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Saturday, July 17, 2010

ARURICULAR NERVE STIMULATION FOR TREATING MIGRAINE vs NEUROMUSCULAR DENTISTRY AND DIAGNOSTIC ORTHOTIC TREATMENT

An article in Headache "Implanted auriculotemporal nerve stimulator for the treatment of refractory chronic migraine' (see abstract below) reports on a case of refractory headache with phonopobia treated by implanted peripheral nerve stimulators. Treatment reduced but did not eliminate the patients pain. The authors chose to only treat only a single branch of the mandibular nerve and did not address the entire Trigeminal Nervous system. A second article in Headache "Suboccipital nerve blocks for suppression of chronic migraine: safety, efficacy, and predictors of outcome." discusses the use of occipital nerve blocks in treating migraines. The correction of forward head position thru neuromuscular dentistry can frequently eliminate the need for these blocks.

The ULF-TENS utilized by Neuromuscular Dentistry stimulates all three divisions of the Trigeminal nerve. The anti-dromic stimulation also causes plsing and relaxation of the masticatory muscles. A diagnostic orthotic is used to continually reduce the noxious input to the Trigeminal system which is implicated in almost all migraines and most headaches. The trigeminal nerve is often referred to as the dentist's nerve. Neuromuscular dentists often utilize occipital nerve blocks during treatment but can also utilize ULF TENS of he XI cranial nerve, the accessory nerve to eliminate or reduce the need for these blocks.

According to Wikipedia ""The auriculotemporal nerve is a branch of the mandibular nerve that runs with the superficial temporal artery and vein, and provides sensory innervation to various regions on the side of the head" The orgin of the nerve "arises as two roots from the posterior division of the mandibular nerve (The mandibular nerve is a branch of the trigeminal nerve). These roots encircle the middle meningeal artery (a branch of the mandibular part of the maxillary artery, which is in turn a terminal branch of the external carotid artery). The roots then converge to form a single nerve."
The clinical significance according to Wikipedia is "This nerve as it courses posteriorly to the condylar head, is frequently injured in temporomandibular joint surgery, causing an ipsilateral parasthesia of the auricle and skin surrounding the ear. Actually, it is the main nerve that supplies the TMJ, along with branches of the masseteric nerve and the deep temporal."

This does seem to explain one more reason why Neuromuscular Dentistry is so successful at long term prevention, elimination and treatment of of migraines and other headaches. TMJ disorders are frequently called "The Great Imposter" .

An article in Sleep and Health Journal "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR" can be found at http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor as well as another article originally published by the American Equilibration Society that discusses the scientific basis for Neuromuscular Dentistry http://www.sleepandhealth.com/neuromuscular-dentistry

The treatment of migraines with peripheral nerve stimulators is an excellent idea but only after a trial of a Neuromuscular Orthotic has not proven successful. Neuromuscular Dentistry leads to healing of the entire trigeminal nervous system as well as correcting cervical and orthopedic problems that interfere with complete relief.

An excellent dermatone distribution of the Trigeminal and occipital nerves can be found at http://en.wikipedia.org/wiki/File:Gray784.png

te connections of the trigeminal nerves and occipital nerves are furher explored in "Functional connectivity between trigeminal and occipital nerves revealed by occipital nerve blockade and nociceptive blink reflexes" (see link below)
http://www.clusterattack.com/blog/wp-content/uploads/2009/11/busch-2006-functional-connectivity-between-trigeminal-and-occipital-nerves-revealed-by-occipital-nerve-blockade-and-nociceptive-blink-reflexes.pdf

The summary of this article notes the occipital nerve and trigeminal nerve connections. These explain why occipital migraines and cervical pain are relieved thru neuromuscular dental treatment when it is not explained by cervical orthopedic corrections.

Headache. 2010 Jun;50(6):1064-9.
Implanted auriculotemporal nerve stimulator for the treatment of refractory chronic migraine.
Simopoulos T, Bajwa Z, Lantz G, Lee S, Burstein R.

Beth Israel Deaconess Medical Center - Anesthesia, Boston, MA, USA.
Abstract
OBJECTIVE: To report a case of improved pain control and function in a patient with chronic migraine after treatment with auriculotemporal nerve stimulation. METHODS: The patient is a 52-year-old woman with refractory pain in the bilateral temporal distribution and marked phonophobia as a result of chronic migraine. RESULTS: After a successful trial period, the patient underwent implantation of bilateral peripheral nerve stimulators targeting the auriculotemporal nerves. At 16 months of follow up, her average pain intensity declined from 8-9/10 on the numeric rating scale to 5/10. Her function improved as assessed by the Migraine Disability Assessment, from total disability (grade IV) to mild disability (grade II). Her phonophobia became far less debilitating. CONCLUSION: Auriculotemporal nerve stimulation may be useful tool in the treatment of refractory pain in the temporal distribution due to chronic migraine.

FROM WIKIPEDIA AURICULARTEMPORAL NERVE

"The auriculotemporal nerve is a branch of the mandibular nerve that runs with the superficial temporal artery and vein, and provides sensory innervation to various regions on the side of the head"

"Origin
The auriculotemporal nerve arises as two roots from the posterior division of the mandibular nerve (The mandibular nerve is a branch of the trigeminal nerve). These roots encircle the middle meningeal artery (a branch of the mandibular part of the maxillary artery, which is in turn a terminal branch of the external carotid artery). The roots then converge to form a single nerve.

Course
The auriculotemporal nerve passes laterally to the neck of the mandible, gives off parotid branches and then turns superiorly, posterior to its head and moving anteriorly, gives off anterior branches to the auricle. It then crosses over the root of the zygomatic process of the temporal bone, deep to the superficial temporal artery

Innervation
The somatosensory root (superior) originates from branches of the mandibular nerve, which pass through the otic ganglion without synapsing. Then they form the somatosensory (superior) root of the auriculotemporal nerve. The two roots re-unite and shortly after the branching of secretomotor fibers to the parotid gland (parotid branches) the auriculotemporal nerve comprises exclusively somatosensory fibers, which ascend to the superficial temporal region. Supplies the auricle, external acoustic meatus, outer side of the tympanic membrane and the skin in the temporal region (superficial temporal branches). It also carries a few articular branches which go on to supply the temporomandibular joint.
The parasympathetic root (inferior) carries postganglionic fibers to the parotid gland. These parasympathetic, preganglionic secretomotor fibers originate from the glossopharyngeal nerve (CN IX) as one of its branches, the lesser petrosal nerve. This nerve synapses in the otic ganglion and its postganglionic fibers form the inferior, parasympathetic root of the auriculotemporal nerve. The two roots re-unite and shortly after the "united" auriculotemporal branch gives off parotid branches, which serve as secretomotor fibers for the parotid gland.

Clinical significance

This nerve as it courses posteriorly to the condylar head, is frequently injured in temporomandibular joint surgery, causing an ipsilateral parasthesia of the auricle and skin surrounding the ear. Actually, it is the main nerve that supplies the TMJ, along with branches of the masseteric nerve and the deep temporal.
After a parotidectomy, the nerves from the Auriculotemporal Nerve that previously innervated the parotid gland can reattach to the sweat glands in the same region. The result is sweating along the cheek with the consumption of foods (Frey's syndrome). Treatment involves the application of an antiperspirant or glycopyrrolate to the cheek, Jacobsen's neurectomy along the middle ear promontory, and lifting of the skin flap with the placement of a tissue barrier (harvested or cadaveric) to interrupt the misguided innervation of the sweat glands.
Pain related to a condition call parotiditis, or commonly referred to as " the mumps" will be carried by the auriculotemporal nerve."

Headache. 2010 Jun;50(6):1041-4.
Suboccipital nerve blocks for suppression of chronic migraine: safety, efficacy, and predictors of outcome.
Weibelt S, Andress-Rothrock D, King W, Rothrock J.

University of Alabama Headache, Treatment and Research Program, University of Alabama School of Medicine, Birmingham, AL, USA.
Abstract
BACKGROUND: Approximately 1 in 50 Americans is afflicted by chronic migraine (CM). Many patients with CM describe cervicogenic headache. Options for treating CM effectively are at present quite limited. OBJECTIVE: To determine the safety and efficacy of occipital nerve blocks (ONBs) used to treat cervicogenic chronic migraine (CCM) and to identify variables predictive of a positive treatment response. METHODS: Using a uniform dose and injection paradigm, we performed ONBs consecutively on a series of patients presenting with CCM. Patients were stratified according to specific findings found to be present or absent on physical examination. A positive treatment outcome was defined as a 50% or greater reduction in headache days per month over the 30 days following treatment relative to the 30-day pre-treatment baseline. We used a 5-point Likert scale as one of the secondary outcome variables. RESULTS: We treated 150 consecutive patients with unilateral (37) or bilateral (113) ONBs. At the 1-month follow-up visit 78 (52%) exhibited evidence of a positive treatment response according to the primary outcome variable, and 90 (60%) reported their headache disorder to be "better" (44; 29%) or "much better" (46; 30%). A total of 8 (5%) patients reported adverse events within the ensuing 72 hours, and 3 (2%) experienced adverse events that reversed spontaneously but required emergent evaluation and management. CONCLUSION: For suppression of CCM, ONBs may offer an attractive alternative to orally administered prophylactic therapy.

PMID: 20618817 [PubMed - in process]

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posted by Dr Shapira at 9:32 PM

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