Why Headaches Hurt and Why Neuromuscular Dentistry Is Extremely Effective In Treating A Wide Variety Of Headaches and Migraine.

This is a post that was originally posted in Sleep and Health Journal. I thought the information on the mechanics, physiologic and neurologic understanding of how neuromuscular dentistry not only treats headaches but actually works prophylactically to prevent or eliminate many headaches and migraines.

The trigeminal nerve is almost universally implicated in all headaches and migraines whether they are vascular, muscular or hormonal in origin. Diagnostic evaluation and treatment of headaches utilizing a Diagnostic Neuromuscular Orthotic can lead to life changing results. The 12 Cranial Nerves are responsible for about 80% of all neural input into the brain and around 70% of that input comes from the Trigeminal Nerve. The Trigeminal Nerve accounts for about half of total nervous system brain input.

The sensations of pain felt with headaches and migraines are carried via pain fibers (nociceptive) of the Trigeminal Nerve. The trigeminal nerve innervates the teeth, jaw muscles, jaw joints (TMJ, TemporomMandibular Joint), the tensor of the ear drum, the tensor of the soft palate that opens and closes the eustacian tubes, the lining of the maxillary and frontal sinuses and most importantly the periodontal ligaments the most awesome feedback mechanism found anywhere n the human body. There are at least 27 different nerve endings capable of transmitting messages thru the trigeminal nerve to the brain.

Trigeminally innervated muscles are required for verbal communication, biting, chewing, swallowing, breathing and posture. The trigeminal Nerve is often called “The Dentists Nerve” because it innervates all of the structures of the mouth.

There are three branches of the trigeminal nerve that divide at the trigeminal ganglion.

The first is the ophthalmic nerve carries sensory input from the upper eyelid, the conjunctiva and cornea, the nose and nasal and frontal sinus mucosa as well as from the forehead and scalp. Most important is the innervations to the meninges (dura) and blood vessels of the brain.

The second is the Maxillary division (nerve) of the Trigeminal Nerve carries sensory information from the lower eyelid, the upper lip, the nares, the cheeks, all of the maxillary teeth and mucosa (gums), the hard and soft palate and upper areas of the pharynx and the maxillary and ethmoid sinuses. Most important again is additional innervations to different areas of the meninges.

The third division of the Trigeminal Nerve is the Mandibular Nerve that carries sensory input from the lower lip, mandibular (lower jaw) teeth and gums, parts of the ear and again important branches to the meninges of the brain.

The proprioceptive input carries information about jaw position, touch, temperature and pain. The lingual branch of the mandibular nerve gives partial innervation to the tongue.

The motor fibers of the trigeminal nerve also pass thru the mandibular division of the trigeminal nerve and control eight muscles including four that provide for jaw movement:

Masseter Muscle

Temporalis Muscle

Medial Pterygoid Muscle

Lateral Pterygoid Muscle

An additional four trigeminally innervated muscle are:

Tensor Veli Palatini that controls the soft palate and opens and closes the Eustachian tube.

Tensor Veli Tympani that controls the tautness of the ear drum.

Mylohyoid Muscle

Anterior Digastric muscle, which are used for mouth opening jaw muscles.

It is importance of the trigeminal nerve that allows almost miraculous resolution of many headaches and migraines when a diagnostic neuromuscular orthotic is carefully adjusted to decrease nociceptive input to the trigeminal nervous system.

It is essential to initially utilize a reversible neuromuscular orthotic prior to making major permanent occlusal changes. This allows the patient to go through a period of trial therapy to evaluate improvement (or lack of improvement) and to allow postural corrections to occur.

The use of Sphenopalatine Ganglion Blocks in association with the orthotic allows the trained neuromuscular dentist to directly address neural input associated with trigeminal autonomic headaches such as cluster headaches, SUNCT and Paroxysmal Hemicrania. See my previous post:

Saturday, December 3, 2011

TRIGEMINAL AUTONOMIC CEPHALGIAS, Chronic Headaches Related To Trigeminal Nerve Respond well to Neuromuscular Dentistry & Sphenopalatine Ganglion Block

The following paragraph is from the website of the:

National Institute of Neurological Disorders and Stroke (NINDS) of the NIH

Why Headaches Hurt:

Information about touch, pain, temperature, and vibration in the head and neck is sent to the brain by the trigeminal nerve, one of 12 pairs of cranial nerves that start at the base of the brain.

The nerve has three branches that conduct sensations from the scalp, the blood vessels inside and outside of the skull, the lining around the brain (the meninges), and the face, mouth, neck, ears, eyes, and throat.

Brain tissue itself lacks pain-sensitive nerves and does not feel pain. Headaches occur when pain-sensitive nerve endings called nociceptors react to headache triggers (such as stress, certain foods or odors, or use of medicines) and send messages through the trigeminal nerve to the thalamus, the brain's "relay station" for pain sensation from all over the body. The thalamus controls the body's sensitivity to light and noise and sends messages to parts of the brain that manage awareness of pain and emotional response to it. Other parts of the brain may also be part of the process, causing nausea, vomiting, diarrhea, trouble concentrating, and other neurological symptoms.

TRIGEMINAL AUTONOMIC CEPHALGIAS, Chronic Headaches Related To Trigeminal Nerve Respond well to Neuromuscular Dentistry & Sphenopalatine Ganglion Block

The Trigeminal Nerve is often called the Dentist's Nerve because it goes to the teeth, jaw muscles, jaw joints (TMJ),and periodontal ligament. Trigeminal innervation of the sinuses, eustacian tubes, tensor of the ear drum (tensor tympani), soft palate, tongue and meninges of the brain explain why there are so many disorders associated with jaw function, TMJ and TMD.

There are a special group of disorders called the Trigeminal Autonomic Cephalgias (See National Institute of Neurological Disorders and Stroke web information below). Sphenopalatine Ganglion Blocks are an autonomic block that can be used to treat many types of migraine, Tension-tyoe headaches and chronic daily headaches but the SPG block are especially useful for autonomic cephalgias.

Cluster Headaches are primarily found in males and frequently awake patients from sleep. Oxygen is also an excellent treatment if it is administered immediately. Triptans, neurosurgery as well as antipsychotics and calcium channel blockers are also used prophylactically. Utilization of implanted electrodes and or neurosurgery where the nerves are resected are techniques that are often used. The Sphenopalatine Ganglion block (an autonomic block can be used both diagnostically and therapeutically) is probably one of the safest and most effective treatments for cluster headaches and when done with plain lidocaine are almost free of side effects. Paroxysmal hemicrania and SUNCT (Short-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing) are other Autonomic trigeminal that have similarities to cluster headaches. The National Institute of Neuromuscular Disorders and Stroke can be found below)

A diagnostic neuromuscular orthotic can also be utilized prophylactically with cluster headaches. A diagnostic neuromuscular orthotic is used to treat both the sommatic and autonomic aspects of the trigeminal nerves. They are particularly effective at treating muscle spasm, myofascial pain and trigger points in masticatory muscles. The combination of both therapies, a diagnostic neuromuscular orthotic and self administered autonomic Sphenopalatine Ganglion Blocks (SPG Block) can virtually "Cure" cluster headaches in some patients. An added advantage to the diagnostic orthotic is that it can frequently eliminate tension-type headaches and chronic daily headaches (muscular orgin headaches) that are almost always trigeminally modulated.

The SPG block is a simple procedure that my patients learn to self administer in one or two appointments. The block is done transmucosally with a cotton tipped applicator with lidocaine (no epinephrine or preservatives). No needles ever penetrate the patient but rather the saturated cotton is passed intranasally (though the nose) to the area adjacent to the ganlion. The anaesthetic passes through the tissue to the ganglion.

According to Wikipedia the Sphenopalatine Ganglion is also called the "The pterygopalatine ganglion (Synonym: ganglion pterygopalatinum, meckel's ganglion, nasal ganglion, sphenopalatine ganglion) is a parasympathetic ganglion found in the pterygopalatine fossa. (This is where the cotton tip applicator contacts mucosa) It is one of four parasympathetic ganglia of the head and neck. The others are the submandibular ganglion, otic ganglion, and ciliary ganglion. The flow of blood to the nasal mucosa, in particular the venous plexus of the conchae, is regulated by the pterygopalatine ganglion and heats or cools the air in the nose.

(The structure of the Sphenopalatine Ganglion also from Wikipedia below)

The pterygopalatine ganglion (of Meckel), the largest of the parasympathetic ganglia associated with the branches of the Maxillary Nerve (branch of trigeminal nerve), is deeply placed in thepterygopalatine fossa, close to the sphenopalatine foramen. It is triangular or heart-shaped, of a reddish-gray color, and is situated just below the maxillary nerve as it crosses the fossa.

The pterygopalatine ganglion supplies the lacrimal gland (tear ducts), paranasal sinuses, glands of the mucosa of the nasal cavity and pharynx, the gingiva, and the mucous membrane and glands of the hard palate. It communicates anteriorly with the nasopalatine nerve.

According to Wikipedia (below) there are sensory, sympathetic and parasympatheic roots

Its sensory root is derived from two sphenopalatine branches of the maxillary nerve; their fibers, for the most part, pass directly into the palatine nerves; a few, however, enter the ganglion, constituting its sensory root.

Parasympathetic root

Its parasympathetic root is derived from the nervus intermedius (a part of the facial nerve) through the greater petrosal nerve.

In the pterygopalatine ganglion, the preganglionic parasympathetic fibers from the greater petrosal branch of the facial nerve synapse with neurons whose postganglionic axons, vasodilator, and secretory fibers are distributed with the deep branches of the trigeminal nerve to the mucous membrane of the nose, soft palate, tonsils, uvula, roof of the mouth, upper lip and gums, and upper part of the pharynx. It also sends postganglionic parasympathetic fibers to the lacrimal nerve (a branch of the Ophthalmic nerve, also part of the trigeminal nerve) via the zygomatic nerve, a branch of the maxillary nerve (from the trigeminal nerve), which then arrives at the lacrimal gland.

The nasal glands are innervated with secretomotor from the nasopalatine and greater palatine nerve. Likewise, the palatine glands are innervated by the nasopalatine, greater palatine nerve and lesser palatine nerves. The pharyngeal nerve innervates pharyngeal glands. These are all branches of maxillary nerve.

Sympathetic root

The ganglion also consists of sympathetic efferent (postganglionic) fibers from the superior cervical ganglion. These fibers, from the superior cervical ganglion, travel through the carotid plexus, and then through the deep petrosal nerve. The deep petrosal nerve joins with the greater petrosal nerve to form the nerve of the pterygoid canal, which enters the ganglion.

TRIGEMINAL AUTONOMIC CEPHALGIAS

Some primary headaches are characterized by severe pain in or around the eye on one side of the face and autonomic(or involuntary) features on the same side, such as red and teary eye, drooping eyelid, and runny nose. These disorders, called trigeminal autonomic cephalgias (cephalgia meaning head pain), differ in attack duration and frequency, and have episodic and chronic forms. Episodic attacks occur on a daily or near-daily basis for weeks or months with pain-free remissions. Chronic attacks occur on a daily or near-daily basis for a year or more with only brief remissions.

Cluster headache - the most severe form of primary headache-involves sudden, extremely painful headaches that occur in "clusters," usually at the same time of the day and night for several weeks. They strike one side of the head, often behind or around one eye, and may be preceded by a migraine-like aura and nausea. The pain usually peaks 5 to 10 minutes after onset and continues at that intensity for up to 3 hours. The nose and the eye on the affected side of the face may get red, swollen, and teary. Some people will experience restlessness and agitation, changes in heart rate and blood pressure, and sensitivity to light, sound, or smell. Cluster headaches often wake people from sleep.

Cluster headaches generally begin between the ages of 20 and 50 but may start at any age, occur more often in men than in women, and are more common in smokers than in nonsmokers. The attacks are usually less frequent and shorter than migraines. It's common to have 1 to 3 cluster headaches a day with 2 cluster periods a year, separated by months of freedom from symptoms. The cluster periods often appear seasonally, usually in the spring and fall, and may be mistaken for allergies. A small group of people develop a chronic form of the disorder, which is characterized by bouts of headaches that can go on for years with only brief periods (1 month or less) of remission. Cluster headaches occur more often at night than during the day, suggesting they could be caused by irregularities in the body's sleep-wake cycle. Alcohol (especially red wine) and smoking can provoke attacks. Studies show a connection between cluster headache and prior head trauma. An increased familial risk of these headaches suggests that there may be a genetic cause.

Treatment options include oxygen therapy-in which pure oxygen is breathed through a mask to reduce blood flow to the brain-and triptan drugs. Certain antipsychotic drugs, calcium-channel blockers, and anticonvulsants can reduce pain severity and frequency of attacks. In extreme cases, electrical stimulation of the occipital nerve to prevent nerve signaling or surgical procedures that destroy or cut certain facial nerves may provide relief.

Paroxysmal hemicrania is a rare form of primary headache that usually begins in adulthood. Pain and related symptoms may be similar to those felt in cluster headaches, but with shorter duration. Attacks typically occur 5 to 40 times per day, with each attack lasting 2 to 45 minutes. Severe throbbing, claw-like, or piercing pain is felt on one side of the face-in, around, or behind the eye and occasionally reaching to the back of the neck. Other symptoms may include red and watery eyes, a drooping or swollen eyelid on the affected side of the face, and nasal congestion. Individuals may also feel dull pain, soreness, or tenderness between attacks or increased sensitivity to light on the affected side of the face. Paroxysmal hemicrania has two forms: chronic, in which individuals experience attacks on a daily basis for a year or more, and episodic, in which the headaches may stop for months or years before recurring. Certain movements of the head or neck, external pressure to the neck, and alcohol use may trigger these headaches. Attacks occur more often in women than in men and have no familial pattern.

The nonsteroidal anti-inflammatory drug indomethacin can quickly halt the pain and related symptoms of paroxysmal hemicrania, but symptoms recur once the drug treatment is stopped. Non-prescription analgesics and calcium-channel blockers can ease discomfort, particularly if taken when symptoms first appear.

SUNCT (Short-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing) is a very rare type of headache with bursts of moderate to severe burning, piercing, or throbbing pain that is usually felt in the forehead, eye, or temple on one side of the head. The pain usually peaks within seconds of onset and may follow a pattern of increasing and decreasing intensity. Attacks typically occur during the day and last from 5 seconds to 4 minutes per episode. Individuals generally have five to six attacks per hour and are pain-free between attacks. This primary headache is slightly more common in men than in women, with onset usually after age 50. SUNCT may be episodic, occurring once or twice annually with headaches that remit and recur, or chronic, lasting more than 1year.

Symptoms include reddish or bloodshot eyes (conjunctival injection), watery eyes, stuffy or runny nose, sweaty forehead, puffy eyelids, increased pressure within the eye on the affected side of the head, and increased blood pressure.

Cephalalgia. 2009 Jul 13. [Epub ahead of print] LinksSluder's neuralgia: a trigeminal autonomic cephalalgia?

SUNCT is very difficult to treat. Anticonvulsants may relieve some of the symptoms, while anesthetics and corticosteroid drugs can treat some of the severe pain felt during these headaches. Surgery and glycerol injections to block nerve signaling along the trigeminal nerve have poor outcomes and provide only temporary relief in severe cases. Doctors are beginning to use deep brain stimulation (involving a surgically implanted battery-powered electrode that emits pulses of energy to surrounding brain tissue) to reduce the frequency of attacks in severely affected individuals.

Oomen KP, van Wijck AJ, Hordijk GJ, de Ru JA.
Department of Otolaryngology, Central Military Hospital, Utrecht, The Netherlands.
Oomen KPQ, van Wijck AJM, Hordijk GJ & de Ru JA. Sluder's neuralgia: a trigeminal autonomic cephalalgia? Cephalalgia 2009. London. ISSN 0333-1024The objective was to formulate distinctive criteria to substantiate our opinion that Sluder's neuralgia and cluster headache are two different clinical entities. A systematic review was carried out of all available, original literature on Sluder's neuralgia. Pain characteristics, periodicity and associated signs and symptoms were studied and listed according to frequency of appearance. Eleven articles on Sluder's neuralgia were evaluated. Several differences between Sluder's neuralgia and cluster headache became evident. Based on described symptoms, new criteria for Sluder's neuralgia could be formulated. Sluder's neuralgia and cluster headache could possibly be regarded as two different headache syndromes, and Sluder's neuralgia could be a trigeminal autonomic cephalalgia.
PMID: 19614698 [PubMed - as supplied by publisher]

Trigeminal Nerve Pain or TMJ? Neuromuscular Dentistry or SPG Blocks may help solve problems.

Question: My dentist diagonesed that I might have a TMJ problem, previously had MRI scan for trigeminal nerve pain but came negative, what could the problem be?

Dr Shapira Response: The trigeminal nerve supplies approximately 50% of all input to the brain. Because the MRI scan was normal does not mean the pain is not from or mediated by the trigeminal nerve. This can include TM Joint problems, TMD, Myofascial Pain, otalgia (trigeminal). All of these problems are mediated by the trigeminal nerve which is why neuromuscular dentistry is such an effective approach to chronic pain of the head and neck.

Sphenopalatine Ganglion Blocks can address the autonomic connections of the trimeninal nerve. It is usually a simplification to just call something a "TMJ" problem because there are usually multiple concerns based on symptomatology.

I normally spend an hour or more reviewing the history of patients with pain. The patient gave me no information about the SYMPTOMS that caused her to seek treatment. An accurate chronological history is an essential element in understanding how to approach a problem to bring relief. An MRI will show organic problems but are rarely the diagnostic approach to chronic pain. It is helpful in that it rules out tumors, growths, etc.

An examination of the craniomandibular and cervical musculature is incredibly important in anyone with headaches, facial pain, migraines, trgeminal pain, ear or jaw pain. Evaluation of the TM Joints and jaw motion is also very important.

The Neuromuscular Diagnostic work-up includes EMG evaluation of the jaw and/or neck muscles, Computerized scans of jaw movement and function, Sonography is sometimes used as well.

I get headaches more when I am tired or stressed or when it is sinus season

Glendale: I get headaches more when I am tired or stressed or when it is sinus season

Dr Shaira response: These are very common statement for people with neuromuscular problems, TMJ disorders or TMD

The reason is that most headaches are primarily modulated by the trigeminal nerve. The lining of the sinuses is innervated by the trigeminal nerve so the addition of sinus irritation to and existing problem is enough to push you over the edge. Stress in general is related to TMJ disorders, myofascial pain and headache. There are different types of stress our bodies cope with.

Structural stress is all about muscles, joints, bones, habits, trauma, bite, whiplash etc. Posture is about proper or improper alignment of all these body parts. The Quadrant Theory of Guzay shows that jaw position is incredible important in determining head posture. Head posture is extremely important in treating any chronic pain patient.

Emotional or life stress includes stresses related to family, money, jobs, children , parents, friends etc.

Biochemical stress includes diet, vitamins , minerals, organic disease, aleergies hormones an so on.

When our ability to cope is less than the total of our stresses and the system tells us pain, headache, sinus pressure etc.

It is always the total of stresses exceding our ability to cope that pushes pain over the edge. When you state stress or sinus season pushes you over the edge you are correct. Correcting the underlying structural stress will also raise the threshold before you feel pain. Total stress including all types is the culprit. Lowering any of the components will improve your quality of life.

A neuromuscular diagnostic orthotic is designed to remove noxious (painful) input to the brain, allow the muscles and joints to heal and for posture to correct..

Headaches, Ear Pain, Mouth, Jaw and Tooth Pain related to TMJ, Whiplash and Unstable Atlas

Frank: What are the costs of treatment and is it covered by insurance? I have severely ground teeth. I clench a lot but mostly during day. 61 yrs old I do TMJ massage and that slightly helps. The headaches occur 4-10 times month. Headaches are inside my ears, above ears, in mouth and jaw and seem to sometimes be in the teeth and roof of mouth. I had whiplash injury. When I have atlas aligned it helps but does not stay in alignment.

Dr Shapira response: Insurance sometimes covers part of the cost but most insurance companies are worried primarily about shareholders and profits. Several years ago Chicago HMO agreed to pay 100% of the costs even though it was specifically excluded by their policy. Dr Mitchell Trubitt was the medical director after I showed him (trial of 6 patients) that covering TMJ disorders and neuromuscular dentistry saved them money. For many years I saw 15-25 new Chicago HMO patients patients a month and sometimes more. Success was incredible when cost was not an issue. Unfortunately United Health Care bought out Chicago HMO and they did not continue coverage. An article in Crano showed a 300% increase in medical costs in every field of medicine (except obstetrics) in patients with TMJ disorders.

As to your symptoms and treatment, I would suggest you have and examination and a diagnostic neuromuscular orthotic. It will protect your teeth from damage and address the myofascial pain it sounds like you are having.

Are you complete free of pain on your non-headache days or is the pain at more tolerable levels. Many patients "live" on drugs like ibuprofen and count headache days only when it doesn't work. The cost of living in pain is far greater than the cost of treatment. Chronic pain can suck the life out of you and the joy out of life.

The whiplash and Atlas are directly related to the jaw muscles and jaw joint and it is almost impossible to have a stable atlas / axis / craio articulation without correcting jaw position. The mandible acts like a counterbalance to the head and should be considered "the last vertebrae" which must be stabilized in a healthy position.

A diagnostic neuromuscular orthotic is the best way to determine if treatment will be effective. The orthotic is a reversible treatment that can be a life changer.

Frank: I'm in California? Is that a problem?

My headaches (or severe muscle pain in head neck teeth ears etc.) somedays is completely gone. But if I touch certain muscles they always feel like spasms and are very painful. Even 2 muscles on the side of my neck. Will it help to have all teeth capped to get them back to proper height? Will the cartilage that's wornoff ever grow back? Massage helps some I think? Cold laser helps quite a bit but I will have to do it forever. I no longer grind teeth,I just clench my jaw during the day even though my teeth aren't touching. I probably use 6-10 advil a month. But I use certain homeopathics and ice-cold therapy which are intermittent. ??????????????? I dream of a headache free pain free life.... Sometimes my headache so to speak is in my throat and in the teeth themselves and center of the ears. TKU Frank

Dr Shapira response: Frank, I don't think your pain is ever gone if the muscles are still painful to touch. It just means your pain level is below threshold but it takes a lot of energy to control pain and keep it below threshold. I term that energy "vital energy" it is the energy that makes you happy and lets you enjoy life rather than merely tolerate living. Do not start with having your teeth capped. What if it makes the pain worse. Start with a removable diagnostic neuromuscular orthotic that will let you treat the problem and evaluate success before making irreversible changes. Proceed with caps or other permanent correction only after controllling or eliminating pain to where you have a good quality of life. It is unlikely that cartilage that is totally gone will grow back but damaged cartilage can heal if it is given an ideal situation for healing.

Cold laser is safe but usually not long lasting. Trigger point injections tend to give more lasting results with hot trigger points in muscles. Spray and stretch can give amazing results. The pain patterns you describe are myofascial pain but that is just a guess without an exam.

California, is that a problem? I see long distance patients but to be successful I need several days intensive treatment to try to reach a relative homeostasis. My office can accomadate you but the first series of visits would be Monday thru Wednesday or Thursday and would require you arriving Sunday. Your original question about costs and insurance comes into play because the diagnostic stage of treatment including diagnostic orthotic, trigger points, etc may be an out of pocket expense. I would probably want to have my A/O chiropracter evaluate your Atlas after delivery of an appliance Monday afternoon.

Treatment is all about quality of life and relief of pain. There are no guarantees but my goal is to relieve as much pain as possible. I recently treated a woman who spent 50 years with a continuous headache and received total relief. I did do a reconstruction on that patient (wife of a physician) but only AFTER the pain was relieved.

New Report in Journal Headache on Chronic and Episodic Migraine.

This new report in Headache. 2011 Nov 22 looks at differences between Chronic Migraine (More than 15 headache days/month) compared to Episodic Migraine (less than 15 headache days/month) The study found that "those with Chronic Migraine were significantly more likely to experience "severe" headache impact (72.9% vs 42.3%) and had higher odds of greater adverse headache impact compared with persons with Episodic Migraine.

The study found that "Significant predictors of adverse headache impact in both groups included younger age, higher MSS (migraine symptom severity) score, higher average long-duration headache pain severity rating, and depression."

"Lower annual household income, anxiety, and higher standardized headache day frequency predicted adverse headache impact in Episodic Migraine but not in Chronic Migraine."

Not surprising, rates of depression were more than double among persons with Chronic Migraine compared to Episodic Migraine and rates of anxiety were nearly triple in the Chronic Migraine group.

When patients are treated with a diagnostic neuromuscular orthotic it is common to see changes in personality and temperament as the pain is reduced or eliminated. I have often found that I don't "meet" the patient till the second, third or fourth visit because they were "lost" in their pain. As the pain dissipates you actually meet the real person, not the one at the effect of constant pain.

This study (PubMed abstract below) describes Chronic Migraine as more than 15 days of headache while episodic is less than 15. In my experience both of these groups actually are in constant pain but they describe lower levels of pain as feeling good. When patients are feeling better they can be more objective about how bad they really felt prior.

It is essential to understand that the depression and anxiety are somatopsychic effects of being in constant pain. Dpression is a "normal" response to constant pain.

Headache. 2011 Nov 22. doi: 10.1111/j.1526-4610.2011.02046.x. [Epub ahead of print]

Headache Impact of Chronic and Episodic Migraine: Results From the American Migraine Prevalence and Prevention Study.

Buse D, Manack A, Serrano D, Reed M, Varon S, Turkel C, Lipton R.

Source

From Montefiore Headache Center, Montefiore Medical Center, Bronx, NY, USA (D. Buse); Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA (D. Buse and R. Lipton); Allergan, Inc., Irvine, CA, USA (A. Manack, S. Varon, and C. Turkel); Clinical Research, Vedanta Research, Chapel Hill, CA, USA (D. Serrano and M. Reed).

Abstract

Background.- The Headache Impact Test-6 (HIT-6) has been demonstrated to be a reliable and valid measure that assesses the impact of headaches on the lives of persons with migraine. Originally used in studies of episodic migraine (EM), HIT-6 is finding increasing applications in chronic migraine (CM) research. Objectives.- (1) To examine the headache-impact on persons with migraine (EM and CM) using HIT-6 in a large population sample; (2) to identify predictors of headache-impact in this sample; (3) to assess the magnitude of effect for significant predictors of headache-impact in this sample. Methods.- The American Migraine Prevalence and Prevention study is a longitudinal, population-based study that collected data from persons with severe headache from 2004 to 2009 through annual, mailed surveys. Respondents to the 2009 survey who met International Classification of Headache Disorders 2 criteria for migraine reported at least 1 headache in the preceding year, and completed the HIT-6 questionnaire were included in the present analysis. Persons with migraine were categorized as EM (average <15 headache days per month) or CM (average ≥15 headache days per month). Predictors of headache-impact examined include: sociodemographics; headache days per month; a composite migraine symptom severity score (MSS); an average pain severity rating during the most recent long-duration headache; depression; and anxiety. HIT-6 scores were analyzed both as continuous sum scores and using the standard, validated categories: no impact; some impact; substantial impact; and severe impact. Group contrasts were based on descriptive statistics along with linear regression models. Multiple imputation techniques were used to manage missing data. Results.- There were 7169 eligible respondents (CM = 373, EM = 6554). HIT-6 scores were normally distributed. After converting sum HIT-6 scores to the standard categories, those with CM were significantly more likely to experience "severe" headache impact (72.9% vs 42.3%) and had higher odds of greater adverse headache impact compared with persons with EM (OR = 3.5, 95% CI = 2.77-4.41, P < .0001). Significant predictors of adverse headache impact in both groups included younger age, higher MSS score, higher average long-duration headache pain severity rating, and depression. Lower annual household income, anxiety, and higher standardized headache day frequency predicted adverse headache impact in EM but not CM. With few exceptions, gender, race, and body mass index did not significantly predict adverse headache impact. Finally, rates of depression were more than double among persons with CM (CM = 25.2%, EM = 10.0%), and rates of anxiety were nearly triple (CM = 23.6%, EM = 8.5%). Conclusions.- This work further establishes HIT-6 as a useful instrument for characterizing CM and understanding the increased disease related burden. Persons with CM had significantly higher odds of greater adverse headache impact, when compared with EM. Predictors of greater headache impact for both groups included higher MSS scores, higher average headache pain severity, and depression. Additional predictors unique to EM included higher average household income, younger age, higher standardized headache day frequency, and anxiety. This finding may be related to differences in sample size and power. Further exploration is warranted.

© 2011 American Headache Society.

Cervicogenic Headaches, TMJ, TMD, and the Trigeminocervical System. Treatment should include trigger point injections and greater occipital blocks.

Headaches and TMJ disorders usually have multiple symptoms. According to an article in Nov 2011 Neurologist these include the following symptoms: complaints of dizziness, tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain.

I firmly believe that the autonomic symptoms ot temporomandibular disorders must be addressed. A neuromuscular orthotic can alleviate many of the symptoms but SPG blocks, greater occipital blocks and trigger point injections are frequently required for more effective treatment. All of these treatments are minimally ivasive and safer and more effective than use of tiptans or topomax.

The abstract reported the following results:

Total number of 147 patients were included. Chief complaints in decreasing frequency: dizziness (93%), tinnitus (4%), headache (3%), and ear discomfort (0.7%). Overall symptoms in decreasing frequency: dizziness (97%), headache (88%), neck pain (63%), tinnitus (23%), and ear discomfort (22%). Improvements after GON/TPI: neck range of motion (71%), headache (57%), neck pain (52%), ear discomfort (47%), dizziness (46%), and tinnitus (30%). Dizziness responders had neck position asymmetries (84%), reproducible dizziness by cervical and suboccipital musculature vibration (75%), and preinjection posterior vertex sensory changes (60%).

Neurologist. 2011 Nov;17(6):312-7.

Role of greater occipital nerve blocks and trigger point injections for patients with dizziness and headache.

Baron EP, Cherian N, Tepper SJ.

Source

Department of Neurology, Cleveland Clinic Neurological Institute, Center for Headache and Pain, Cleveland, OH.

Abstract

BACKGROUND:

: The trigeminocervical system is integral in cervicogenic headache. Cervicogenic headache frequently coexists with complaints of dizziness, tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain. Controversy exists as to whether this constellation of symptoms may be cervically mediated.

OBJECTIVES:

: To determine whether a wider spectrum of cervically mediated symptoms exist, and to investigate a potential role of greater occipital nerve blocks (GON) and trigger point injections (TPI) in these patients.

METHODS:

: Retrospective review of GON/TPI performed in a tertiary otoneurology/headache clinic from May 2006 to March 2007 for suspected cervically mediated symptoms. Data included chief complaint, secondary symptoms, response to injection, pre-GON/TPI posterior vertex sensation changes to pinprick, cervical spine examination, and response to vibration of cervical and suboccipital musculature.

RESULTS:

: Total number of 147 patients were included. Chief complaints in decreasing frequency: dizziness (93%), tinnitus (4%), headache (3%), and ear discomfort (0.7%). Overall symptoms in decreasing frequency: dizziness (97%), headache (88%), neck pain (63%), tinnitus (23%), and ear discomfort (22%). Improvements after GON/TPI: neck range of motion (71%), headache (57%), neck pain (52%), ear discomfort (47%), dizziness (46%), and tinnitus (30%). Dizziness responders had neck position asymmetries (84%), reproducible dizziness by cervical and suboccipital musculature vibration (75%), and preinjection posterior vertex sensory changes (60%).

CONCLUSIONS:

: A wider spectrum of cervically mediated symptoms may exist by influence of trigeminocervical and vestibular circuitry through cervical afferent neuromodulation. Certain examination findings may help to predict benefit from GON/TPI.

Intractable Cluster Headache: Sphenopalatine Ganglion Blocks May be Treatment of Choice.

Cluster headaches is a primary neurovascular headache and is associated with autonomic symptoms. A sphenopalatineablation with radiofrequency is suggested in the following abstract. I disagree. If patients get relief from a sphenopalatine block of their cluster hedaches they will probably find intranasal prophylactic SPB blocks are also effective. An old study on SPG ablation at Mayo was discontinued due to adverse outcomes.

Correction of underlying trigeminal aberations through a neuromuscular orthotic and SPG blocks is a safer and more conservative alternative to SPG ablation.

I would only consider ablation as a very last line of treatment.

Curr Pain Headache Rep. 2010 Apr;14(2):160-3.

Role of sphenopalatine ganglion neuroablation in the management of cluster headache.

Narouze SN.

Source

Pain Management Department, Anesthesiology Institute, Cleveland Clinic, OH 44195, USA. narouzs@ccf.org

Abstract

Cluster headache is a primary neurovascular headache. It is a strictly unilateral head pain that is associated with cranial autonomic symptoms and usually follows circadian and circannual patterns. Chronic cluster headache, which accounts for about 10% to 15% of patients with cluster headache, lacks the circadian pattern and is often resistant to pharmacological management. The sphenopalatineganglion (SPG), located in the pterygopalatine fossa, is involved in the pathophysiology of cluster headache and has been a target for blocks and other surgical approaches. Percutaneous radiofrequency ablation of the SPG was shown to have encouraging results in those patients with intractable cluster headaches.

Sphenopalatine Ganglion Implicated in Migraines and Cluster Headaches via Cerebrovascular Autonomic Physiology

The pathophysiology or cause of almost all headaches, migraines, cluster headaches and tension-type headache involve the Trigeminal Nerve which can effectively be treated in mane headache sufferers through neuromuscular dentistry. Another pathway of relieving chronic headache pain is by utilizing a SPG or Sphenopalatine Ganglion Block which affects the autonomic nervous system and is readily accessible to dentists with either palatal injection or nasal swab.

Newer techniques involving neurostimulation hold promise but the simple use of lidocaine on a nasal swab often produces miraculous relief for patients. When combined with a diagnostic neuromuscular orthotic a 50 - 80% success rate easily achieved in most patients. The following PubMed abstract discusses possible new avenues of addressing the sphenopalatine ganglion. I would advise patients to start with nasal or palatal block. Nasal blocks are easily learned by patients for home administration and can be used to prophylactically to abort migraines similar to triptans or topomax with fewer side effects.

Prog Neurol Surg. 2011;24:171-9. Epub 2011 Mar 21.

Sphenopalatine ganglion interventions: technical aspects and application.

Oluigbo CO, Makonnen G, Narouze S, Rezai AR.

Source

Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio 43210, USA.

Abstract

Recent research has highlighted the important role of the sphenopalatine ganglion (SPG) in cerebrovascular autonomic physiology and in the pathophysiology of cluster and migraine headaches as well as conditions of stroke and cerebral vasospasm. The relatively accessible location of the SPG within the pterygopalatine fossa and the development of options for minimally invasive approaches to the SPG make it an attractive target for neuromodulation approaches. The obvious advantage of SPG stimulation compared to ablative procedures on the SPG such as radiofrequency destruction and stereotactic radiosurgery is its reversibility and adjustable features. The on-going design of strategies for transient and continuous SPG stimulation on as needed basis using implantable SPG stimulators is an exciting new development which is expected to expand the clinical versatility of this technique.

Copyright © 2011 S. Karger AG, Basel.

PMID:

21422787

[PubMed - in process]

Migraines and Vomiting for 15 Years. Neuromuscular Dentistry and SPG Blocks May Resolve Symptoms.

Anne: I've been getting migraine headaches for the past 15 or so years. I always have terrible nausea and vomiting. I have tried many many different things with no luck. I had a migraine yesterday where I vomited non-stop for 12+ hours. The migraines are typically on the right side behind my eye but this time I also noticed pain in my upper jaw.

Dr Shapira response:

Dear Anne,

A diagnostic neuromuscular orthotic can often give dramtic results in lowering the frequency and severity of migraine attacks (and associated nausea) and is especially helpful with tension-type headaches and referred muscle headaches. The muscular headaches are frequently the trigger for the migraines. The nausea is a secondary autonomic effect. The trigeminal nerve (or dentists nerve) is involved in almost all migraines and other types of headache. It is also associate with autonomic symptoms. An SPG block can sometimes offer amazing relief. There is an out of print book "Miracles on Park Avenue" that discusses some of the benefits of SPG blocks.

An Spenopalatine Ganglion Block can be done at the first sign of a headache and prevent a full attack. I usually teach my patients this easy technique.

I do see long distance patients, but I like a complete history and phone interview before scheduling. I usually will have patients come in Sunday and I see them Monday AM and PM, Tuesday AM and PM and Wednesday morning for their first set of appointments. Call my office if you would like me to see you at 847-623-5530.

A neuromuscular work-up will usually show the problems and allow for correction but their may be other factors besides the jaws, jaw muscles, jaw joints, posture and trigeminal nerves. Allergies or chemical triggers can still serve as headache triggers.

Chronic Daily Headache: Neurological Sciences Study Showed 17 of 20 Patients Required Neurmuscular Orthotic

A neuromuscular orthotic is used to correct occlusal discrepancies that can cause chronic daily headaches, migraines and tension-type headaches.The current study (abstract below) showed that 85% of patients with chronic daily headache has significant discrepancies between their occlusion and their ideal neuromuscular position.

The majority of dentists treating TMJ disorders and chronic head and neck pain are lost when it comes to establishing the neuromuscular position. The neuromuscular rest position and occlusion can only be determined after uilizing ultra-low frequency TENS to relax muscles and deprogram the occlusion.

I prefer the term Diagnostin Neuromuscular Orthotic because even though Neuromuscular Dentistry is extremely effective it is imprortant to establish success prior to long term restoration. The diagnostic orthotic is used to find this three dimensional relaxed position.

I see chronic headache and TMJ disorder patients on a long distance basis. The first series of appointments are to establish improved posture and a functionally correted Diagnostic Neuromuscular Orthotic.

I will have my out of town patients arrive on Sunday and then see them Monday AM for diagnostic evaluation, radiographs, impressions and examination. I then deliver the Diagnostic Orthotic Monday afternoon. It is adjusted Tuesday AM and PM and on Wednesday morning. This protocol allows me to send patients home after a short series of appointments with a functionally corrected neuromuscular diagnostic orthotic. I frequently will also do trigger point injections, SPG blocks and other physical therapy modalities.

I insist I receive a complete history and conduct a phone interview prior to giving the patient an appointment. This is essntial to be able to rapidly help patients get relief from chronic daily headaches, migraines and head and neck pain.

Neurol Sci. 2011 May;32 Suppl 1:S161-4.

Chronic daily headache: suggestion for the neuromuscular oral therapy.

Didier H, Marchetti C, Borromeo G, Tullo V, D'amico D, Bussone G, Santoro F.

Source

Fondazione IRCCS Cà Granda, Dipartimento di Scienze Chirurgiche Ricostruttive e Diagnostiche Sezione di Odontostomatologia, Università degli Studi di Milano, Via della Commenda 10, 10122 Milan, Italy.

Abstract

Tweny patients (M: 4, F: 16, mean age 37 ± 11 years) with diagnosis of chronic daily headache (CDH), after drug withdrawal, were under electromyography, kinesiography and masticatory muscle deprogramming by TENS to identify the physiological rest position of the mandible. Our purpose was to clarify a possible role of the neuromuscular stomatognathic system. Examinations showed that 17 patients needed a neuromuscular orthosis, an occlusal device, to provisionally correct the detected discrepancies of jaw position. Of those, the 10 patients who showed an occlusal sagittal discrepancy higher than 2 mm and/or a lateral deviation higher than 0.4 mm, associated with more than three parafunctional activities, had a meaningful decrease on frequency/intensity of migraine crisis and/or of days of headache. VAS pain score during crisis decreased from 9.0 ± 0.9 to 4.9 ± 2.7; frequency of crisis were from 20.7 ± 5.2 to 9.5 ± 7.7. Baseline pain were from 5.3 ± 1.2 to 3.0 ± 1.3. Satisfying clinical results can be reached combining behavioural education and neuromuscular orthosis. This can be very helpful in patients who show significant discrepancy of jaw position that only TENS deprogramming can reveal and kinesiography can detect with such accuracy.

PMID:

21533736

[PubMed - indexed for MEDLINE]