DiagnosticTree/FrontalHeadache: Difference between revisions

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Created page with "{ "tree_id": "frontal-headache", "region": "Frontal Headache", "start": "rom-1", "redflags": { "emergency": [ { "id": "rf-e1", "label": "Thunderclap headache — subarachnoid haemorrhage", "question": "Did this headache reach maximum severity within seconds to minutes — described as 'the worst headache of my life'?", "rationale": "Sudden-onset severe headache is the cardinal symptom of subarachnoid haemorrhage until pr..."
 
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{
{
   "tree_id": "frontal-headache",
   "model": "bayesian_lr_scoring",
   "region": "Frontal Headache",
   "version": "1.0",
   "start": "rom-1",
   "region_label": "Frontal Headache",
 
   "description": "Probabilistic scoring model for frontal headache using Bayesian likelihood ratio updating with Thurstonian pairwise tiebreakers. Muscles drawn from T&S Vol.1: SCM (Ch.7), Semispinalis Capitis (Ch.16), Occipitofrontalis/Frontalis (Ch.14), Zygomaticus Major (Ch.13). SCM is split into clavicular and sternal divisions, scored separately due to clinically distinct referral and autonomic patterns (Subclavius principle). Bold muscles (SCM both divisions, semispinalis) carry higher priors; facial satellites (frontalis, zygomaticus) carry lower priors as they are almost always satellites of the key TrPs. Converted from legacy DiagnosticTree format 2026-07.",
   "redflags": {
  "thresholds": {
    "emergency": [
    "early_exit_posterior": 0.55,
      {
    "early_exit_gap": 0.18,
        "id": "rf-e1",
    "pairwise_trigger": 0.22
        "label": "Thunderclap headache — subarachnoid haemorrhage",
        "question": "Did this headache reach maximum severity within seconds to minutes — described as 'the worst headache of my life'?",
        "rationale": "Sudden-onset severe headache is the cardinal symptom of subarachnoid haemorrhage until proven otherwise",
        "action": "Call emergency services immediately. Do not proceed."
      },
      {
        "id": "rf-e2",
        "label": "Raised intracranial pressure",
        "question": "Is the headache worse on waking, accompanied by vomiting, or associated with progressive neurological deficits (visual field loss, diplopia, limb weakness)?",
        "rationale": "Morning headache with vomiting and neurological signs suggests raised ICP — space-occupying lesion must be excluded",
        "action": "Emergency referral. Do not proceed."
      },
      {
        "id": "rf-e3",
        "label": "Meningitis / encephalitis",
        "question": "Is there fever, photophobia, neck stiffness, or non-blanching rash?",
        "rationale": "Meningism requires immediate medical assessment",
        "action": "Call emergency services immediately. Do not proceed."
      }
    ],
    "urgent": [
      {
        "id": "rf-u1",
        "label": "Temporal arteritis (Giant cell arteritis)",
        "question": "Is the patient aged 50+ with scalp tenderness, jaw claudication (jaw pain that builds with chewing then eases with rest), or visual symptoms such as transient vision loss?",
        "rationale": "Temporal arteritis can cause irreversible blindness within hours of visual symptoms. Same-day investigation required.",
        "action": "Same-day GP referral + ESR and CRP. Do not delay for further myofascial assessment."
      },
      {
        "id": "rf-u2",
        "label": "Acute angle-closure glaucoma",
        "question": "Is there sudden severe unilateral eye pain, blurred vision, halos around lights, or a fixed mid-dilated pupil?",
        "rationale": "Acute angle-closure glaucoma produces severe frontal and orbital pain and can cause irreversible vision loss within hours",
        "action": "Emergency ophthalmology referral. Do not proceed."
      },
      {
        "id": "rf-u3",
        "label": "Cervical instability",
        "question": "Is there a history of significant head or neck trauma combined with upper cervical pain, arm symptoms, or gait disturbance?",
        "rationale": "Cervical instability or fracture can refer pain to the frontal region and must be excluded before any cervical assessment",
        "action": "Urgent spinal assessment — no manual therapy until cleared."
      }
    ]
   },
   },
 
   "emergency": [
   "nodes": {
    {
 
      "id": "rf-e1",
     "rom-1": {
      "label": "Thunderclap headache",
       "type": "rom",
      "question": "Did the headache reach maximum intensity within seconds to a minute \u2014 described as 'the worst headache of my life' or like a blow to the head?"
       "question": "Is the frontal headache aggravated, altered, or consistently reproduced by neck movements — rotation, flexion, or sustained postures such as looking down?",
    },
       "movement": "Cervical rotation / flexion / sustained posture",
     {
       "direction": "aggravating",
      "id": "rf-e2",
       "clinical_rationale": "Neck movement implicates cervical muscles (SCM, semispinalis capitis). Absence of neck aggravation with frontal pain points toward facial muscles (frontalis, zygomaticus major) or non-myofascial sources.",
       "label": "Signs of raised intracranial pressure",
       "muscles_implicated": ["SCM (Clavicular head)", "SCM (Sternal head)", "Semispinalis Capitis"],
       "question": "Is there headache that is worse on waking, progressively worsening over days or weeks, or associated with vomiting, visual changes, or altered consciousness?"
       "muscles_excluded": ["Frontalis", "Zygomaticus Major"],
    },
       "yes": "symptom-1",
    {
       "no": "rom-2"
       "id": "rf-e3",
       "label": "Meningism",
       "question": "Is there neck stiffness with fever, photophobia, or a non-blanching rash?"
    },
    {
      "id": "rf-e4",
       "label": "Acute angle-closure glaucoma",
      "question": "Is there frontal or periorbital pain with sudden visual blurring, halos around lights, nausea, or a hard red eye?"
    },
    {
      "id": "rf-e5",
       "label": "SNOOP screen \u2014 secondary headache flags",
      "question": "Any of: Systemic signs (fever, weight loss, cancer, HIV, immunosuppression); Neurological deficit or altered consciousness; Onset sudden (thunderclap); Onset after age 50; Pattern change from previous headaches; Papilloedema or positional/Valsalva aggravation?"
    }
  ],
  "urgent": [
    {
       "id": "rf-u1",
       "label": "Temporal arteritis (giant cell arteritis)",
      "question": "Is the patient aged 50+ with jaw claudication (pain building with chewing then easing), scalp tenderness, or a non-pulsatile tender temporal artery? Same-day ESR/CRP required \u2014 risk of irreversible blindness."
     },
     },
 
    {
    "symptom-1": {
      "id": "rf-u2",
       "type": "symptom",
       "label": "Cervical instability",
       "question": "Is there postural dizziness, spatial disorientation, unsteadiness when walking, or a veering to one side — independent of any ear symptoms?",
       "question": "Is there a history of significant trauma to the head or neck combined with arm symptoms, gait disturbance, or headache worsened by neck loading? No manual therapy or cervical stretch until cleared."
      "symptom_name": "Postural dizziness / disequilibrium",
      "clinical_rationale": "Postural dizziness without nystagmus or Romberg positivity is the hallmark of SCM clavicular division TrPs. It does not occur with SCM sternal or semispinalis capitis TrPs.",
      "muscles_implicated": ["SCM (Clavicular head)"],
      "muscles_excluded": ["SCM (Sternal head)", "Semispinalis Capitis"],
      "yes": "exam-scm-clav-1",
      "no": "symptom-2"
     },
     },
 
    {
    "symptom-2": {
      "id": "rf-u3",
       "type": "symptom",
       "label": "New headache in immunocompromised patient",
       "question": "Is there ipsilateral tearing, eye redness, apparent drooping of the eyelid, or a persistent dry tingling cough — on the same side as the headache?",
       "question": "Is the patient immunocompromised (HIV, cancer, immunosuppressants) with a new or changing headache pattern? Opportunistic intracranial infection must be excluded."
      "symptom_name": "Autonomic features — tearing / rhinitis / palpebral ptosis / cough",
    }
       "clinical_rationale": "These autonomic phenomena are characteristic of SCM sternal division TrPs. The sternal division refers to cheek, orbit, occiput, and vertex; the clavicular division does not produce these autonomic features.",
  ],
       "muscles_implicated": ["SCM (Sternal head)"],
  "muscles": {
       "muscles_excluded": ["Semispinalis Capitis"],
    "scm_clavicular": {
       "yes": "exam-scm-sternal-1",
       "label": "SCM \u2014 Clavicular Division",
       "no": "rom-3"
       "prior": 0.13,
       "page": "Muscle:Sternocleidomastoid",
       "key_trp_note": "The clavicular division is the chief myofascial source of ipsilateral frontal headache and drives frontalis satellite TrPs. Treating the clavicular SCM often resolves frontalis without direct treatment. NO autonomic phenomena \u2014 the absence of tearing and rhinitis distinguishes it from the sternal division. May also produce postural dizziness, imbalance, and dysmetria.",
       "subtitle": "Frontal headache aggravated by neck posture/head load; dizziness or imbalance; NO tearing or rhinitis"
     },
     },
 
     "scm_sternal": {
     "rom-3": {
       "label": "SCM \u2014 Sternal Division",
       "type": "rom",
       "prior": 0.13,
       "question": "Is there significant posterior head or occipital pain accompanying the frontal headache — i.e. pain that wraps from the back of the head through to the forehead?",
       "page": "Muscle:Sternocleidomastoid",
       "movement": "Posterior head / occipital component",
       "key_trp_note": "The sternal division refers to cheek, supraorbital ridge, temple, occiput, and vertex \u2014 the frontal component is part of a wider pattern. Cardinal features are ipsilateral autonomic phenomena: profuse tearing, rhinitis, apparent ptosis. Drives zygomaticus major and orbicularis oculi satellites. SCM Compression Test resolves concurrent sore throat on swallowing. Treat sternal SCM before facial satellites.",
      "direction": "location",
       "subtitle": "Cheek/orbital/frontal pain with autonomic phenomena \u2014 tearing, rhinitis, apparent ptosis"
       "clinical_rationale": "Semispinalis capitis TrPs refer from the occipital region through the cranium to the forehead. The pain wraps around the head rather than originating in the frontal region. SCM sternal division also refers to the occiput but with the autonomic features screened above.",
      "muscles_implicated": ["Semispinalis Capitis"],
      "muscles_excluded": ["SCM (Clavicular head)", "SCM (Sternal head)"],
       "yes": "exam-semispinalis-1",
      "no": "exam-scm-clav-1"
     },
     },
 
     "semispinalis": {
     "exam-scm-clav-1": {
       "label": "Semispinalis Capitis",
       "type": "examination",
       "prior": 0.13,
       "question": "Does flat palpation of the clavicular head of the SCM — from the medial clavicle upward toward the mastoid — reproduce the patient's frontal headache or dizziness?",
       "page": "Muscle:Semispinalis_Capitis",
       "exam_type": "palpation",
       "key_trp_note": "The defining referral is a band-like headache encircling the head, maximal at the temple, continuing forward over the eye. Nuchal-line tenderness (Location 1) is enthesopathy driven by a midbelly TrP (Location 2) \u2014 palpate midbelly for the causal TrP. DO NOT inject Location 2 (vertebral artery proximity at C1). Greater occipital nerve entrapment may coexist. Frequently a satellite of upper trapezius and splenius capitis key TrPs \u2014 treat those first.",
       "landmark": "Clavicular head: lies deep and posterior to the sternal head. Palpate with flat pressure from the medial third of the clavicle upward toward the mastoid. TrPs typically found in the mid-belly.",
       "subtitle": "Band-like headache encircling occiput \u2192 temple \u2192 over the eye; worse with sustained neck flexion"
      "positive_finding": "Reproduces frontal headache, or provokes or worsens dizziness / spatial disorientation",
      "muscles_implicated": ["SCM (Clavicular head)"],
       "yes": "result-scm-clavicular",
      "no": "result-overlap"
     },
     },
 
     "frontalis": {
     "exam-scm-sternal-1": {
       "label": "Frontalis (Occipitofrontalis)",
       "type": "examination",
       "prior": 0.086667,
       "question": "Does pincer palpation of the sternal head of the SCM reproduce the patient's facial pain, orbital pain, or familiar headache — or does pressing the central muscle belly reproduce a sore throat on swallowing?",
       "page": "Muscle:Occipitofrontalis",
       "exam_type": "palpation",
       "key_trp_note": "Frontalis TrPs are nearly always satellites of clavicular division SCM TrPs \u2014 check and treat SCM first. Pain stays local to the forehead with no referral to eye or occiput. A habitually furrowed brow or raised eyebrows at rest is the cardinal sign. Suspect supraorbital nerve entrapment if the pain has a neuritic burning quality above the medial eyebrow.",
       "landmark": "Sternal head: encircle the muscle belly between thumb and forefinger from mastoid to sternum. For the sore throat test (SCM Compression Test): grasp the SCM firmly in a pincer grip and ask the patient to swallow — positive if throat pain resolves with compression.",
       "subtitle": "Pain localised to the forehead itself; no referral to eye/cheek/occiput; furrowed brow at rest"
       "positive_finding": "Reproduces facial pain, orbital pain, or sore throat resolves with SCM compression",
      "muscles_implicated": ["SCM (Sternal head)"],
      "yes": "result-scm-sternal",
      "no": "result-overlap"
     },
     },
 
     "zygomaticus": {
     "exam-semispinalis-1": {
       "label": "Zygomaticus Major",
       "type": "examination",
      "prior": 0.086667,
       "question": "Does deep flat palpation of the posterior neck muscles — midway between the midline and the mastoid, at the level of C1–C2 — reproduce the patient's head pain or refer pain through the cranium toward the forehead?",
      "page": "Muscle:Zygomaticus_Major",
       "exam_type": "palpation",
       "key_trp_note": "Zygomaticus major TrPs refer in a distinctive nasal arc: cheek \u2192 lateral nose \u2192 nasal bridge \u2192 mid-forehead. TrP tightness restricts jaw opening 10\u201320mm; inactivation restores opening immediately (intratreatment confirmation). Nearly always a satellite of SCM sternal division or masticatory TrPs \u2014 treat the key TrP first.",
       "landmark": "Semispinalis capitis: deep posterior cervical muscle. Palpate approximately 2–3 cm lateral to the midline at the level of C1–C2, pressing firmly against the cervical laminae. TrPs are deep and may require sustained pressure.",
      "subtitle": "Nasal arc: cheek up the side of the nose to mid-forehead; jaw opening may be restricted 10\u201320mm"
      "positive_finding": "Reproduces occipital-to-frontal wrap-around head pain, or localised occipital tenderness with frontal referral",
    }
      "muscles_implicated": ["Semispinalis Capitis"],
  },
      "yes": "result-semispinalis",
  "questions": [
      "no": "result-overlap"
    {
      "id": "q_primary_pattern",
      "text": "What is the PRIMARY pattern of the frontal headache?",
      "sublabel": "This first split separates the muscles by mechanism. Choose the dominant pattern.",
       "type": "choice",
       "answers": [
        {
          "id": "neck_posture_dizziness",
          "label": "Neck movement, posture, or head load aggravates \u2014 OR dizziness/imbalance accompanies the frontal headache",
          "sublabel": "Turning the head, looking down, carrying a bag, sustained forward head position, or balance disturbance alongside the pain",
          "lr": {
            "scm_clavicular": 6.0,
            "scm_sternal": 2.0,
            "semispinalis": 2.5,
            "frontalis": 1.0,
            "zygomaticus": 0.4
          }
        },
        {
          "id": "encircling_band",
          "label": "Band-like headache encircling from the occiput through the temple and forward over the eye",
          "sublabel": "Worsened by sustained neck flexion \u2014 reading, computing, sewing; often bilateral or sub-occipital at onset",
          "lr": {
            "semispinalis": 9.0,
            "scm_clavicular": 1.0,
            "scm_sternal": 1.0,
            "frontalis": 0.4,
            "zygomaticus": 0.3
          }
        },
        {
          "id": "cheek_orbital_autonomic",
          "label": "Cheek, orbit, temple, and frontal pain \u2014 as part of a wider facial pattern, often with tearing or a watering/congested nose",
          "sublabel": "Pain spreads across the cheek and around the eye with autonomic features on the same side",
          "lr": {
            "scm_sternal": 8.0,
            "zygomaticus": 2.0,
            "scm_clavicular": 0.8,
            "semispinalis": 0.6,
            "frontalis": 0.5
          }
        },
        {
          "id": "local_forehead",
          "label": "Frontal pain that stays LOCAL to the forehead itself",
          "sublabel": "No prominent neck component; pain confined to the forehead; patient may have a habitually furrowed brow",
          "lr": {
            "frontalis": 9.0,
            "scm_clavicular": 1.5,
            "scm_sternal": 0.5,
            "semispinalis": 0.4,
            "zygomaticus": 0.6
          }
        },
        {
          "id": "nasal_arc",
          "label": "A curved NASAL ARC \u2014 from the cheek, up along the side of the nose, to the mid-forehead",
          "sublabel": "Pain traces an arc up the side of the nose; jaw opening may be mildly restricted",
          "lr": {
            "zygomaticus": 10.0,
            "scm_sternal": 2.0,
            "frontalis": 0.6,
            "scm_clavicular": 0.4,
            "semispinalis": 0.3
          }
        }
      ]
     },
     },
 
     {
     "rom-2": {
       "id": "q_autonomic",
       "type": "rom",
       "text": "Alongside the frontal headache, are there ipsilateral AUTONOMIC phenomena \u2014 profuse tearing, rhinitis (watering or congested nose), conjunctival redness, or apparent drooping of the eyelid on the same side?",
       "question": "Is jaw opening restricted — less than approximately 40 mm between the upper and lower incisors — or is there pain along the side of the nose or cheek accompanying the frontal headache?",
       "sublabel": "These separate the two SCM divisions. Confirm pupils equal and reactive to exclude true Horner syndrome.",
       "movement": "Jaw opening / nasal arc pain",
       "type": "binary",
       "direction": "aggravating",
       "answers": [
       "clinical_rationale": "Zygomaticus major TrPs refer pain in an arc from the cheek along the lateral nose to the mid-forehead. TrP tightness can restrict jaw opening by 10–20 mm. This distinguishes zygomaticus major from frontalis, which refers locally over the forehead only.",
        {
      "muscles_implicated": ["Zygomaticus Major"],
          "id": "yes",
      "muscles_excluded": ["Frontalis"],
          "label": "Yes \u2014 tearing, rhinitis, conjunctival redness, or apparent ptosis on the pain side",
      "yes": "exam-zygomaticus-1",
          "lr": {
      "no": "exam-frontalis-1"
            "scm_sternal": 9.0,
            "zygomaticus": 1.5,
            "scm_clavicular": 0.2,
            "semispinalis": 0.4,
            "frontalis": 0.5
          }
        },
        {
          "id": "no",
          "label": "No \u2014 no autonomic phenomena",
          "lr": {
            "scm_sternal": 0.3,
            "scm_clavicular": 1.4,
            "semispinalis": 1.2,
            "frontalis": 1.2,
            "zygomaticus": 0.9
          }
        }
      ]
     },
     },
 
    {
    "exam-zygomaticus-1": {
      "id": "q_neck_flexion",
       "type": "examination",
       "text": "Is cervical flexion restricted or does it reproduce the headache?",
       "question": "Does pincer palpation of the zygomaticus major — with one gloved digit inside the cheek and one outside, running from the zygomatic bone toward the angle of the mouth — reproduce the patient's pain or refer pain upward along the nose toward the forehead?",
       "sublabel": "Ask the patient to slowly lower the chin toward the chest \u2014 is the range reduced (normally chin comes within 1\u20132 finger-breadths of the sternum), or does flexion provoke or intensify the frontal or band-like pain?",
       "exam_type": "palpation",
       "type": "binary",
       "landmark": "Zygomaticus major: patient supine or seated with jaws comfortably propped open. Pincer palpation from zygomatic bone (origin) toward corner of mouth (insertion). Taut band is palpable chiefly by the outside finger.",
       "answers": [
       "positive_finding": "Reproduces cheek-to-nasal-arc-to-forehead pain pattern, or spot tenderness in a taut band",
        {
       "muscles_implicated": ["Zygomaticus Major"],
          "id": "yes",
       "yes": "result-zygomaticus",
          "label": "Yes \u2014 cervical flexion is restricted or reproduces the headache",
      "no": "exam-frontalis-1"
          "lr": {
            "semispinalis": 7.0,
            "scm_clavicular": 0.7,
            "scm_sternal": 0.6,
            "frontalis": 0.4,
            "zygomaticus": 0.3
          }
        },
        {
          "id": "no",
          "label": "No \u2014 full pain-free cervical flexion",
          "lr": {
            "semispinalis": 0.2,
            "scm_clavicular": 1.2,
            "scm_sternal": 1.2,
            "frontalis": 1.2,
            "zygomaticus": 1.2
          }
        }
      ]
    },
    {
      "id": "q_dizziness",
      "text": "Is there postural dizziness, imbalance, or disturbed weight perception (dysmetria) \u2014 without vertigo, nystagmus, or a positive Romberg?",
       "sublabel": "Non-vestibular imbalance: veering toward one side on a straight-line walk, dizziness worse lying without a pillow or on quick head rotation. Romberg negative, no nystagmus.",
       "type": "binary",
       "answers": [
        {
          "id": "yes",
          "label": "Yes \u2014 non-vestibular dizziness, imbalance, or dysmetria",
          "lr": {
            "scm_clavicular": 8.0,
            "scm_sternal": 0.8,
            "semispinalis": 0.6,
            "frontalis": 0.5,
            "zygomaticus": 0.4
          }
        },
        {
          "id": "no",
          "label": "No \u2014 no dizziness or imbalance",
          "lr": {
            "scm_clavicular": 0.4,
            "scm_sternal": 1.1,
            "semispinalis": 1.1,
            "frontalis": 1.1,
            "zygomaticus": 1.1
          }
        }
      ]
     },
     },
 
     {
     "exam-frontalis-1": {
       "id": "q_jaw_opening",
       "type": "examination",
       "text": "Is jaw opening restricted \u2014 and does the restriction improve immediately when the relevant facial or masticatory trigger points are released?",
       "question": "Does flat palpation above the medial end of the eyebrow — pressing the fingertip crosswise over the frontalis muscle fibres against the underlying frontal bone — reproduce the patient's forehead pain?",
       "sublabel": "Measure interincisal opening. Zygomaticus (and masticatory) TrP tightness may reduce opening by 10\u201320mm; immediate restoration on TrP inactivation is a confirmatory sign.",
       "exam_type": "palpation",
      "type": "binary",
       "landmark": "Frontalis: flat palpation against the frontal bone, above the medial end of the eyebrow. Press firmly and run the fingertip crosswise over the thin, superficial muscle fibres. The TrP is a spot of focal tenderness in a taut band.",
       "answers": [
      "positive_finding": "Reproduces localised forehead pain spreading upward and over the ipsilateral forehead",
        {
      "muscles_implicated": ["Frontalis"],
          "id": "yes",
      "yes": "result-frontalis",
          "label": "Yes \u2014 jaw opening restricted 10\u201320mm",
      "no": "result-overlap"
          "lr": {
            "zygomaticus": 6.0,
            "scm_sternal": 1.3,
            "scm_clavicular": 0.6,
            "semispinalis": 0.6,
            "frontalis": 0.5
          }
        },
        {
          "id": "no",
          "label": "No \u2014 jaw opening is full and unrestricted",
          "lr": {
            "zygomaticus": 0.3,
            "scm_sternal": 1.0,
            "scm_clavicular": 1.1,
            "semispinalis": 1.1,
            "frontalis": 1.1
          }
        }
      ]
     },
     },
 
     {
     "result-scm-clavicular": {
       "id": "q_brow_posture",
       "type": "result",
       "text": "Does the patient have a habitually furrowed brow or persistently raised eyebrows at rest?",
       "diagnosis": "SCM — Clavicular Division Trigger Point",
       "sublabel": "A visible sign of chronic frontalis overload \u2014 observe the resting brow position during history-taking.",
       "confidence": "high",
       "type": "binary",
      "wiki_page": "Muscle:Sternocleidomastoid",
       "answers": [
      "chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
         {
      "notes": "The clavicular division produces three dominant presentations, any one of which may predominate: (1) ipsilateral frontal headache — commonly mistaken for tension or sinus headache; (2) postural dizziness and disequilibrium — veers toward the TrP side on straight-line walking; (3) dysmetria — same object feels heavier when held on the unaffected side. In rare cases, hearing may be impaired on the same side.",
          "id": "yes",
       "treatment_hint": "Correct forward head posture first — the single most important perpetuating factor. Flat palpation of the clavicular head from medial clavicle upward. Spray and stretch (superior to inferior), ischemic compression. Treating SCM often resolves satellite TrPs (frontalis, orbicularis oculi) without direct treatment.",
          "label": "Yes \u2014 habitually furrowed or raised brow at rest",
      "also_consider": ["Scalene muscles", "Splenius cervicis", "Semispinalis capitis"],
          "lr": {
       "less_likely": [
            "frontalis": 5.0,
         { "muscle": "SCM Sternal Division", "reason": "Autonomic features (tearing, rhinitis, palpebral fissure narrowing) absent" },
            "scm_clavicular": 1.2,
        { "muscle": "Semispinalis Capitis", "reason": "No posterior head wrap-around pain" },
            "scm_sternal": 0.8,
        { "muscle": "Frontalis", "reason": "Frontalis TrPs are satellites of clavicular division — treat SCM first" },
            "semispinalis": 0.7,
        { "muscle": "Zygomaticus Major", "reason": "No jaw restriction or nasal arc pain" }
            "zygomaticus": 0.7
      ],
          }
      "confirmatory": [
         },
        "Straight-line walking test — patient veers toward the side of active clavicular TrP while walking toward a fixed point",
         {
         "Romberg's sign is NEGATIVE — distinguishes from vestibular pathology",
          "id": "no",
         "Nystagmus absent — presence of nystagmus indicates vestibular pathology, not myofascial",
          "label": "No \u2014 resting brow position is normal",
        "Dysmetria test — same object may feel heavier when held on the unaffected side",
          "lr": {
        "Hearing restoration manoeuvre — rotate head toward affected side and tilt chin down; any hearing change confirms clavicular division involvement"
            "frontalis": 0.5,
      ],
            "scm_clavicular": 1.0,
      "satellite_trps": ["Frontalis", "Orbicularis oculi", "Scalene muscles", "Sternalis", "Pectoralis major"],
            "scm_sternal": 1.0,
      "landing_page_topics": [
            "semispinalis": 1.0,
        "Full dizziness differentiation protocol — Romberg, nystagmus, straight-line walking",
            "zygomaticus": 1.0
        "Neurological screen — postural BP, carotid auscultation",
          }
        "Hearing restoration manoeuvre",
         }
        "Dysmetria — weight perception test",
        "Forward head posture correction — axial extension exercise",
        "Sleep posture and workstation setup"
      ],
      "related_pages": [
        { "label": "Scalene TrPs →", "page": "Muscle:Scalene" },
         { "label": "Frontalis TrP →", "page": "Muscle:Frontalis" }
       ]
       ]
     },
     },
 
     {
     "result-scm-sternal": {
       "id": "q_sore_throat",
       "type": "result",
       "text": "Does the SCM Compression Test relieve a concurrent sore throat on swallowing \u2014 firmly gripping the sternal belly and asking the patient to swallow eases pharyngeal pain?",
       "diagnosis": "SCM — Sternal Division Trigger Point",
       "sublabel": "Pathognomonic of a sternal-division central TrP. Also note a dry tingling cough from a TrP near the sternal attachment.",
       "confidence": "high",
       "type": "binary",
      "wiki_page": "Muscle:Sternocleidomastoid",
       "answers": [
      "chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
         {
      "notes": "The sternal division refers to cheek, temple, supraorbital ridge, occiput, and vertex. The autonomic phenomena (tearing, conjunctival redness, rhinitis, palpebral fissure narrowing) are often more alarming to the patient than the pain itself. A dry tingling cough TrP near the sternal attachment and sore throat on swallowing (resolved by SCM compression) are pathognomonic of central sternal division involvement. The forehead and orbital pain pattern is frequently diagnosed as sinusitis, tension headache, or trigeminal neuralgia.",
          "id": "yes",
       "treatment_hint": "Pincer palpation of the sternal head. Spray and stretch (superior to inferior). Correct forward head posture — essential for lasting relief. Address satellite TrPs only after SCM TrPs are resolved.",
          "label": "Yes \u2014 compression relieves the sore throat on swallowing",
       "also_consider": ["SCM Clavicular Division", "Scalene muscles", "Splenius capitis"],
          "lr": {
      "less_likely": [
            "scm_sternal": 7.0,
         { "muscle": "SCM Clavicular Division", "reason": "Autonomic features present — more consistent with sternal division" },
            "scm_clavicular": 0.5,
        { "muscle": "Semispinalis Capitis", "reason": "Autonomic features and orbital referral absent in semispinalis" },
            "semispinalis": 0.5,
        { "muscle": "Frontalis", "reason": "Frontalis TrPs are satellites of sternal division — treat SCM first" },
            "frontalis": 0.5,
        { "muscle": "Zygomaticus Major", "reason": "No jaw restriction or nasal arc pain" }
            "zygomaticus": 0.8
      ],
          }
      "confirmatory": [
         },
         "SCM Compression Test positive — pharyngeal pain resolves when sternal head is compressed in a pincer grip during swallowing",
         {
         "Apparent ptosis (palpebral fissure narrowing) without miosis or enophthalmos — excludes true Horner syndrome",
          "id": "no",
        "Autonomic phenomena ipsilateral to TrP — tearing, rhinitis, conjunctival redness",
          "label": "No \u2014 no sore throat, or compression does not change it",
        "Visual symptom: venetian blinds / window frame phenomenon — contrast sensitivity disturbance distinct from blurred or double vision",
          "lr": {
        "Dry tingling cough triggered by palpation near sternal attachment"
            "scm_sternal": 0.8,
      ],
            "scm_clavicular": 1.1,
      "satellite_trps": ["Scalene muscles", "Sternalis", "Pectoralis major", "Orbicularis oculi", "Frontalis", "Zygomaticus Major"],
            "semispinalis": 1.1,
      "landing_page_topics": [
            "frontalis": 1.1,
        "Full sternal vs clavicular division comparison",
            "zygomaticus": 1.0
        "Horner syndrome exclusion protocol",
          }
        "SCM Compression Test technique",
         }
        "Autonomic phenomena — differential from true neurological signs",
        "CN XI entrapment and trapezius weakness"
      ],
      "related_pages": [
        { "label": "Scalene TrPs →", "page": "Muscle:Scalene" },
         { "label": "Zygomaticus Major TrP →", "page": "Muscle:Zygomaticus_Major" }
       ]
       ]
     },
     },
 
     {
     "result-semispinalis": {
       "id": "q_flexion_activities",
       "type": "result",
       "text": "Is the headache clearly provoked by sustained forward-head activities \u2014 reading, computing, sewing, or writing with the head flexed for long periods?",
       "diagnosis": "Semispinalis Capitis Trigger Point",
       "sublabel": "The checkrein loading mechanism of semispinalis capitis \u2014 sustained neck flexion chronically loads the muscle.",
       "confidence": "high",
       "type": "binary",
       "wiki_page": "Muscle:Semispinalis_Capitis",
       "answers": [
       "chapter_ref": "Travell & Simons Vol.1 — Ch.16 Semispinalis Capitis",
        {
      "notes": "TrPs in the semispinalis capitis refer pain diffusely over the back of the head and through the cranium, producing an intense ache or pressure deep in the forehead and behind the eye. The pain wraps around the head from occiput to frontal region. Greater occipital nerve entrapment by semispinalis capitis TrP taut bands produces a superficial scalp tingling and hot prickling quality that is distinct from the deep aching referral — patients with nerve entrapment cannot tolerate heat and prefer an ice pack, whereas TrP referral patients find moist heat provides relief.",
          "id": "yes",
      "treatment_hint": "Spray and stretch with the neck in flexion. Deep ischemic compression. Address perpetuating forward head posture. Check for satellite TrPs in the occipitalis and splenius capitis.",
          "label": "Yes \u2014 clearly provoked by sustained forward-head activity",
      "also_consider": ["Occipitalis", "Splenius Capitis", "SCM Sternal Division", "Posterior Digastric"],
          "lr": {
      "less_likely": [
            "semispinalis": 4.0,
         { "muscle": "SCM Clavicular Division", "reason": "No postural dizziness; posterior head wrap-around pain more consistent with semispinalis" },
            "scm_clavicular": 1.2,
        { "muscle": "SCM Sternal Division", "reason": "No autonomic features; occipital origin of pain argues against sternal division" },
            "scm_sternal": 0.9,
        { "muscle": "Frontalis", "reason": "No neck movement aggravation; pain wraps from occiput rather than originating frontally" },
            "frontalis": 1.2,
        { "muscle": "Zygomaticus Major", "reason": "No jaw restriction or nasal arc; no cheek TrP" }
            "zygomaticus": 0.7
          }
        },
         {
          "id": "no",
          "label": "No \u2014 not clearly related to sustained neck flexion",
          "lr": {
            "semispinalis": 0.5,
            "scm_clavicular": 1.0,
            "scm_sternal": 1.0,
            "frontalis": 0.9,
            "zygomaticus": 1.1
          }
        }
      ]
    }
  ],
  "pairwise": [
    {
      "id": "pw_scm_clav_sternal",
      "pair": [
        "scm_clavicular",
        "scm_sternal"
       ],
       ],
       "confirmatory": [
       "text": "Tiebreaker \u2014 SCM Clavicular vs Sternal Division",
        "Pain quality distinction — deep aching TrP referral (patient prefers moist heat) versus superficial hot prickling nerve entrapment (patient prefers ice pack)",
      "question": "Are there autonomic phenomena (tearing, rhinitis, apparent ptosis) with the frontal headache, OR is the headache dominated by postural aggravation and dizziness WITHOUT any tearing or rhinitis?",
        "Greater occipital nerve entrapment suspected if pain is superficial, tingling, and heat-intolerant — caused by TrP taut band compressing the nerve",
      "answers": [
        "TrP located approximately 2–3 cm lateral to the midline at C1–C2 level — deep palpation against the cervical laminae required",
        {
        "Sustained neck flexion reproduces or worsens the occipital-to-frontal pain"
          "id": "autonomic_present",
      ],
          "label": "Autonomic phenomena present \u2014 tearing, rhinitis, apparent ptosis",
      "satellite_trps": ["Occipitalis", "Splenius Capitis", "Trapezius/Upper"],
          "lr": {
      "landing_page_topics": [
            "scm_sternal": 5.0,
        "Greater occipital nerve entrapment — heat vs cold preference as diagnostic sign",
            "scm_clavicular": 0.2
        "Distinction from occipital neuralgia",
          }
        "Posterior digastric as co-involved muscle",
         },
         "See also Ch.16 for full semispinalis cervicis detail"
         {
      ],
          "id": "postural_dizziness",
      "related_pages": [
          "label": "Postural aggravation and/or dizziness, NO autonomic phenomena",
         { "label": "Occipitalis TrP →", "page": "Muscle:Occipitofrontalis" },
          "lr": {
        { "label": "Splenius Capitis TrP →", "page": "Muscle:Splenius_Capitis" }
            "scm_sternal": 0.2,
            "scm_clavicular": 5.0
          }
        }
       ]
       ]
     },
     },
 
     {
     "result-zygomaticus": {
       "id": "pw_semispinalis_scm_clav",
       "type": "result",
       "pair": [
      "diagnosis": "Zygomaticus Major Trigger Point",
         "semispinalis",
      "confidence": "high",
         "scm_clavicular"
      "wiki_page": "Muscle:Zygomaticus_Major",
      "chapter_ref": "Travell & Simons Vol.1 — Ch.13 Cutaneous I: Facial Muscles",
      "notes": "TrPs refer pain in a curving arc from the cheek along the lateral side of the nose, across the nasal bridge, and up to the mid-forehead. TrP tightness can restrict jaw opening by 10–20 mm — this is reversible on TrP inactivation. Pain is commonly misattributed to sinusitis (nasal arc component) or tension headache (forehead component). Palpebral fissure narrowing may be present — exclude Horner syndrome by confirming normal pupillary reactivity.",
      "treatment_hint": "Patient supine, jaws propped open. Pincer palpation and injection (pincer grasp, 25g needle, 0.5% procaine) are more effective than spray and stretch for this muscle — stretch is difficult to achieve adequately. Inactivate SCM and masticatory TrPs as key drivers.",
       "also_consider": ["Masseter", "Temporalis", "SCM Sternal Division", "Buccinator"],
      "less_likely": [
         { "muscle": "SCM Clavicular Division", "reason": "No dizziness; no neck movement as primary aggravator" },
         { "muscle": "SCM Sternal Division", "reason": "No autonomic features; nasal arc and cheek TrP present" },
        { "muscle": "Semispinalis Capitis", "reason": "No posterior head component; no neck movement aggravation" },
        { "muscle": "Frontalis", "reason": "Pain follows nasal arc rather than remaining local to forehead; jaw restriction present" }
       ],
       ],
       "confirmatory": [
       "text": "Tiebreaker \u2014 Semispinalis Capitis vs SCM Clavicular",
        "Measure jaw opening — restriction of 10–20 mm below normal (36–44 mm) that improves after TrP inactivation confirms zygomaticus major contribution",
      "question": "Is the headache an encircling band (occiput \u2192 temple \u2192 over the eye) reproduced by neck flexion, OR is it a frontal headache aggravated by head load and accompanied by dizziness?",
        "Pain arc confirmed by palpation — pressing on the mid-muscle belly between zygomatic bone and corner of mouth reproduces the nasal arc and forehead referral",
      "answers": [
        "Palpebral fissure narrowing without miosis — exclude Horner syndrome",
         {
         "Masticatory dysfunction (trismus) present or in history — primary activating mechanism"
          "id": "encircling_flexion",
      ],
          "label": "Encircling band reproduced by cervical flexion",
      "satellite_trps": ["Zygomaticus Minor", "Orbicularis Oculi", "Buccinator", "Platysma"],
          "lr": {
      "landing_page_topics": [
            "semispinalis": 4.5,
        "Jaw opening measurement and re-measurement after TrP release",
            "scm_clavicular": 0.25
        "Palpebral fissure narrowing — Horner exclusion",
          }
        "Spray and stretch technique with eye protection",
         },
         "Injection technique — pincer grasp"
         {
      ],
          "id": "frontal_dizziness",
      "related_pages": [
          "label": "Frontal headache with head-load aggravation and dizziness",
         { "label": "Buccinator TrP →", "page": "Muscle:Buccinator" },
          "lr": {
        { "label": "Masseter TrP →", "page": "Muscle:Masseter" }
            "semispinalis": 0.25,
            "scm_clavicular": 4.5
          }
        }
       ]
       ]
     },
     },
 
     {
     "result-frontalis": {
       "id": "pw_frontalis_scm_clav",
       "type": "result",
       "pair": [
       "diagnosis": "Frontalis Trigger Point",
         "frontalis",
      "confidence": "high",
         "scm_clavicular"
      "wiki_page": "Muscle:Frontalis",
      "chapter_ref": "Travell & Simons Vol.1 — Ch.14 Cutaneous II: Occipitofrontalis",
      "notes": "TrPs in the frontalis belly refer pain locally — spreading upward and over the ipsilateral forehead. The referred pain remains in the region of the muscle, similar to the deltoid pattern, and does not radiate to the nose or orbit. Frontalis TrPs are most commonly satellites of TrPs in the clavicular division of the SCM. Active TrPs in the medial half of the frontalis belly can entrap the supraorbital nerve, producing a unilateral frontal headache with a neuritic quality (tingling, burning) rather than the dull aching of TrP referral. Habitual frowning and raised-eyebrow expressions in anxious patients are the dominant perpetuating postural factor.",
      "treatment_hint": "Pressure release is the treatment of choice — spray and stretch is unsatisfactory because the frontalis is so difficult to stretch. Deep massage is also effective. Dry needling with acupuncture needle is effective if local twitch response is elicited. Needle: 2.5 cm (1 inch), 24- or 25-gauge, directed across the fibres nearly tangent to the skin. First inactivate SCM clavicular division TrPs — frontalis TrPs often resolve spontaneously.",
      "also_consider": ["SCM Clavicular Division", "Occipitalis", "Zygomaticus Major"],
      "less_likely": [
         { "muscle": "SCM Clavicular Division", "reason": "Treat SCM clavicular TrPs first — frontalis is typically a satellite; check whether clavicular TrPs are active" },
        { "muscle": "SCM Sternal Division", "reason": "No autonomic features; pain remains local to forehead" },
        { "muscle": "Semispinalis Capitis", "reason": "No posterior head component; no neck movement aggravation" },
        { "muscle": "Zygomaticus Major", "reason": "No nasal arc; no jaw restriction; pain is local to forehead only" }
      ],
      "confirmatory": [
        "TrP located above the medial end of the eyebrow — flat palpation against the frontal bone",
        "Supraorbital nerve entrapment suspected if pain has a neuritic quality (tingling, burning) rather than dull aching — TrP in medial half of frontalis; relieved by TrP inactivation",
        "Habitual frowning or raised-eyebrow posture observed on patient examination",
         "SCM clavicular division TrPs active on the same side — confirms satellite relationship; treat SCM first and reassess"
       ],
       ],
       "satellite_trps": ["Occipitalis", "SCM Clavicular Division (as key TrP)"],
       "text": "Tiebreaker \u2014 Frontalis vs SCM Clavicular",
       "landing_page_topics": [
      "question": "Does the pain stay strictly LOCAL to the forehead with a furrowed brow at rest, OR is it a frontal headache with a clear neck-posture/head-load component or dizziness? (Note: frontalis is almost always a satellite of clavicular SCM \u2014 examine SCM regardless.)",
         "Supraorbital nerve entrapment — neuritic vs myofascial pain quality",
       "answers": [
        "Satellite TrP relationship with SCM clavicular division",
         {
        "Biofeedback monitoring of frontalis — anxiety and muscle tension",
          "id": "local_forehead_brow",
        "Injection technique — tangential needle approach"
          "label": "Strictly local to the forehead; furrowed brow at rest; no neck component",
      ],
          "lr": {
      "related_pages": [
            "frontalis": 4.0,
         { "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
            "scm_clavicular": 0.3
        { "label": "Occipitalis TrP →", "page": "Muscle:Occipitofrontalis" }
          }
        },
         {
          "id": "neck_component",
          "label": "Neck-posture/head-load component or dizziness present",
          "lr": {
            "frontalis": 0.3,
            "scm_clavicular": 4.0
          }
        }
       ]
       ]
     },
     },
 
     {
     "result-overlap": {
       "id": "pw_zygomaticus_scm_sternal",
       "type": "overlap",
       "pair": [
      "text": "Findings are inconclusive. Multi-muscle involvement or atypical presentation is likely. Perform a full palpation screen of all muscles in this region.",
         "zygomaticus",
       "screen_these": [
         "scm_sternal"
         "SCM — Clavicular head (flat palpation from medial clavicle upward)",
        "SCM — Sternal head (pincer palpation full length)",
        "Semispinalis capitis (deep flat palpation at C1–C2, 2–3 cm lateral to midline)",
        "Frontalis (flat palpation above medial eyebrow against frontal bone)",
         "Zygomaticus major (pincer palpation with jaws propped open)"
       ],
       ],
       "wiki_page": "Differential:FrontalHeadache"
       "text": "Tiebreaker \u2014 Zygomaticus Major vs SCM Sternal",
      "question": "Is the pain a discrete NASAL ARC (cheek \u2192 side of nose \u2192 mid-forehead) with restricted jaw opening, OR a wider cheek/orbital/frontal pattern with autonomic phenomena? (Note: zygomaticus is almost always a satellite of sternal SCM \u2014 examine SCM regardless.)",
      "answers": [
        {
          "id": "nasal_arc_jaw",
          "label": "Discrete nasal arc with restricted jaw opening",
          "lr": {
            "zygomaticus": 4.0,
            "scm_sternal": 0.3
          }
        },
        {
          "id": "wider_autonomic",
          "label": "Wider cheek/orbital pattern with autonomic phenomena",
          "lr": {
            "zygomaticus": 0.3,
            "scm_sternal": 4.0
          }
        }
      ]
    }
  ],
  "treatment_dag": {
    "edges": [
      {
        "from": "scm_clavicular",
        "to": "frontalis",
        "type": "key_satellite",
        "label": "Clavicular SCM is the key TrP driving frontalis satellites \u2014 treat SCM first; frontalis often resolves without direct treatment"
      },
      {
        "from": "scm_sternal",
        "to": "zygomaticus",
        "type": "key_satellite",
        "label": "Sternal SCM is the key TrP driving zygomaticus major satellites \u2014 treat SCM first; zygomaticus often resolves without direct treatment"
      },
      {
        "from": "scm_clavicular",
        "to": "scm_sternal",
        "type": "functional_unit",
        "label": "Both SCM divisions frequently active together \u2014 examine and treat in the same session"
      },
      {
        "from": "semispinalis",
        "to": "frontalis",
        "type": "secondary_load",
        "label": "Forehead pain may persist as a semispinalis referral component \u2014 address after the key TrPs resolve"
      },
      {
        "from": "scm_sternal",
        "to": "semispinalis",
        "type": "antagonist_risk",
        "label": "\u26a0 Releasing anterior neck (SCM) may reactively load posterior extensors (semispinalis) \u2014 treat in alternating cycles"
      }
    ],
    "edge_type_labels": {
      "key_satellite": "Treat first \u2014 key TrP driving satellites",
      "functional_unit": "Treat concurrently in same session",
      "secondary_load": "Treat after primary resolves",
      "antagonist_risk": "\u26a0 Treat in alternating cycles \u2014 reactive activation risk"
     }
     }
   },
   },
   "broad_differential": [
   "broad_differential": [
     {
     {
      "id": "bd-1",
       "condition": "Tension-type headache",
       "condition": "Tension-type headache",
       "confidence": "common",
       "confidence": "uncommon",
       "mimics": "Bilateral or unilateral frontal pressure — the most common misdiagnosis for frontalis and SCM clavicular TrP headache",
       "mimics": "Bilateral pressing or tightening frontal pain overlapping strongly with semispinalis capitis and bilateral SCM referral",
       "distinguishing_feature": "Myofascial frontal headache responds to TrP treatment and has identifiable taut bands with spot tenderness. Tension headache is a diagnosis of exclusion — always examine the SCM clavicular division and frontalis before applying this label.",
       "distinguishing_feature": "Tension-type headache carries a high probability of pericranial TrP involvement; the pressing quality matches the steady deep ache of myofascial referral. Pericranial muscle tenderness rather than sustained EMG contraction is the consistent finding. All muscles in this algorithm should be screened.",
       "action": "Full TrP palpation screen before accepting tension headache diagnosis."
       "action": "Systematic TrP examination of pericranial and cervical muscles with perpetuating-factor correction as first-line."
     },
     },
     {
     {
      "id": "bd-2",
       "condition": "Migraine without aura",
       "condition": "Sinusitis (maxillary / frontal)",
       "confidence": "uncommon",
       "confidence": "common",
       "mimics": "Unilateral or bilateral frontal/temporal headache reproduced by overlapping SCM, semispinalis, and masticatory referral",
       "mimics": "Frontal and nasal pain from zygomaticus major and SCM sternal TrPs is consistently misdiagnosed as sinusitis",
       "distinguishing_feature": "Pericranial TrP tenderness persists between attacks and rises with attack intensity; the myofascial and vascular components coexist. TrP treatment addresses the myofascial trigger component without replacing migraine-specific medication.",
       "distinguishing_feature": "Sinusitis requires fever, purulent nasal discharge, or radiographic sinus opacification. Absence of these features with frontal/nasal pain should prompt TrP examination.",
       "action": "Screen for pericranial TrPs in migraine patients and address perpetuating factors alongside standard migraine management."
       "action": "Examine zygomaticus major and SCM sternal division before prescribing antibiotics for recurring sinus pain."
     },
     },
     {
     {
      "id": "bd-3",
       "condition": "Cervicogenic headache",
       "condition": "Migraine",
       "confidence": "uncommon",
       "confidence": "common",
       "mimics": "Predominantly unilateral frontal headache precipitated by neck movement, overlapping SCM and semispinalis patterns",
       "mimics": "Unilateral frontal/orbital headache from SCM sternal division TrPs closely resembles migraine — especially with the autonomic accompaniments (tearing, rhinitis, light sensitivity)",
       "distinguishing_feature": "Consistent unilaterality, precipitation by specific neck movements or sustained postures, and reduced cervical segmental mobility accompanying the TrPs. Most patients have TrPs that reproduce their headache.",
       "distinguishing_feature": "Classic migraine has prodrome, nausea, photophobia, and phonophobia in combination. Myofascial headache from SCM is postural, reproduced by neck movement and palpation, and lacks nausea and GI symptoms. However, SCM TrPs can trigger genuine migraines in susceptible individuals.",
       "action": "Conservative myofascial TrP management before attributing restriction to fibrous fixation or proceeding to invasive treatment."
       "action": "Examine SCM in all headache patients. Migraine and myofascial pain frequently co-exist."
     },
     },
     {
     {
       "id": "bd-4",
       "condition": "Sinusitis vs referred sinus-pattern pain",
      "condition": "Temporal arteritis (Giant cell arteritis)",
       "confidence": "uncommon",
       "confidence": "uncommon — but critical",
       "mimics": "Frontal and maxillary pressure \u2014 zygomaticus and masticatory referral is often described as sinus pain; sternal SCM produces rhinitis",
       "mimics": "Temporal and frontal headache in patients over 50",
       "distinguishing_feature": "True sinusitis has fever, purulent discharge, and radiographic mucosal changes. TrP-referred sinus pain has normal imaging, no fever or discharge, and is reproduced by palpating the relevant TrPs.",
       "distinguishing_feature": "Jaw claudication, scalp tenderness, ESR markedly elevated (often >50 mm/hr). Visual symptoms demand same-day assessment.",
       "action": "Palpate the relevant TrPs and confirm the referral pattern; request sinus imaging only if clinical features make true sinusitis plausible."
       "action": "Same-day GP referral + ESR and CRP in any patient aged 50+ with new frontal or temporal headache."
     },
     },
     {
     {
      "id": "bd-5",
       "condition": "Occipital neuralgia",
       "condition": "Occipital neuralgia",
      "confidence": "rare",
      "mimics": "Occipital and frontal pain with burning or shooting quality overlapping semispinalis referral and greater occipital nerve entrapment",
      "distinguishing_feature": "Paroxysmal stabbing with aching between attacks radiating frontally. The greater occipital nerve may be entrapped by semispinalis taut bands, producing neuritic pain and myofascial ache together. Treat TrPs before any neuroablative procedure.",
      "action": "Treat semispinalis TrPs first; refer to neurology only if the neuritic component persists after adequate TrP treatment."
    },
    {
      "condition": "Analgesic (medication-overuse) rebound headache",
       "confidence": "uncommon",
       "confidence": "uncommon",
       "mimics": "Wrap-around occipital-to-frontal head pain from semispinalis capitis TrPs",
       "mimics": "Daily or near-daily frontal headache in frequent analgesic users, most of whom also have active TrPs",
       "distinguishing_feature": "Neuralgic pain is superficial, tingling, hot prickling quality — patient prefers ice pack and cannot tolerate heat. Myofascial TrP referral is deep aching — patient prefers moist heat. Greater occipital nerve block produces temporary relief in true occipital neuralgia.",
       "distinguishing_feature": "Analgesic use on more than 10\u201315 days per month; headache becomes refractory and prophylaxis loses effect. Detoxification must accompany TrP treatment.",
       "action": "Use heat/cold preference test as bedside screen. Distinguish from greater occipital nerve entrapment by semispinalis capitis TrP bands."
       "action": "Refer for a medication-withdrawal protocol alongside TrP assessment; begin TrP treatment concurrently."
     },
     },
     {
     {
      "id": "bd-6",
       "condition": "Post-traumatic headache",
       "condition": "Acute angle-closure glaucoma",
       "confidence": "uncommon",
       "confidence": "rare — but emergency",
       "mimics": "Frontal headache following whiplash or closed head injury; semispinalis and SCM are the most commonly activated TrPs after motor-vehicle trauma",
       "mimics": "Severe unilateral frontal and orbital pain",
       "distinguishing_feature": "History of trauma; clinically indistinguishable from tension-type headache and likely driven by the same myofascial mechanism. Semispinalis and splenius capitis are commonly involved regardless of impact direction.",
       "distinguishing_feature": "Fixed mid-dilated pupil, decreased visual acuity, nausea, halos around lights. Immediate ophthalmology referral required.",
       "action": "Systematic TrP screen with attention to semispinalis, SCM, upper trapezius, and splenius capitis; refer if neurological or vestibular features suggest central involvement."
       "action": "Examine pupils in all severe unilateral headache presentations."
     },
     },
     {
     {
      "id": "bd-7",
       "condition": "Cluster headache with myofascial component",
       "condition": "Cervicogenic headache",
       "confidence": "rare",
       "confidence": "common",
       "mimics": "Severe unilateral frontal/orbital headache with autonomic features overlapping sternal SCM tearing and rhinitis",
       "mimics": "Frontal headache referred from upper cervical joints (C0–C2) — overlaps significantly with semispinalis capitis and SCM TrP patterns",
       "distinguishing_feature": "Classic cluster is strictly unilateral, periorbital, 15\u2013180 minutes, with prominent autonomic features in bouts. An SCM TrP can contribute to or trigger attacks by referring to the suboccipital region and inducing nasal stuffiness; treating it may reduce frequency.",
       "distinguishing_feature": "Cervicogenic headache is typically unilateral, non-throbbing, with ipsilateral neck stiffness and restricted cervical ROM. Diagnostic cervical nerve block produces temporary headache relief. Myofascial and cervicogenic components frequently coexist.",
       "action": "Examine for SCM TrPs in cluster patients, especially chronic cluster; myofascial treatment may reduce frequency without replacing prophylactic medication."
       "action": "Examine cervical ROM and upper cervical joint tenderness alongside TrP palpation."
     },
     },
     {
     {
      "id": "bd-8",
       "condition": "Giant cell (temporal) arteritis",
       "condition": "Intracranial space-occupying lesion",
       "confidence": "rare",
       "confidence": "rare — but must be excluded",
       "mimics": "New frontal/temporal headache in patients over 50 with scalp and temporal tenderness overlapping semispinalis and temporalis referral",
       "mimics": "Progressive unilateral frontal headache",
       "distinguishing_feature": "Jaw claudication, non-pulsatile tender temporal artery, visual symptoms, and raised ESR/CRP. This is a sight-threatening emergency, not a myofascial pattern \u2014 it is in the urgent red-flag screen for this reason.",
       "distinguishing_feature": "Headache worse in the morning, worse on Valsalva (coughing, sneezing, straining), progressive neurological deficits, papilloedema.",
       "action": "Same-day ESR/CRP and referral if suspected; do not attribute to TrPs. Temporal artery biopsy confirms."
       "action": "Refer for neuroimaging if headache is progressive, positional (worse lying flat), or accompanied by any neurological signs."
     }
     }
   ]
   ]
}
}

Latest revision as of 12:06, 4 July 2026

{ 

 "model": "bayesian_lr_scoring",
 "version": "1.0",
 "region_label": "Frontal Headache",
 "description": "Probabilistic scoring model for frontal headache using Bayesian likelihood ratio updating with Thurstonian pairwise tiebreakers. Muscles drawn from T&S Vol.1: SCM (Ch.7), Semispinalis Capitis (Ch.16), Occipitofrontalis/Frontalis (Ch.14), Zygomaticus Major (Ch.13). SCM is split into clavicular and sternal divisions, scored separately due to clinically distinct referral and autonomic patterns (Subclavius principle). Bold muscles (SCM both divisions, semispinalis) carry higher priors; facial satellites (frontalis, zygomaticus) carry lower priors as they are almost always satellites of the key TrPs. Converted from legacy DiagnosticTree format 2026-07.",
 "thresholds": {
   "early_exit_posterior": 0.55,
   "early_exit_gap": 0.18,
   "pairwise_trigger": 0.22
 },
 "emergency": [
   {
     "id": "rf-e1",
     "label": "Thunderclap headache",
     "question": "Did the headache reach maximum intensity within seconds to a minute \u2014 described as 'the worst headache of my life' or like a blow to the head?"
   },
   {
     "id": "rf-e2",
     "label": "Signs of raised intracranial pressure",
     "question": "Is there headache that is worse on waking, progressively worsening over days or weeks, or associated with vomiting, visual changes, or altered consciousness?"
   },
   {
     "id": "rf-e3",
     "label": "Meningism",
     "question": "Is there neck stiffness with fever, photophobia, or a non-blanching rash?"
   },
   {
     "id": "rf-e4",
     "label": "Acute angle-closure glaucoma",
     "question": "Is there frontal or periorbital pain with sudden visual blurring, halos around lights, nausea, or a hard red eye?"
   },
   {
     "id": "rf-e5",
     "label": "SNOOP screen \u2014 secondary headache flags",
     "question": "Any of: Systemic signs (fever, weight loss, cancer, HIV, immunosuppression); Neurological deficit or altered consciousness; Onset sudden (thunderclap); Onset after age 50; Pattern change from previous headaches; Papilloedema or positional/Valsalva aggravation?"
   }
 ],
 "urgent": [
   {
     "id": "rf-u1",
     "label": "Temporal arteritis (giant cell arteritis)",
     "question": "Is the patient aged 50+ with jaw claudication (pain building with chewing then easing), scalp tenderness, or a non-pulsatile tender temporal artery? Same-day ESR/CRP required \u2014 risk of irreversible blindness."
   },
   {
     "id": "rf-u2",
     "label": "Cervical instability",
     "question": "Is there a history of significant trauma to the head or neck combined with arm symptoms, gait disturbance, or headache worsened by neck loading? No manual therapy or cervical stretch until cleared."
   },
   {
     "id": "rf-u3",
     "label": "New headache in immunocompromised patient",
     "question": "Is the patient immunocompromised (HIV, cancer, immunosuppressants) with a new or changing headache pattern? Opportunistic intracranial infection must be excluded."
   }
 ],
 "muscles": {
   "scm_clavicular": {
     "label": "SCM \u2014 Clavicular Division",
     "prior": 0.13,
     "page": "Muscle:Sternocleidomastoid",
     "key_trp_note": "The clavicular division is the chief myofascial source of ipsilateral frontal headache and drives frontalis satellite TrPs. Treating the clavicular SCM often resolves frontalis without direct treatment. NO autonomic phenomena \u2014 the absence of tearing and rhinitis distinguishes it from the sternal division. May also produce postural dizziness, imbalance, and dysmetria.",
     "subtitle": "Frontal headache aggravated by neck posture/head load; dizziness or imbalance; NO tearing or rhinitis"
   },
   "scm_sternal": {
     "label": "SCM \u2014 Sternal Division",
     "prior": 0.13,
     "page": "Muscle:Sternocleidomastoid",
     "key_trp_note": "The sternal division refers to cheek, supraorbital ridge, temple, occiput, and vertex \u2014 the frontal component is part of a wider pattern. Cardinal features are ipsilateral autonomic phenomena: profuse tearing, rhinitis, apparent ptosis. Drives zygomaticus major and orbicularis oculi satellites. SCM Compression Test resolves concurrent sore throat on swallowing. Treat sternal SCM before facial satellites.",
     "subtitle": "Cheek/orbital/frontal pain with autonomic phenomena \u2014 tearing, rhinitis, apparent ptosis"
   },
   "semispinalis": {
     "label": "Semispinalis Capitis",
     "prior": 0.13,
     "page": "Muscle:Semispinalis_Capitis",
     "key_trp_note": "The defining referral is a band-like headache encircling the head, maximal at the temple, continuing forward over the eye. Nuchal-line tenderness (Location 1) is enthesopathy driven by a midbelly TrP (Location 2) \u2014 palpate midbelly for the causal TrP. DO NOT inject Location 2 (vertebral artery proximity at C1). Greater occipital nerve entrapment may coexist. Frequently a satellite of upper trapezius and splenius capitis key TrPs \u2014 treat those first.",
     "subtitle": "Band-like headache encircling occiput \u2192 temple \u2192 over the eye; worse with sustained neck flexion"
   },
   "frontalis": {
     "label": "Frontalis (Occipitofrontalis)",
     "prior": 0.086667,
     "page": "Muscle:Occipitofrontalis",
     "key_trp_note": "Frontalis TrPs are nearly always satellites of clavicular division SCM TrPs \u2014 check and treat SCM first. Pain stays local to the forehead with no referral to eye or occiput. A habitually furrowed brow or raised eyebrows at rest is the cardinal sign. Suspect supraorbital nerve entrapment if the pain has a neuritic burning quality above the medial eyebrow.",
     "subtitle": "Pain localised to the forehead itself; no referral to eye/cheek/occiput; furrowed brow at rest"
   },
   "zygomaticus": {
     "label": "Zygomaticus Major",
     "prior": 0.086667,
     "page": "Muscle:Zygomaticus_Major",
     "key_trp_note": "Zygomaticus major TrPs refer in a distinctive nasal arc: cheek \u2192 lateral nose \u2192 nasal bridge \u2192 mid-forehead. TrP tightness restricts jaw opening 10\u201320mm; inactivation restores opening immediately (intratreatment confirmation). Nearly always a satellite of SCM sternal division or masticatory TrPs \u2014 treat the key TrP first.",
     "subtitle": "Nasal arc: cheek up the side of the nose to mid-forehead; jaw opening may be restricted 10\u201320mm"
   }
 },
 "questions": [
   {
     "id": "q_primary_pattern",
     "text": "What is the PRIMARY pattern of the frontal headache?",
     "sublabel": "This first split separates the muscles by mechanism. Choose the dominant pattern.",
     "type": "choice",
     "answers": [
       {
         "id": "neck_posture_dizziness",
         "label": "Neck movement, posture, or head load aggravates \u2014 OR dizziness/imbalance accompanies the frontal headache",
         "sublabel": "Turning the head, looking down, carrying a bag, sustained forward head position, or balance disturbance alongside the pain",
         "lr": {
           "scm_clavicular": 6.0,
           "scm_sternal": 2.0,
           "semispinalis": 2.5,
           "frontalis": 1.0,
           "zygomaticus": 0.4
         }
       },
       {
         "id": "encircling_band",
         "label": "Band-like headache encircling from the occiput through the temple and forward over the eye",
         "sublabel": "Worsened by sustained neck flexion \u2014 reading, computing, sewing; often bilateral or sub-occipital at onset",
         "lr": {
           "semispinalis": 9.0,
           "scm_clavicular": 1.0,
           "scm_sternal": 1.0,
           "frontalis": 0.4,
           "zygomaticus": 0.3
         }
       },
       {
         "id": "cheek_orbital_autonomic",
         "label": "Cheek, orbit, temple, and frontal pain \u2014 as part of a wider facial pattern, often with tearing or a watering/congested nose",
         "sublabel": "Pain spreads across the cheek and around the eye with autonomic features on the same side",
         "lr": {
           "scm_sternal": 8.0,
           "zygomaticus": 2.0,
           "scm_clavicular": 0.8,
           "semispinalis": 0.6,
           "frontalis": 0.5
         }
       },
       {
         "id": "local_forehead",
         "label": "Frontal pain that stays LOCAL to the forehead itself",
         "sublabel": "No prominent neck component; pain confined to the forehead; patient may have a habitually furrowed brow",
         "lr": {
           "frontalis": 9.0,
           "scm_clavicular": 1.5,
           "scm_sternal": 0.5,
           "semispinalis": 0.4,
           "zygomaticus": 0.6
         }
       },
       {
         "id": "nasal_arc",
         "label": "A curved NASAL ARC \u2014 from the cheek, up along the side of the nose, to the mid-forehead",
         "sublabel": "Pain traces an arc up the side of the nose; jaw opening may be mildly restricted",
         "lr": {
           "zygomaticus": 10.0,
           "scm_sternal": 2.0,
           "frontalis": 0.6,
           "scm_clavicular": 0.4,
           "semispinalis": 0.3
         }
       }
     ]
   },
   {
     "id": "q_autonomic",
     "text": "Alongside the frontal headache, are there ipsilateral AUTONOMIC phenomena \u2014 profuse tearing, rhinitis (watering or congested nose), conjunctival redness, or apparent drooping of the eyelid on the same side?",
     "sublabel": "These separate the two SCM divisions. Confirm pupils equal and reactive to exclude true Horner syndrome.",
     "type": "binary",
     "answers": [
       {
         "id": "yes",
         "label": "Yes \u2014 tearing, rhinitis, conjunctival redness, or apparent ptosis on the pain side",
         "lr": {
           "scm_sternal": 9.0,
           "zygomaticus": 1.5,
           "scm_clavicular": 0.2,
           "semispinalis": 0.4,
           "frontalis": 0.5
         }
       },
       {
         "id": "no",
         "label": "No \u2014 no autonomic phenomena",
         "lr": {
           "scm_sternal": 0.3,
           "scm_clavicular": 1.4,
           "semispinalis": 1.2,
           "frontalis": 1.2,
           "zygomaticus": 0.9
         }
       }
     ]
   },
   {
     "id": "q_neck_flexion",
     "text": "Is cervical flexion restricted or does it reproduce the headache?",
     "sublabel": "Ask the patient to slowly lower the chin toward the chest \u2014 is the range reduced (normally chin comes within 1\u20132 finger-breadths of the sternum), or does flexion provoke or intensify the frontal or band-like pain?",
     "type": "binary",
     "answers": [
       {
         "id": "yes",
         "label": "Yes \u2014 cervical flexion is restricted or reproduces the headache",
         "lr": {
           "semispinalis": 7.0,
           "scm_clavicular": 0.7,
           "scm_sternal": 0.6,
           "frontalis": 0.4,
           "zygomaticus": 0.3
         }
       },
       {
         "id": "no",
         "label": "No \u2014 full pain-free cervical flexion",
         "lr": {
           "semispinalis": 0.2,
           "scm_clavicular": 1.2,
           "scm_sternal": 1.2,
           "frontalis": 1.2,
           "zygomaticus": 1.2
         }
       }
     ]
   },
   {
     "id": "q_dizziness",
     "text": "Is there postural dizziness, imbalance, or disturbed weight perception (dysmetria) \u2014 without vertigo, nystagmus, or a positive Romberg?",
     "sublabel": "Non-vestibular imbalance: veering toward one side on a straight-line walk, dizziness worse lying without a pillow or on quick head rotation. Romberg negative, no nystagmus.",
     "type": "binary",
     "answers": [
       {
         "id": "yes",
         "label": "Yes \u2014 non-vestibular dizziness, imbalance, or dysmetria",
         "lr": {
           "scm_clavicular": 8.0,
           "scm_sternal": 0.8,
           "semispinalis": 0.6,
           "frontalis": 0.5,
           "zygomaticus": 0.4
         }
       },
       {
         "id": "no",
         "label": "No \u2014 no dizziness or imbalance",
         "lr": {
           "scm_clavicular": 0.4,
           "scm_sternal": 1.1,
           "semispinalis": 1.1,
           "frontalis": 1.1,
           "zygomaticus": 1.1
         }
       }
     ]
   },
   {
     "id": "q_jaw_opening",
     "text": "Is jaw opening restricted \u2014 and does the restriction improve immediately when the relevant facial or masticatory trigger points are released?",
     "sublabel": "Measure interincisal opening. Zygomaticus (and masticatory) TrP tightness may reduce opening by 10\u201320mm; immediate restoration on TrP inactivation is a confirmatory sign.",
     "type": "binary",
     "answers": [
       {
         "id": "yes",
         "label": "Yes \u2014 jaw opening restricted 10\u201320mm",
         "lr": {
           "zygomaticus": 6.0,
           "scm_sternal": 1.3,
           "scm_clavicular": 0.6,
           "semispinalis": 0.6,
           "frontalis": 0.5
         }
       },
       {
         "id": "no",
         "label": "No \u2014 jaw opening is full and unrestricted",
         "lr": {
           "zygomaticus": 0.3,
           "scm_sternal": 1.0,
           "scm_clavicular": 1.1,
           "semispinalis": 1.1,
           "frontalis": 1.1
         }
       }
     ]
   },
   {
     "id": "q_brow_posture",
     "text": "Does the patient have a habitually furrowed brow or persistently raised eyebrows at rest?",
     "sublabel": "A visible sign of chronic frontalis overload \u2014 observe the resting brow position during history-taking.",
     "type": "binary",
     "answers": [
       {
         "id": "yes",
         "label": "Yes \u2014 habitually furrowed or raised brow at rest",
         "lr": {
           "frontalis": 5.0,
           "scm_clavicular": 1.2,
           "scm_sternal": 0.8,
           "semispinalis": 0.7,
           "zygomaticus": 0.7
         }
       },
       {
         "id": "no",
         "label": "No \u2014 resting brow position is normal",
         "lr": {
           "frontalis": 0.5,
           "scm_clavicular": 1.0,
           "scm_sternal": 1.0,
           "semispinalis": 1.0,
           "zygomaticus": 1.0
         }
       }
     ]
   },
   {
     "id": "q_sore_throat",
     "text": "Does the SCM Compression Test relieve a concurrent sore throat on swallowing \u2014 firmly gripping the sternal belly and asking the patient to swallow eases pharyngeal pain?",
     "sublabel": "Pathognomonic of a sternal-division central TrP. Also note a dry tingling cough from a TrP near the sternal attachment.",
     "type": "binary",
     "answers": [
       {
         "id": "yes",
         "label": "Yes \u2014 compression relieves the sore throat on swallowing",
         "lr": {
           "scm_sternal": 7.0,
           "scm_clavicular": 0.5,
           "semispinalis": 0.5,
           "frontalis": 0.5,
           "zygomaticus": 0.8
         }
       },
       {
         "id": "no",
         "label": "No \u2014 no sore throat, or compression does not change it",
         "lr": {
           "scm_sternal": 0.8,
           "scm_clavicular": 1.1,
           "semispinalis": 1.1,
           "frontalis": 1.1,
           "zygomaticus": 1.0
         }
       }
     ]
   },
   {
     "id": "q_flexion_activities",
     "text": "Is the headache clearly provoked by sustained forward-head activities \u2014 reading, computing, sewing, or writing with the head flexed for long periods?",
     "sublabel": "The checkrein loading mechanism of semispinalis capitis \u2014 sustained neck flexion chronically loads the muscle.",
     "type": "binary",
     "answers": [
       {
         "id": "yes",
         "label": "Yes \u2014 clearly provoked by sustained forward-head activity",
         "lr": {
           "semispinalis": 4.0,
           "scm_clavicular": 1.2,
           "scm_sternal": 0.9,
           "frontalis": 1.2,
           "zygomaticus": 0.7
         }
       },
       {
         "id": "no",
         "label": "No \u2014 not clearly related to sustained neck flexion",
         "lr": {
           "semispinalis": 0.5,
           "scm_clavicular": 1.0,
           "scm_sternal": 1.0,
           "frontalis": 0.9,
           "zygomaticus": 1.1
         }
       }
     ]
   }
 ],
 "pairwise": [
   {
     "id": "pw_scm_clav_sternal",
     "pair": [
       "scm_clavicular",
       "scm_sternal"
     ],
     "text": "Tiebreaker \u2014 SCM Clavicular vs Sternal Division",
     "question": "Are there autonomic phenomena (tearing, rhinitis, apparent ptosis) with the frontal headache, OR is the headache dominated by postural aggravation and dizziness WITHOUT any tearing or rhinitis?",
     "answers": [
       {
         "id": "autonomic_present",
         "label": "Autonomic phenomena present \u2014 tearing, rhinitis, apparent ptosis",
         "lr": {
           "scm_sternal": 5.0,
           "scm_clavicular": 0.2
         }
       },
       {
         "id": "postural_dizziness",
         "label": "Postural aggravation and/or dizziness, NO autonomic phenomena",
         "lr": {
           "scm_sternal": 0.2,
           "scm_clavicular": 5.0
         }
       }
     ]
   },
   {
     "id": "pw_semispinalis_scm_clav",
     "pair": [
       "semispinalis",
       "scm_clavicular"
     ],
     "text": "Tiebreaker \u2014 Semispinalis Capitis vs SCM Clavicular",
     "question": "Is the headache an encircling band (occiput \u2192 temple \u2192 over the eye) reproduced by neck flexion, OR is it a frontal headache aggravated by head load and accompanied by dizziness?",
     "answers": [
       {
         "id": "encircling_flexion",
         "label": "Encircling band reproduced by cervical flexion",
         "lr": {
           "semispinalis": 4.5,
           "scm_clavicular": 0.25
         }
       },
       {
         "id": "frontal_dizziness",
         "label": "Frontal headache with head-load aggravation and dizziness",
         "lr": {
           "semispinalis": 0.25,
           "scm_clavicular": 4.5
         }
       }
     ]
   },
   {
     "id": "pw_frontalis_scm_clav",
     "pair": [
       "frontalis",
       "scm_clavicular"
     ],
     "text": "Tiebreaker \u2014 Frontalis vs SCM Clavicular",
     "question": "Does the pain stay strictly LOCAL to the forehead with a furrowed brow at rest, OR is it a frontal headache with a clear neck-posture/head-load component or dizziness? (Note: frontalis is almost always a satellite of clavicular SCM \u2014 examine SCM regardless.)",
     "answers": [
       {
         "id": "local_forehead_brow",
         "label": "Strictly local to the forehead; furrowed brow at rest; no neck component",
         "lr": {
           "frontalis": 4.0,
           "scm_clavicular": 0.3
         }
       },
       {
         "id": "neck_component",
         "label": "Neck-posture/head-load component or dizziness present",
         "lr": {
           "frontalis": 0.3,
           "scm_clavicular": 4.0
         }
       }
     ]
   },
   {
     "id": "pw_zygomaticus_scm_sternal",
     "pair": [
       "zygomaticus",
       "scm_sternal"
     ],
     "text": "Tiebreaker \u2014 Zygomaticus Major vs SCM Sternal",
     "question": "Is the pain a discrete NASAL ARC (cheek \u2192 side of nose \u2192 mid-forehead) with restricted jaw opening, OR a wider cheek/orbital/frontal pattern with autonomic phenomena? (Note: zygomaticus is almost always a satellite of sternal SCM \u2014 examine SCM regardless.)",
     "answers": [
       {
         "id": "nasal_arc_jaw",
         "label": "Discrete nasal arc with restricted jaw opening",
         "lr": {
           "zygomaticus": 4.0,
           "scm_sternal": 0.3
         }
       },
       {
         "id": "wider_autonomic",
         "label": "Wider cheek/orbital pattern with autonomic phenomena",
         "lr": {
           "zygomaticus": 0.3,
           "scm_sternal": 4.0
         }
       }
     ]
   }
 ],
 "treatment_dag": {
   "edges": [
     {
       "from": "scm_clavicular",
       "to": "frontalis",
       "type": "key_satellite",
       "label": "Clavicular SCM is the key TrP driving frontalis satellites \u2014 treat SCM first; frontalis often resolves without direct treatment"
     },
     {
       "from": "scm_sternal",
       "to": "zygomaticus",
       "type": "key_satellite",
       "label": "Sternal SCM is the key TrP driving zygomaticus major satellites \u2014 treat SCM first; zygomaticus often resolves without direct treatment"
     },
     {
       "from": "scm_clavicular",
       "to": "scm_sternal",
       "type": "functional_unit",
       "label": "Both SCM divisions frequently active together \u2014 examine and treat in the same session"
     },
     {
       "from": "semispinalis",
       "to": "frontalis",
       "type": "secondary_load",
       "label": "Forehead pain may persist as a semispinalis referral component \u2014 address after the key TrPs resolve"
     },
     {
       "from": "scm_sternal",
       "to": "semispinalis",
       "type": "antagonist_risk",
       "label": "\u26a0 Releasing anterior neck (SCM) may reactively load posterior extensors (semispinalis) \u2014 treat in alternating cycles"
     }
   ],
   "edge_type_labels": {
     "key_satellite": "Treat first \u2014 key TrP driving satellites",
     "functional_unit": "Treat concurrently in same session",
     "secondary_load": "Treat after primary resolves",
     "antagonist_risk": "\u26a0 Treat in alternating cycles \u2014 reactive activation risk"
   }
 },
 "broad_differential": [
   {
     "condition": "Tension-type headache",
     "confidence": "uncommon",
     "mimics": "Bilateral pressing or tightening frontal pain overlapping strongly with semispinalis capitis and bilateral SCM referral",
     "distinguishing_feature": "Tension-type headache carries a high probability of pericranial TrP involvement; the pressing quality matches the steady deep ache of myofascial referral. Pericranial muscle tenderness rather than sustained EMG contraction is the consistent finding. All muscles in this algorithm should be screened.",
     "action": "Systematic TrP examination of pericranial and cervical muscles with perpetuating-factor correction as first-line."
   },
   {
     "condition": "Migraine without aura",
     "confidence": "uncommon",
     "mimics": "Unilateral or bilateral frontal/temporal headache reproduced by overlapping SCM, semispinalis, and masticatory referral",
     "distinguishing_feature": "Pericranial TrP tenderness persists between attacks and rises with attack intensity; the myofascial and vascular components coexist. TrP treatment addresses the myofascial trigger component without replacing migraine-specific medication.",
     "action": "Screen for pericranial TrPs in migraine patients and address perpetuating factors alongside standard migraine management."
   },
   {
     "condition": "Cervicogenic headache",
     "confidence": "uncommon",
     "mimics": "Predominantly unilateral frontal headache precipitated by neck movement, overlapping SCM and semispinalis patterns",
     "distinguishing_feature": "Consistent unilaterality, precipitation by specific neck movements or sustained postures, and reduced cervical segmental mobility accompanying the TrPs. Most patients have TrPs that reproduce their headache.",
     "action": "Conservative myofascial TrP management before attributing restriction to fibrous fixation or proceeding to invasive treatment."
   },
   {
     "condition": "Sinusitis vs referred sinus-pattern pain",
     "confidence": "uncommon",
     "mimics": "Frontal and maxillary pressure \u2014 zygomaticus and masticatory referral is often described as sinus pain; sternal SCM produces rhinitis",
     "distinguishing_feature": "True sinusitis has fever, purulent discharge, and radiographic mucosal changes. TrP-referred sinus pain has normal imaging, no fever or discharge, and is reproduced by palpating the relevant TrPs.",
     "action": "Palpate the relevant TrPs and confirm the referral pattern; request sinus imaging only if clinical features make true sinusitis plausible."
   },
   {
     "condition": "Occipital neuralgia",
     "confidence": "rare",
     "mimics": "Occipital and frontal pain with burning or shooting quality overlapping semispinalis referral and greater occipital nerve entrapment",
     "distinguishing_feature": "Paroxysmal stabbing with aching between attacks radiating frontally. The greater occipital nerve may be entrapped by semispinalis taut bands, producing neuritic pain and myofascial ache together. Treat TrPs before any neuroablative procedure.",
     "action": "Treat semispinalis TrPs first; refer to neurology only if the neuritic component persists after adequate TrP treatment."
   },
   {
     "condition": "Analgesic (medication-overuse) rebound headache",
     "confidence": "uncommon",
     "mimics": "Daily or near-daily frontal headache in frequent analgesic users, most of whom also have active TrPs",
     "distinguishing_feature": "Analgesic use on more than 10\u201315 days per month; headache becomes refractory and prophylaxis loses effect. Detoxification must accompany TrP treatment.",
     "action": "Refer for a medication-withdrawal protocol alongside TrP assessment; begin TrP treatment concurrently."
   },
   {
     "condition": "Post-traumatic headache",
     "confidence": "uncommon",
     "mimics": "Frontal headache following whiplash or closed head injury; semispinalis and SCM are the most commonly activated TrPs after motor-vehicle trauma",
     "distinguishing_feature": "History of trauma; clinically indistinguishable from tension-type headache and likely driven by the same myofascial mechanism. Semispinalis and splenius capitis are commonly involved regardless of impact direction.",
     "action": "Systematic TrP screen with attention to semispinalis, SCM, upper trapezius, and splenius capitis; refer if neurological or vestibular features suggest central involvement."
   },
   {
     "condition": "Cluster headache with myofascial component",
     "confidence": "rare",
     "mimics": "Severe unilateral frontal/orbital headache with autonomic features overlapping sternal SCM tearing and rhinitis",
     "distinguishing_feature": "Classic cluster is strictly unilateral, periorbital, 15\u2013180 minutes, with prominent autonomic features in bouts. An SCM TrP can contribute to or trigger attacks by referring to the suboccipital region and inducing nasal stuffiness; treating it may reduce frequency.",
     "action": "Examine for SCM TrPs in cluster patients, especially chronic cluster; myofascial treatment may reduce frequency without replacing prophylactic medication."
   },
   {
     "condition": "Giant cell (temporal) arteritis",
     "confidence": "rare",
     "mimics": "New frontal/temporal headache in patients over 50 with scalp and temporal tenderness overlapping semispinalis and temporalis referral",
     "distinguishing_feature": "Jaw claudication, non-pulsatile tender temporal artery, visual symptoms, and raised ESR/CRP. This is a sight-threatening emergency, not a myofascial pattern \u2014 it is in the urgent red-flag screen for this reason.",
     "action": "Same-day ESR/CRP and referral if suspected; do not attribute to TrPs. Temporal artery biopsy confirms."
   }
 ]

}

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