TREATMENT OF TRIGEMINAL AUTONOMIC CEPHALGIAS: NEUROMUSCULAR DENTISTRY ALTERNATIVE TO IMPLANTED SUPRAORBITAL/SUPRATROCHLEAR NEUROMODULATION

A recent article in neuromodulation is a case study of five patients with implanted neuromodulators. The good news is that there is hope when all other treatments failures but there can be numerous complications as noted in pubmed abstract that follows. The devices must be removed for diagnostic MRI. Some patients required multiple applications but the systems were effective in major pain relief and reduction or elimination of opiod use.

Neuromuscular Dentistry offers a less invasive and frequently extremely effective alternative treatment. A diagnostic neuromuscular orthotic is retained by the lower teeth and alters the input to the trigeminal nervous system. The trigeminal nervous system acts as an input/output for our brain. Approximately 50 % of all brain input comes from the periodontal ligaments and the muscles of the trigeminal nervous system. Neuromuscular dentistry does utilize the use of a nonimplanted neuromuscular stimulator in the form of ULF TENS. This allows relaxation of trigeminally innervated muscles and the autonomic system follows suit. In computer lingo these headaches are I/O errors or input output erros. GARBAGE IN- GARBAGE OUT IS BAD INFO INTO COMPUTER GIVES BAD OUTPUT. Nociceptive inputs are eliminated with the diagnostic orthotic and stabilized. SPG (Sphenopalatine Ganglion blocks) Blocks are frequently used in combination with a neuromuscular orthotic when there is not rapid relief of all symptoms.

The beauty of the SPG Block is that it can be easily performed by patients to prevent episodes and does not require opiods or dangerous neurologic medications but utilizes lidocaine and administered by a hollow cotton swab.

I propose that a neuromuscular diagnostic orthotic should be considered a first linr treatment priot to invasive procedures. A sleep study should be used to rule out obstructive sleep apnea, hypopnea, UARS (upper airway resistance syndrome) and RERAs or respiratory related arousals that are frequently present in these patients and associated with their disorders.

PUBMED ABSTRACT:

Neuromodulation. 2012 May 2. doi: 10.1111/j.1525-1403.2012.00455.x. [Epub ahead of print]

The Treatment of Medically Intractable Trigeminal Autonomic Cephalalgia With Supraorbital/Supratrochlear Stimulation: A Retrospective Case Series.

Vaisman J, Markley H, Ordia J, Deer T.

Source

Pain and Wellness Center, Peabody, MA, USA; New England Regional Headache Center, Worcester, MA, USA; and The Center for Pain Relief, Charleston, WV, USA.

Abstract

Introduction:  This is a retrospective case series of five patients with intractable trigeminal autonomic cephalalgia (TAC) who were implanted with a supraorbital/supratrochlear neuromodulation system. Objectives:  The aim of this Institutional Review Board-approved study was to investigate the percentage of pain relief, treatment response, pain level, work status, medication intake, implantation technique, lead placement, programming information, and device use. Results:  Trial stimulation led to implantation of all five patients. All patients reported improvement in their functional status in regard to activities of daily living. The device was revised in two patients due to skin erosion. It was later reimplanted in both patients due to worsening of symptoms, again with good pain relief. The device was explanted in two other patients because of the need to perform a magnetic resonance imaging or implant an automatic implantable cardioverter defibrillator. The follow-up of the patients ranged between 18 months and 36 months, with a mean of 25.2 months. There was no change in work status. Following the implant, the Visual Analog Scale score was reduced to a mean of 1.6 from an initial mean score of 8.9. Three patients were completely weaned off opioid medications, while two patients continued to take opioid at a lower dosage. All patients experienced a decrease of the adjuvant neuropathic drugs. Conclusion:  Supraorbital/supratrochlear nervestimulation appears to be a promising modality for the treatment of patients with intractable TAC.

© 2012 International Neuromodulation Society.

PMID:

22551506

[PubMed - as supplied by publisher]

Cluster Headache Relief With Sphenopalatine Ganglion Block

A recent article reported on the treatment of cluster headaches with Sphenopalatine Ganglion Blocks. While neuromuscular diagnostic orthotics may relieve or eliminate cluster headaches they may still require treatment on occasion. I frequently teach my patients how to self administer the blocks intranasally with cotton tip applicators. The PubMed abstract is at the end of the blog. J Med Case Rep. 2012 Feb 15;6:64:e23-27 Cluster headache with ptosis responsive to intranasal lidocaine application: a case report.


Another recent article discussed use of sphenopalatine ganglion blocks when doing sinus endoscopic surgery and showed a 50% reduction in time in recovery. What the paper did not mention was that frequently chronic sinus pressure, pain and/or headaches can be treated or eliminated with SPG (sphenoalatine ganglion) Blocks without surgery. J Med Case Rep. 2012 Feb 15;6: Cluster headache with ptosis responsive to intranasal lidocaine application: a case report.

Neuromuscular Dentistry as part of a comprehensive treatment of TMJ (TMD) disorder treatment is extremely effective in eliminating chronic daily migraine and tension headaches and chronic sinus and facial pain. It frequently eliminates or r lessens the frequency of episodic pain. SPG blocks are an easily self administered technique that patients accept and that has a very high margin of safety.

J Med Case Rep. 2012 Feb 15;6:64.

Cluster headache with ptosis responsive to intranasal lidocaine application: a case report.

Bakbak B, Gedik S, Koktekir BE, Okka M.

Source

Department of Ophthalmology, Selcuk University Selcuklu Medical Faculty, Konya, Turkey. drberkerbakbak@yahoo.com.

Abstract

ABSTRACT:

INTRODUCTION:

The application of lidocaine to the nasal mucosal area corresponding to the sphenopalatine fossa has been shown to be effective at extinguishing pain attacks in patients with a cluster headache. In this report, the effectiveness of local administration of lidocaine on cluster headache attacks as a symptomatic treatment of this disorder is discussed. CASES

PRESENTATION:

A 22-year-old Turkish man presented with a five-year history of severe, repeated, unilateral periorbital pain and headache, diagnosed as a typical cluster headache. He suffered from rhinorrhea, lacrimation and ptosis during headaches. He had tried several unsuccessful daily medications. We applied a cotton tip with lidocaine hydrochloride into his left nostril for 10 minutes. The ptosis responded to the treatment and the intensity of his headache decreased.

CONCLUSION:

Intranasal lidocaine is a useful treatment for the acute management of a cluster headache. Intranasal lidocaine blocks the neural transmission of the sphenopalatine ganglion, which contributes to the trigeminal nerve as well as containing both parasympathetic and sympathetic fibers.

Am J Rhinol Allergy. 2012 Jan-Feb;26(1):e23-7.

Bilateral sphenopalatine ganglion blockade improves postoperative analgesia after endoscopic sinus surgery.

DeMaria S Jr, Govindaraj S, Chinosorvatana N, Kang S, Levine AI.

Source

Department of Anesthesiology, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA. samuel.demaria@mountsinai.org

Abstract

BACKGROUND:

Endoscopic sinus surgery (ESS) is a common procedure preferably done with an anesthetic technique ensuring effective postoperative analgesia while speeding discharge home. Although anesthesia administered locally in conjunction with vasoconstricting agents is known to minimize intraoperative bleeding, its usefulness in providing postoperative analgesia has not been well characterized. The results supporting the use of regional anesthesia for sinus surgery have also been limited. Using a randomized, double-blinded and placebo-controlled design, we evaluated recovery times, opioid consumption, and nausea and vomiting after ESS when patients were randomized to either general anesthesia (GA) alone or with regional blockade.

METHODS:

Subjects were 70 adults scheduled for sinus surgery. All participants underwent propofol/remifentanil/nitrous oxide anesthesia and similar intraoperative care. Patients received either GA alone or with sphenopalatine ganglion (SPG) blocks in a double-masked study design. Independent observers recorded readiness for discharge, incidence of nausea/vomiting, and pain scores every 15 minutes until discharge. Overall opioid use in the recovery area was also a secondary end point. Twenty-four hours later, patients were called and asked to rate their pain and overall satisfaction with their pain control.

RESULTS:

Block group participants were considered ready for discharge after 45 minutes and discharged from the hospital ∼40 minutes sooner than GA group participants. The block group required less total fentanyl in the recovery room than did the GA group. The incidences of nausea and vomiting did not differ significantly. Data at 24 hours postoperatively did not differ significantly between groups but trended toward increased satisfaction in the block group. No lasting adverse events were observed.

CONCLUSION:

Regional anesthesia using targeted nerve blocks is effective in ESS. The combination of GA and SPG blockade appears to shorten hospital stay and reduce narcotic requirements in the recovery area. No demonstrable benefits were observed after 24 hours regarding pain management.

TMJ, TMD, Headaches and Fibromyalgia: Is Neuromuscular Dentistry a Cure?

A recent article in the Journal of Craniofacial Surgery ties symptoms of TMJ disorders and Fibromyalgia. The article suggests that "the need for an integrated diagnosis and treatment of these patients, which suggest that the FM could be a medium- or long-term risk factor for the development of TMD." What is also known is that Fibromyalgia is frequently related a sleep disorders.

The National Heart Lung and Blood Institue of the NIH published a report that considers Sleep apnea to be a TMJ disorder. The paper "Cardiovascular and Sleep Related Consequences of Temporomandibular Disorders" suggests that fibromyalgia may actuallly be a consequence of TMJ disorders. While Fibromyalgia is often difficult to treat the TMJ and Headache component is usually very responsive to Neuromuscular Dental Treatment. It is not uncommon to see many other fibromyalgia symptoms self correct after treatment of the TMD and Jaw muscular components.

I suggest that all Fibromyalgia patients should be fitted with Diagnostic Neuromuscular Orthotics as an integral part of the diagnostic and treatment sequences. Patients report signifcant and often life changing symptom reduction after reversible treatment with a neuromuscular diagnostic orthotic.

J Craniofac Surg. 2012 Mar;23(2):615-8.

Signs and symptoms of temporomandibular dysfunction in fibromyalgic patients.

Fraga BP, Santos EB, Farias Neto JP, Macieira JC, Quintans LJ Jr, Onofre AS, De Santana JM, Martins-Filho PR, Bonjardim LR.

Source

From the *Health Science, Federal University of Sergipe, Aracaju, Sergipe; †Department of Nursing, University of São Paulo, São Paulo; and Departments of ‡Physical Therapy, §Medicine, and ∥Physiology, Federal University of Sergipe, Aracaju, Sergipe, Brazil.

Abstract

OBJECTIVE:

The objective of this study was to determine the frequency of signs and symptoms of temporomandibular disorder (TMD) in fibromyalgic patients.

METHODS:

Sixty subjects of both sexes (mean age, 49.2 ± 13.8 years) with fibromyalgia (FM) diagnosis were included in this study. All patients were examined by a calibrated investigator to identify the presence of TMD using the Research Diagnostic Criteria for TMD.

RESULTS:

The most common signs (A) and symptoms (B) reported by FM patients were (A) pain in the masticatory muscles (masseter, 80%; posterior digastric, 76.7%), pain in the temporomandibular joint (83.3%), and 33.3% and 28.3%, respectively, presented joint sounds when opening and closing the mouth; (B) headache (97%) and facial pain (81.7%). In regard to the classic triad for the diagnosis of the TMD, it was found that 35% of the FM patients presented, at the same time, pain, joint sounds, and alteration of the mandibular movements. It was verified that myofascial pain without limitation of mouth opening was the most prevalent diagnosis (47%) for the RDC subgroup I. For the subgroup II, the disk displacement with reduction was the most prevalent diagnosis (21.6%). For the subgroup III, 36.7% of the subjects presented osteoarthritis.

CONCLUSIONS:

Thus, there is a high prevalence of signs and symptoms of TMD in FM patients, indicating the need for an integrated diagnosis and treatment of these patients, which suggest that the FM could be a medium- or long-term risk factor for the development of TMD.

Chicago: Headaches, TMJ, TMD, and Neuromuscular Dentistry

Treatment of Chronic Daily Headaches, Tension Headaches, morning headaches and Migraines is frequently is best done thru Neuromuscular Dentistry. All of the disorders mentioned are largely under the influence of the Trigeminal Nervous System.

Neuromuscular Dentists use diagnostics neuromuscular orthotics to allow the Jaw Joints (TMJ, Temporomandibular Joints, TM Joints), the Jaw muscles (stomatognathic muscles), Cervical (NECK) Muscles and nervous system to heal. The use of reversible treatment initially is crucially important to allow correction of the entire postural chain.

Dentists and Physicians do not "heal" their patients but rather remove the impediments to healing. As healing occurs and pain decreases patients experience a feeling of well being. This feeling of well being is as important as the reductions in pain. This feeling of well being is the result of decreases in nociceptive input to the brain. The brain works like a computer and nociceptive input creates negative feedback. In IT language this is an I/O (input/output) error. The expression Garbage In - Garbage Out used to describe I/O errors can also be used to explain how incompatible neuromuscular jaw function creates headaches, migraines, stress, anxiety and sleep disorders.

The Aqualizer Appliance, Neuromuscular Dentistry and Muscle Engrams

An important new article on Muscle Engrams was published in the October Cranio Journal (pubmed abstract follows).

This paper was written by my good friend and respected colleague Dr Martin Lerman who is also the inventor of the Aqualizer appliance. Dr Lerman has proven that the muscle engrams of neuromuscular dentistry as described by Dr Barney Jankelson exist. While Dr Jankelson utilized ULF TENS (ultra low frequency trancutaneous electrical neurostimulation) to eliminate the muscle activity of the Engram Dr Lerman utilizes an Aqualizer Appliance.

An interesting side note is that Dr Jankelson used to use Aqualizers with his patients on TENS prior to taking a bite. The Engram is the way the body masquerades bite discrepancies by correction thru conditioned muscle reflex. As Dr Lerman clearly shows eliminating the Engram is an essential step evaluating underlying neuromuscular bite discrepancies. The Aqualizer which utilizes Pascal's third law balances pressure bilaterally by fluid dynamics. Pitch Roll and Yaw are corrected.

Patients with TMJ disorders, headaches, facial pain, masticatory muscle pain or neck pain will all find that Engrams are an obstacle to healing. Elimination of the Engram and correction of the (engram free) bite will lead to healing and elimination of pain.

This is an important article and I will discuss it in more detail in the future.

Elimination of headaches, Migraines and facial pain by identifying and bypassing Engrams is the heart of Neuromuscular Dentistry. Read more about Neuromuscular Dentistry in Sleep and Health Journal online @

http://www.sleepandhealth.com/neuromuscular-dentistry

Cranio. 2011 Oct;29(4):297-303.

The muscle engram: the reflex that limits conventional occlusal treatment.

Lerman MD.

Source

Jumar Corporation, Prescott, Arizona, USA. lesboblyn@aol.com

Abstract

The engram (the masticatory "muscle memory") is shown to be a conditionable reflex whose muscle conditioning lasts less than two minutes, far shorter than previously thought. This reflex, reinforced and stored in the masticatory muscles at every swallow, adjusts masticatory muscle activity to guide the lower arch unerringly into its ICP. These muscle adjustments compensate for the continually changing intemal and external factors that affect the mandible's entry into the ICP. A simple quick experiment described in this article isolates the engram, enabling the reader to see its action clearly for the first time. It is urged that every reader perform this experiment. This experiment shows how the engram, by hiding the masticatory muscles' reaction (the hit-and-slide), limits the success of the therapist in achieving occlusion-muscle compatibility. This finding has major clinical implications. It means that, as regards the muscle aspect of treating occlusion, the dentist treating occlusion conventionally is working blind, a situation the neuromuscular school of occlusal thought seeks to correct. The controversy over occlusion continues.

Occipital Nerve Block Effective in treating and eliminating a variety of headaches.

Ihave been treating chronic headches , neuralgias and facial pain with occipital nerve blocks and greater occipital nerve blocks for many years. This study showed less effectiveness in treating facial pain and neuralgias.

A major problem with many studies is that they ty to minimize the number of variables. While this is good for clinical studies to determine effectiveness of single treatments it is detrimental in comprehensive patient care.

I frequently combine occipital nerve blocks with ULF TENS, Diagnostic Orthotics, Trigger Point injections and SPG blocks. There is enormous crossover in symptoms as well as neural connections that are excitatory or inhibitoy between these structures..

Blocks and combinations of blocks and trigger points utilized with a diagnostic neuromuscular orthotic and ULF TENS give almost universal improvement and frequently elimination of symptoms. These combinations are appropriate for treating chronic pain, especially tension-type headaches, migraines, cluster headaches and autonomic cephalgias.

I will usually teach patients how to block the SPG (sphenopalatine ganglion) at home to prevent headaches and migraines when the diagnostic orthotic doesn't eliminate the headaches completely.

J Headache Pain. 2012 Mar 3. [Epub ahead of print]

Occipital nerve block is effective in craniofacial neuralgias but not in idiopathic persistent facial pain.

Jürgens TP, Müller P, Seedorf H, Regelsberger J, May A.

Source

Department of Systems Neuroscience, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

Abstract

Occipital nerve block (ONB) has been used in several primary headache syndromes with good results. Information on its effects in facial pain is sparse. In this chart review, the efficacy of ONB using lidocaine and dexamethasone was evaluated in 20 patients with craniofacial pain syndromes comprising 8 patients with trigeminal neuralgia, 6 with trigeminal neuropathic pain, 5 with persistent idiopathic facial pain and 1 with occipital neuralgia. Response was defined as an at least 50% reduction of original pain. Mean response rate was 55% with greatest efficacy in trigeminal(75%) and occipital neuralgia (100%) and less efficacy in trigeminal neuropathic pain (50%) and persistent idiopathic facial pain (20%). The effects lasted for an average of 27 days with sustained benefits for 69, 77 and 107 days in three patients. Side effects were reported in 50%, albeit transient and mild in nature. ONBs are effective in trigeminal pain involving the second and third branch and seem to be most effective in craniofacial neuralgias. They should be considered in facial pain before more invasive approaches, such as thermocoagulation or vascular decompression, are performed, given that side effects are mild and the procedure is minimally invasive.

PMID:

22383125

[PubMed - as supplied by publisher]

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Study Shows that Cluster Headaches Mediated By Trigeminal Nerve

This study confirms the role of the trigeminal nerve in cluster headaches. A diagnostic neuromuscular orthotic is a reasonable and positive step in confirming not only trigeminal involvement but may alleviate or eliminate cluster headaches. A negative result from a neuromuscular diagnostic orthotic can be followed by addition of a SPG block with safe lidocaine.

In my experience almost all patients have a positive response to SPG blocks (spenopalatine ganglion blocks) or neuromuscular orthotics. Combination of these treatments brings about almost universal sucess of varying levels.

Neurology. 2012 Mar 14. [Epub ahead of print]

Lateralized central facilitation of trigeminal nociception in cluster headache.

Holle D, Gaul C, Zillessen S, Naegel S, Krebs S, Diener HC, Kaube H, Katsarava Z, Obermann M.

Source

From the Department of Neurology (D.H., C.G., S.Z., S.N., S.K., H.-C.D., Z.K., M.O.), University of Duisburg-Essen, Essen; and Interdisciplinary Pain Center (H.K.), University of Freiburg, Freiburg, Germany.

Abstract

OBJECTIVE:

To investigate whether central facilitation of trigeminal pain processing is part of the pathophysiology of cluster headache (CH).

METHODS:

Sixty-six patients with CH (18 episodic CH inside bout, 28 episodic CH outside bout, 20 chronic CH) according to the International Classification of Headache Disorders-II classification, as well as 30 healthy controls, were investigated in a case-control study using simultaneous recordings of the nociceptive blink reflex (nBR) and pain-related evoked potentials (PREP) following nociceptive electrical stimulation on both sides of the forehead (V1).

RESULTS:

nBR latency ratio (headache side/nonheadache side) was decreased in all CH patients independent from CH subtype compared with healthy controls indicating central facilitation at brainstem level. Area under the curve ratio was increased in patients with episodic CH inside bout only. PREP showed decreased N2 latency ratio in patients with chronic CH indicating central facilitation at supraspinal (thalamic or cortical) level.

CONCLUSIONS:

Asymmetric facilitation of trigeminal nociceptive processing predominantly on brainstem level was detected in patients with CH. This alteration is most pronounced in the acute pain phase of the disease, but appears to persist in remission periods. Only chronic CH patients show additional changes of PREP prompting to supraspinal changes of pain processing related to the chronic state of disease in regard to neuronal plasticity, which exceeds changes observed in episodic CH.

PMID:

22422891

[PubMed - as supplied by publisher]