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Sunday, January 30, 2011

Study Shows That Majority of Patients Discontinue Triptan Use. Neuromuscular Dentistry is an Alternative to the Pharmaceutical Approach to Treatment

A recent study (pubmed abstract below) in the Journal Cephalgia showed that "Less than 15% of subjects received more than one triptan product in the 2 years." Triptans which are very successful for a small percentage of patients are not a panacea. The reasons for discontinuation may be numerous. I suspect that many patients treated for "migraines" of various types actually have headaches (albeit severe) of muscular or myofascial orgin often associated with craniomandibular disorders, TMD, Temporomandibular Joint Dysfunction, or other primary disorders of the Trigeminal Nerve related to masticatory function. The study also showed that 80% of patients only received one or two packages of Triptan medication. These patients obviously did not obtain significant relief or the side effects caused them to discontinue treatment.

Drug therapy of chronic daily headaches, atypical migraine, chronic migraine, tension-type headaches and other disorders may be useful as a interim measure but I content that removing the underlying cause of migraines and headaches is the optimum long term solution for chronic headache pain. The basis of Neuromuscular Dentistry is to eliminate the noxious input to the Trigeminal Nervous System that is responsible for headache propagation.

Sleep and Health Journal has my article on Neuromuscular Dentistry that was originally published by the American Equilibration Society. It is an excellent resource for all patients with headaces, migraines and TMJ disorders that are considering Neuromuscular Dental Treatment. The Neuromuscular Dentistry article is available @ http://www.sleepandhealth.com/neuromuscular-dentistry

The use of BOTOX to treat migraines and Tenion-Type headaches actually proves the validity of Neuromuscular Dentistry. The long term block with botulism toxin of neurojunctions in masticatory muscles clearly demonstrate that the pain and headache/ migraines are coming either directly from the musces, ie referred or myofascial pain or that noxious input from these muscles is causing central sensitization of the Trigeminal Nerve and Central Nervous system.

Neuromuscular Dentistry creates a healthy homeostasis where long term healing can occur. Neuromuscular Dentistry is frequently criticised for being expensive. This is actually a falsehood. Initial therapy with a diagnostic orthotic is usually done over a period of a few months and can run several thousan dolars but pales when compared to the costs of MRI's CAT SCANS, Chronic medication use with associated side effects and rebound headaches and awful effects on family and friends as well as patients quality of life. Chronic pain patients frequenty suffer sever guilt for the effects of their pain on the lives of their loved ones.

The reason Neuromuscular Dentistry has a reputation of being extremely expensive is that many patients elect to do full mouth reconstruction as long term stabilzation after their pain is eliminated or substantially reduced. They prefer not to have a long term stabilization appliance. The second phase of Neuromuscular Dental Treatment of Migraines and/or Tension Headaches and TMJ disorders requires stabilization so improvements in quality of life are maintained.

Cast removable orthotics, orthodontics and semi-permanent oral orthotics are alternatives to expensive reconstruction. The quality of life of the patient is what is key not the method of long term stabilization.

There are some dental groups that are involved in treatment of TMJ disorders that chose to ignore widespread clinical success from occlusal therapy and prefer to ebrace the pscho-social approach to these problems. They prefer the medication approach and believe this is more a mental problem than a physical problem. they strongly embrace the use of psychoactive medications and other drugs that frequently have dangerous side effects. Evidenced based medicine is the new watchword in research and drug therapy naturally lends itself to randomized clinical trials. These doctors frequently site these drug studies.

Drug studies are not bad but they are the most pervasive due to billions spent by Big Pharma looking to score big in the market place. Recent studies have shown that positive studies are published as much as two years earlier than studies that show negative results and problematic side effects. It has become common place to see the FDA recall products completely or place dire warnings about drug safety after they have been available for years. Even "safe" drugs like Acetaminophen often have dangerous side effects. The following is from WebMD:

""July 1, 2009 -- The FDA should put new restrictions on acetaminophen, an advisory committee recommended Tuesday, saying the move would protect people from the potential toxicity that can cause liver failure and even death.

The FDA does not have to follow its advisory committees’ recommendations, but it usually does. It will likely be months before the FDA makes a final decision on the drug.

You might not know "acetaminophen," because that's the drug's generic name. One of the nation’s top drugs for pain relief, acetaminophen is found in many over-the-counter products -- including Tylenol, aspirin-free Anacin, Excedrin, and numerous cold medicines. It's also found in many prescription drugs." (end Web MD info)

Many negative studies are never published because funding is discontinued when the results are negative and nobody is that interested in drugs that don't work. When those drugs are already on the market and the initial studies show promise physicians are not always aware of later studies.

Another study (abstract below) used experimental mechanical stimulation to induce hyperaemia associated with cortical spreading depression (CSD) the underlying mechanism behind the aura is associated with neurological disorders that 30% of migraine patients patients additionally suffering from. The most common of the focal neurological disturbances is the aura.

What I find most interesting about the experiment is that proves that Cortical Spreading Depression associated with Aura can be mechanically induced which is exactly the philosophy of Neuromuscular Dentistry. Obviously if you read the study it is designed to find new drugs to treat migraine. It is certainly not their intention to show that migraines are primarily central effect of peripheral stimulation. But as I stated previously Botox is an excellent example of peripherally caused migraines being controlled by changing neurolical input to the trigeminal system. I maintain that if possible removing noxious stimuli is preferable to injection of dangerous toxins.

Some of the dangers and General Side Effects associated with Botox injections follow:

* Bruising (Common)
* Dizziness
* Skin rash
* Tiredness
* Muscle spasm
* Numbness
* General Weaknes
* Drowsines
* Flu-like syndrome 2%
* Feeling generally unwell
* Dryness of the mouth
* Sickness
* Headache 13.3%
* Stiffness

Injections around the eye often have one or more the following side effects:

*Drooping upper eyelid 3.2%
* Drooping brow
* Mild inflammation of the surface of the eye
* Difficulty in completely closing the eye
* Overflow of tears
* Dry eye
* Sensitivity to light

Less Frequent side effects include:
* Inflammation of the surface of the eye
* Turning out or Eversion of the eyelid
* Turning in or Inversion of the eyelid
* Double vision
* Facial weakness
* Facial droop
* Blurred vision

The following side effects are rare but do occur:
* Swelling of the eyelids
* Ulcers develop on the surface of the eye
* Eye pressure increase (Glaucoma)

I do feel that there is a definite role of Botox in the treatment of migraines for some patients but I would advise that initiating treatment with a diagnostic neuromuscular orthotic may prove vastly more successful and safer for the patient and provide a better long term quality of life.

Cephalalgia. 2010 May;30(5):576-81. Epub 2010 Feb 11.
Triptans: low utilization and high turnover in the general population.
Panconesi A, Pavone E, Franchini M, Mennuti N, Bartolozzi M, Guidi L, Banfi R.

Health Authority 11, Empoli, Florence, Italy. a.panconesi@virgilio.it
Studies performed in selected populations have shown a poor utilization of triptans for migraine. Our study was aimed at establishing patterns of triptans utilization in a large community using the pharmaceutical prescriptions database of two consecutive years in a regional Health Authority in Italy. About 0.5% of the population observed received triptans prescriptions in a year, but > 50% of the cases received only one prescription. On the other hand, 46% of triptan users did not receive a triptan prescription in the following year (past users): in 80% of cases, patients received only 1-2 triptan packages. The evaluation of the discontinued triptan type has shown percentages varying between 30 and 70%. The percentage of triptan users who received a triptan prescription for the first time in the successive year of study (new users) was 52%. These findings together highlight a high turnover in triptans utilization. Less than 15% of subjects received more than one triptan product in the 2 years. In conclusion, we observed a low percentage of triptan users and a low rate of utilization, associated with a high percentage of discontinuation and new utilization (high turnover), without any substantial increase in triptans utilization during the years. All these data probably do not support optimal satisfaction with triptan therapy.

PMID: 19732070 [PubMed - indexed for MEDLINE]

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posted by Dr Shapira at 8:27 AM

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