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Thursday, January 14, 2010

21 year old frequent headaches and migraine with no relief.

A recent email brings up many interesting questions. My comments follow this distressing case.

"I am writing this on behalf of our 21 year old son who has dealt with frequent headaches since kindergarten. The headaches have gotten more frequent and more severe as the years have gone by. Currently, he averages 4-5 headaches a week and approximately 2 migraines a month.
He takes Extra Strength Excedrin at the first sign of a headache. If there is no relief within 30 minutes, he will take a Relpax. We have tried food diaries, monitoring sleep patterns, massage therapy, chiropractors, and even sought 3 surgeons asking if his non-union clavicle could possible be the source of his headaches. He has tried Topomax, but no longer takes it daily.
He has had orthodontic work done and now wears a retainer nightly. Only recently have we thought to consider sleep apnea (he has always been a very restless sleeper; i.e. tossing and turning) and possibly TMJ. He is seeing a dentist tomorrow (1/14) and will ask about the TMJ.
Is it possible that this could be the cause of his headaches? I know my son would be thrilled if he could just have one headache a month! Even if it were a migraine, it would be better than what he is dealing with currently.
Thank you for your time, and I apologize if this is the second email you have received from me. I am sending this from work and because I have not heard from you, I am not sure you received my previous post."

This case brings up many interesting questions. When do the headaches occur? Does the patient wake in the morning with headaches or does pain wake him from sleep. Patients that only occur in the morning can sometimes be treated with a nightime only appliance but sleep apnea must be ruled out as a causes. The most common causes of morning headaches are sleep apnea and TMD (includes bruxism and clenching) TMD does not always have pain or clicking in the joint.

A second question is how much extra strength Excedrin (and caffeine) A patient can have a medication rebound headache as well. Orthodontics can make headaches, sleep apnea and TMJ problems better or worse or have no effect. If the ortho pulled the jaw back it is likely to make the problem worse. Also, was there bicuspids removed to treat the case? Removal of teeth, in my experience usually will make sleep apnea worse.

As discussed in previous posts Sleep Apnea is a TMJ disorder and I strongly Rx anyone with morning headaches, migraines or TMJ disorders read the NHLBI (National Heart Lng and Blood Institue) article "CARDIOVASCULAR AND SLEEP-RELATED
CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

The following is excerpted from the NHLBI paper:

"Mandibular Movements, Upper Airway Resistance, Breathing and Swallowing
There appears to an associated increase in coughing in subjects with sleep apnea. Occlusion of
the pharynx can force residual secretions into the glottis and trigger coughing reflexes,
swallowing reflexes, and other reflexes that could contribute to the disorganization of breathing
during sleep. In addition to the muscles of mastication, the tongue plays an important role in
the coordinated events of swallowing and breathing. The integration of breathing and
swallowing is tightly linked, and these events in turn are in some manner linked to blood
pressure regulation. Each of these pathways has been studied by scientists in individual
disciplines, but there is a need for interdisciplinary studies to determine the interactions of the
peripheral and central neural pathways controlling breathing, chewing, swallowing, and
cardiovascular events. The presence of pain in patients with TMD would be expected to
seriously impact upon these reflex and motor pathways. Little is known about the role of tongue
position and how this may be altered in subjects with altered jaw location and structure. Sleep
state has been shown to alter the central modulation of the coordination of breathing, airway
dynamics, swallowing, and associated cardiovascular events. Differences in central modulation
of these events in subjects with sleep apnea and TMD need to be evaluated using sleep as a
dynamic change in the state of the individual."

The paper also suggests 60-90% resolution which frequently occurs in treatment. I believe that Neuromuscular Dental treatment increases that success rate considerably.

Neuromuscular Dentistry has been shown to be "overwhelmingly successful according to Dr Barry Cooper's research reported in Cranio. The PubMED abstracts are include at the bottom of the post for convenience.

Other questions include what were the effects of physical medicine such as Chiropractic and massage and were the treatment combined. Was there no relief or only temporary relief. When either of those therapies only gives temporary relief you should suspect a problem with the neuromuscular bite position. TMD is a repetitive strain condition and breathing and swallowing as well as postural conditions can effect the bite just as the jaw position effects the entire bodies balance. The strongest influence on headaches is thru the trigeminal nerve.

An excellent way to both diagnose a cause and effect of jaw muscles to headache pain is the use of trigger point injections and diagnostic blocks. Frequently a severe headache can be relieved by judicious use of TP injections. Recurrent headaches are usually less frequent and severe if successful.

Cranio. 2009 Apr;27(2):101-8.
Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology of the State University of New York (SUNY) Stony Brook School of Dental Medicine, NY, USA. tmjbcooper@aol.com
A prominent etiological theory proposed for TMD related headache is that it results from a dysfunctional masticatory muscle system, wherein muscle hyperactivity is frequently caused by dental temporomandibular disharmony. The central goal of this article was to determine from a literature review of the subject whether there is significant evidence to support a relationship between headaches and TMD prevalence. A second purpose was to determine from such a review whether any relationship was one of cause and effect and whether treatment of the TMD condition can result in meaningful reduction or resolution of headaches. In the literature, there was a substantial amount of evidence for a positive relationship between TMD and the prevalence of headaches, and most importantly, that these were the muscle tension-type. Evidence for a cause and effect relationship was strong. It generally showed in numerous patients that TMD treatment of a large number of patients resulted in significant improvement in the physiological state of the masticatory system (muscles, joints and dental occlusion). Reduction or resolution of muscle tension-type headaches that were present was clinically significant. The authors concluded that TMD should be considered and explored as a possible causative factor when attempts are made to determine and resolve the cause of headaches in patients with this affliction. A benefit of resolving headaches at an early stage in their development is that it might result in the reduction of its potential for progression to a chronic and possibly migraine headache condition.

Cranio. 2008 Apr;26(2):104-17.
Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology, State University of New York (SUNY) Stony Brook School of Dental Medicine, USA. tmjbcooper@aol.com
Comment in:

Cranio. 2008 Jul;26(3):166; author reply 167.
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

PMID: 18468270 [PubMed - indexed for MEDLINE]

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posted by Dr Shapira at 3:13 AM

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