollow above the nuchal line which holds sufficient mass to apply sustained pressure release effectively.

For both bellies, treating the key TrPs in the SCM clavicular division and posterior cervical muscles first is essential — this often resolves the scalp TrPs as satellites without direct treatment.

Trigger Point Injection

Frontalis: The muscle fibres are thin and very superficial. Use a 25- or 26-gauge, 16 mm (5/8-inch) needle directed across the muscle fibres (parallel to the eyebrow), nearly tangent to the skin. Dry needling with an acupuncture needle is also effective if it produces a local twitch response. Warn the patient that ecchymosis may develop in the injected area, causing a "black eye."

Occipitalis: The muscle belly is thicker than the frontalis and may require a longer 3.7 cm (1.5-inch) needle. The TrPs lie in a small hollow just above the superior nuchal line which holds sufficient muscle mass to receive the needle. Considerable probing may be necessary to locate the TrP precisely. Inject with 0.5% procaine in isotonic saline.

Patient Education

• Avoid persistent frowning and vigorous wrinkling of the forehead — the frontalis is associated with the increased muscle tension of anxiety and is commonly overloaded in tense, expressive individuals
• Learn digital pressure release of the TrPs as a home self-treatment
• Any related key TrPs in the clavicular division of the SCM and posterior neck muscles must be inactivated for lasting relief — address these muscles first
• Patients with occipitalis TrPs should avoid sleeping supine until TrPs are resolved; sleeping on the side eliminates nocturnal pressure on the occipital TrP

Satellite Trigger Points

The occipitofrontalis develops TrPs as satellites of key TrPs in:

• Sternocleidomastoid (clavicular division) — the primary key TrP driver for frontalis satellites
• Semispinalis cervicis — key TrP driver for occipitalis satellites
• Posterior digastric — refers pain and tenderness to the occipital region
• Posterior cervical muscles generally — any muscle referring pain to the occiput may drive occipitalis satellite activity

Related Pages

• Muscle:Sternocleidomastoid — primary key TrP muscle; treat first before scalp muscles
• Muscle:Semispinalis_Cervicis — key TrP source for occipitalis satellites
• Muscle:Suboccipital — closely related occipital pain source; often coexists
• Muscle:Orbicularis_Oculi — adjacent cutaneous muscle; TrPs refer to the nose
• Pain:HeadOcciput — occipital and vertex headache differential
• Pain:HeadFrontal — frontal headache differential
• Differential:NeckPain — neck pain diagnostic tree

References

• Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1: The Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. Chapter 14.