Headaches, Migraines, TMJ, TMD and other CranioMandibular Disorders

This article in the clinical journal of pain makes clear the comorbidities of Headache and TMD. They also show a high correlation of TMD to Migraines.

The article points to central facilitation of nociceptive input in headache syndromes. This is what I call an input/output or I/o error.

"TMD, TMD subtypes, and TMD severity are independently associated with specific headache syndromes and with headache frequency. This differential association suggests that the presence of central facilitation of nociceptive inputs may be of importance, as positive association was observed only when muscular TMD pain was involved."

Clin J Pain. 2011 Sep;27(7):611-5.

Temporomandibular disorders are differentially associated with headache diagnoses: a controlled study.

Gonçalves DA, Camparis CM, Speciali JG, Franco AL, Castanharo SM, Bigal ME.

Source

Department of Dental Materials and Prosthodontics, Araraquara Dental School, Sao Paulo State University, São Paulo, Brazil. danielagg@foar.unesp.br

Abstract

OBJECTIVES:

Temporomandibular disorders (TMDs) are considered to be comorbid with headaches. Earlier population studies have suggested thatTMD may also be a risk factor for migraine progression. If that is true, TMD should be associated with specific headache syndromes (eg, migraineand chronic migraine), but not with headaches overall. Accordingly, our aim was to explore the relationship between TMD subtypes and severity with primary headaches in a controlled clinical study.

METHODS:

The sample consisted of 300 individuals. TMDs were assessed using the Research Diagnostic Criteria for TMD, and primary headache was classified according to International Classification for Headache Disorders-2. Univariate and multivariate models assessed headache diagnoses and frequency as a function of the parameters of TMD.

RESULTS:

Relative to those without TMD, individuals with myofascial TMD were significantly more likely to have chronic daily headaches (CDHs) [relative risk (RR)=7.8; 95% confidence interval (CI), 3.1-19.6], migraine (RR=4.4; 95% CI, 1.7-11.7), and episodic tension-type headache (RR=4.4; 95% CI, 1.5-12.6). Grade of TMD pain was associated with increased odds of CDH (P<0.0001), migraine (P<0.0001), and episodic tension-type headache (P<0.05). TMD severity was also associated with headache frequency. In multivariate analyses, TMD was associated with migraine and CDH (P=0.001). Painful TMD (P=0.0034) and grade of TMD pain (P<0.001) were associated with headache frequency.

DISCUSSION:

TMD, TMD subtypes, and TMD severity are independently associated with specific headache syndromes and with headache frequency. This differential association suggests that the presence of central facilitation of nociceptive inputs may be of importance, as positive association was observed only when muscular TMD pain was involved.

PMID:

21368664

[PubMed - indexed for MEDLINE]

My Headaches Are Destroying My Relationships and My Family

From www. IHATEHeadaches.org e-mail

Susan: I have been having severe chronic daily headaches for over 5 years. I have been diagnosed as sinus headaches, migraines, atypical migraines, TMJ, Trigeminal Neuralgia. I have had numerous CAT Scans and MRI that all appear normal. I have tried multiple medications that seem to slightly ease the pain on a temporay basis but I do not remember the last time I was pain free. My marital life is a mess and my husband doesn't understand how I can have so much pain when all the tests are normal. I am constantly yelling at the kids and the feel horribly guilty. My friends have all but cut off contact but it is probably my fault. I wish the scans could find a tumor so everyone would know the pain was real.
I'm desperate but that just seems to make the pain even worse.

Dr Shapira:
Susan, Please do not give up. I have heard many stories similar to yours. First, because all of the tests have been negative for disease there is excellent hope for significant improvement.. I suggest you seek out a Neuromuscular Dentist who also understands chronic Myofascial Pain and the use of Trigger Point Injections, Sphenopalatine Ganglion Blocks, Spray and stretch techniques.

Susan, it is important to understand that eliminating your pain is not a cure. You have been forever changed by the hell you have been experiencing. The only real cure would be a do-over on the last five years of your life. The goal of treatment is eliminate pain and restore quality to your life and allow you to reconnect with your husband, children, family and friends. The pain you have lived with has changed who you are forever but that may just make you appreciate your life more in the future.

The medical model for Chronic Headaches is diagnostic test and then perscription medicine. I find that patients who have symptoms you describe are easier to treat than expected. I usually spend 1-2 hours on an initial consultation with new patients. Initially we talk so I can understand who you are, how the pain is affecting you, your life and your family. The next part of the consultation is to try to eliminate some or all of the pain you are experiencing at that time.

I usually begin with trigger point deactivation of the cranial and upper body muscles. It is amazing how frequently we can elimnate all or most of the pain just by utilizing techniques described by Dr Janet Travell over 50 years ago. Dt Travell was President John F Kennedy's physician.

The majority of all pain patients experience is muscular in orgin, and turning off the pain allows us to understand the undrlying processes. At this same visit we will make a trial change of proprioception into the central nervous system from the trigeminal nerves.

We can usually eliminate most pain during the first visit the hard work is to make these changes on a long term basis. I tell my patients to set a goal of 50-80% reduction in pain initially. As treatment progresses we continually try to remove 50-80% of remaining pain. This is accomplished by utilizing a diagnostic neuromuscular orthotic to change how the muscles function and to alter trigeminal nerve proprioceptive input to the brain.  Over time there are postural changes and healing.

I often find that I "meet" my patients at the third or fourth appointment.  The patient I meet initially is the person living in pain for months or years but after a few visits I meet the real person who was lost under an avalanche of pain.  There is a great joy in watching people recover and regain their lives.

I practice Neuromuscular Dentistry and Pain Treatment as part of my Chicago area TMJ practice.

SINUS PAIN MISDIAGNOSIS: New Research Your Sinus Headaches or Facial Pain Are Probably Not From Your Sinus

Millions of patients treated for headaches have been diagnosed with sinus headaches or facial pain.  A new article in Curr Opin Otolaryngol Head Neck Surg. 2014 Dec 16 reveals that the majority of patients probably are not having sinus headaches .  The official term used in the article is Rhinogenic or coming from nasal origin or non-rhinogenic or not coming from the nose.  Please see the PubMed Abstract at the end of this blog.

While this study concludes that most of these headaches are not a primary nasal problem that does not mean that the headache does not have an effect on the sinuses and the nose.

Almost 100% of all headaches are connected to Trigeminal Nerves.  The Trigeminal Nerve is often called the Dentists Nerve because the two Largest branches are the Maxillary Nerve and the Mandibular Nerve that go to the Jaw Joints (TMJ) , The Jaw Muscles, the teeth, the gums, the periodontal ligaments and the tongue.  These are the nerves your dentist anaesthisizes for dental work.  A third branch is the Opthalmic Branch.  The sinuses are innervated by fibers from the Maxillary Branch and the Opthalmic Branch of the Trigeminal Nerve.

Another branch of the Trigeminal Nerve controls the blood flow to the anterior two thirds of the meninges of the brain.  Migaines and vascular headaches are controlled by the Trigeminal Nerve.
There is also an autonomic portion of the Trigeminal Nerve that passes thru the Sphenoalatine Ganglion (SPG).  The SPG Block is known to be extremely effective in treating and eliminating not just migraines but also chronic daily headaches, sous headaches, tension headaches and other autonomic headaches.  Learn more at www.thinkbetterlife.com to www.ihateheadaches.org

The input from the Trigeminal Nerves to the brain account for over 50% of total input after a,plification in the Reticular Activating System.  Noxius input can come in from any of the branches of the Trigeminal Nerve but the biggest input is from the Maxillary and Mandibular banshees through propriocetion in the periodontal ligament s and from muscles and joints.  TMJ disorders (TMD) have long been called The Great Imposter because the can come out as so many different types of pain.  Sinus Pain and Sinus Headaches are frequently related to myofascial pain or TMJoint pain.

This new study confirms this frequent misdiagnosis.  Patients who have been diagnosed with sinus headaches should consider being evaluated for a TMJ disorder by a Neuromuscular Dentist.  The most frequent cause of sinus pain is actually referred pain usually from Trigeminally innervated structures.  The lining of the sinus is also innervated by the Trigeminal Nerve leading to the confusion on the source of pain. 

Please read these articles for more information.

TMJ Alias, The Great Imposter, Has a Co-Conspirator: Poor Sleep ......Is Dr Shapira's guest editorial in Cranio Journal

Sat, 02/02/2013 - 09:36 — ilshapira  can be found at http://www.sleepandhealth.com/node/613

SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR

http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

Curr Opin Otolaryngol Head Neck Surg. 2014 Dec 16. [Epub ahead of print]

Rhinogenic and nonrhinogenic headaches.

Agius AM1, Sama A.

Author information

Abstract

PURPOSE OF REVIEW:

To review the present knowledge and the recent publications on the cause, characteristics, course and treatment of chronic and recurring facial pain and headaches. Facial pain is amongst the commonest complaints in ear, nose and throat clinics. Recent articles have presented important evidence-based approach to this common problem.

RECENT FINDINGS:

Recent publications in the fields of otolaryngology and neurology have better defined the differences between rhinogenic and nonrhinogenic facial pain, and place this symptom in the context of rhinosinusitis. Although chronic facial pain has conventionally been considered to be due to sinusitis because of anatomical proximity, there is increasing evidence to support the contrary. Published literature has identified that only 16-20% of patients with sinusitis (purulent or with polyposis) confirmed by nasal endoscopy actually declared symptoms of facial pain. More pertinently, surgical series have shown that up to 40% of patients had persistent postoperative facial pain despite resolution of sinusitis on nasal endoscopy and computed tomography (CT). Rhinogenic pain is generally unilateral, severe, located on the same side and related to rhinogenic symptoms, and almost always accompanied by endoscopic and CT abnormalities. Incidental CT mucosal disease can be noted in 30% of asymptomatic patients.

SUMMARY:

Traditionally, facial pain has often been considered to be caused by chronic rhinosinusitis. Increasing evidence has shown that the commonest cause for chronic facial pain is of nonrhinogenic origin. As otorhinolaryngologists, we deal with facial pain on a daily basis and therefore need to be aware of the different causes for this common symptom.

The following Clinical trial has been discontinued prior to enrollment.

Rhinogenic Headache Improvement After Nasal Operation (RHINO)

This study has been withdrawn prior to enrollment.

(slow accrual)

Sponsor:

University of Missouri-Columbia

Information provided by:

University of Missouri-Columbia

ClinicalTrials.gov Identifier:

NCT00580307

First received: December 12, 2007

Last updated: February 24, 2011

Last verified: February 2011

History of Changes

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  Purpose

Objective: To determine the efficacy of surgical correction of intranasal mucosal contact points in improving quality of life and decreasing medication use in patients with rhinogenic headaches.

Significance: Chronic, debilitating headaches that resist maximal medical treatment by various headache specialists are sometimes linked to structural anomalies within the nose that exert pressure on apposing mucosal surfaces. A number of otolaryngologists have reported success in alleviating rhinogenic headaches with contact point correction surgery. This practice is supported by anecdotal reports along with retrospective and observational studies; however, a prospective study with an appropriate surgical control group has not been conducted. Because the specific effect of contact point correction has not yet been differentiated from the placebo effect of surgery itself, many headache specialists are reluctant to recommend surgical evaluation for their patients. To demonstrate the efficacy of contact point correction surgery to both the headache and otolaryngology communities - and thus, to make this treatment option more widely available to rhinogenic headache sufferers - a randomized controlled trial is needed.

Prolotherapy for Cervical and TMJoint (TMJ) Stability

A recent article (pubmed abstract below) on chronic neck pain should be of great interest to anyone suffering from chronic neck pain, cervicogenic headaches and / or TMJ (TMD).  It is well understood that there are postural implications to both of these disorders and that much of the pain is actually muscular in origin.  So what is the place of prolotherapy or proliferation therapy in treating cervical or TMJoint pain.

See my Highland Park website http://www.thinkbetterlife.com for more information on these topics.

The answer is in stability.  There are numerous functions of the muscles besides moving our body parts.  Muscle Splinting occurs when the muscles tighten to protect an injured joint.  This is a fantastic ability of muscles but when they do it for a long time they experience chronic muscle shortening and develop taut bands and/ or trigger points.  This is one possible  origin of a case of  Myofascial Pain and Dysfunction.  Too much of a good thing creates a problem.  The reason it is so important that the neck and jaw be treated together is for healing of ligament laxity.

I utilize Prolotherapy to tighten lax ligaments but we must also remove the repetitive strain injuries that create lax ligaments.

The following paragraphs by my friend Dr Mark Freund address the compilex relationship of jaw to neck.  Add in ligament laxity and the pot starts to boil.

How can my neck pain be TMJ Dysfunction?

Your jaw has a very powerful influence on the structure and posture of your body. Your body has an innate responsibility to preserve your teeth. Imagine if your bite was so far off that your teeth constantly met so poorly that you started to crack all your teeth and eventually lost all of them. You would most likely starve to death without repairs or dentures. Now imagine what your body does instinctively to preserve your teeth. First, your neck becomes distorted to ensure that your lower teeth and upper teeth meet properly. Next, you develop a new head position to preserve this bite. The lower part of your spine must compensate for the altered head position so you develop a postural abnormality which includes the muscles in the neck and back being strained to hold the head in the proper bite-preserving position. The long term pulling and postural changes result in the standard TMJ complaints: Cranial Distortions, Forward Head Posture, Headaches, Pain or tenderness in the face, jaw joint area, neck and shoulders, Difficulty chewing, Facial Swelling, Postural Distortions and Scoliosis.

These complaints are best address with the team approach involving interaction between a Dentist performing proper bite changes and a Chiropractor aligning the spine and manipulating the cranium into a neutral position. Dr. Mark Freund's approach to TMD (Temporal Mandibular Joint Dysfunction) is only shared by a small number of practitioners throughout the country due to the tremendous amount of education and study required. Dr. Freund practices the upper cervical technique called Atlas Orthogonal which is a very precise, specific gentle instrument adjustment of the top-most segment of the spine. This protocol does not involve hand manipulation of the neck and is extremely safe. Additionally Dr. Freund has undergone extensive education both domestic and internationally alongside Dental professionals, Physical Therapists, Doctors of Osteopathy and Chiropractors. The unique practice of making spinal corrections concurrent with bite changes is one of the most important elements of treating TMJ. Unfortunately not many practitioners are aware of this practice or its' importance.

Mark J. Freund, DC, BCAO

Natural Care Chiropractic, PC

847-265-0600

lindenhurstchiropractic.com

Open Orthop J. 2014 Oct 1;8:326-45. doi: 10.2174/1874325001408010326. eCollection 2014.

Chronic neck pain: making the connection between capsular ligament laxity and cervical instability.

Steilen D, Hauser R, Woldin B, Sawyer S.

Author information

Abstract

The use of conventional modalities for chronic neck pain remains debatable, primarily because most treatments have had limited success. We conducted a review of the literature published up to December 2013 on the diagnostic and treatment modalities of disorders related to chronic neck pain and concluded that, despite providing temporary relief of symptoms, these treatments do not address the specific problems of healing and are not likely to offer long-term cures. The objectives of this narrative review are to provide an overview of chronic neck pain as it relates to cervical instability, to describe the anatomical features of the cervical spine and the impact of capsular ligament laxity, to discuss the disorders causing chronic neck pain and their current treatments, and lastly, to present prolotherapy as a viable treatment option that heals injured ligaments, restores stability to the spine, and resolves chronic neck pain. The capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Chronic neck pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions described herein, including disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, postconcussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches. In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain. In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability. Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Currently, curative treatment options for this type of cervical instability are inconclusive and inadequate. Based on clinical studies and experience with patients who have visited our chronic pain clinic with complaints of chronic neck pain, we contend that prolotherapy offers a potentially curative treatment option for chronic neck pain related to capsular ligament laxity and underlying cervical instability.

KEYWORDS:

Atlanto-axial joint; Barré- Liéou syndrome; C1-C2 facet joint; capsular ligament laxity; cervical instability; cervical radiculopathy; chronic neck pain; facet joints; post-concussion syndrome; prolotherapy; spondylosis; vertebrobasilar insufficiency; whiplash.

TMJ (TemporoMandibular Disorders) and Ovarian Hormones

It is well known that the majority of patients complaining of TMJ Disorders are women even though the anatomy of men and women tend to be very similar.  It is also know that there are estrogen receptors in the TemporoMandibular Joints (TMJ)

A recent article in Pain  discussed the fact that in general most non-cancer pain is more frequent in women as well.  I have frequently found that in premenopausal women it is easy to get near total relief of Chronic Daily Headaches and Status Migraine for up to 25-28 days a month but that it is much harder to completely eliminate pain during ovulation and around menses.

While total pain relief is not immediately achieved the frequency and severity of headaches during those times do gradually decrease over time.  I have found that even the most severe hormonal headaches respond to a Neuromuscular Diagnostic Orthotic.

The Sphenopalatine Ganglion Block can be effective in relieving pain related to hormonal fluctuations. The SPG block has also been shown to be effective in treating anxiety both event related and general trait anxiety.

A great deal of problems may relate to the quality of sleep of women with TMJ Disorders.  The NHLBI published a report on the link between sleep disordered breathing and TMJ disorders.  There is a vast amount of literature that relates the sleep quality to hormonal regulation.

THE IMPORTANCE OF EVALUATING ALL FEMALE FIBROMYALGIA AND  TMJ FOR SLEEP DISORDERED BREATHING  CAN NOT BE UNDERESTIMATED.  IT IS VITAL CLINICIANS REMEMBER THAT MANY WOMEN HAVE UARS OR UPPER AIRWAY RESISTANCE SYNDROME THAT DISTURBS SLEEP AND WORSENS HORMONAL DISRUPTIONS AND INCREASES PAIN

The abstract of the new article in Pain is included below for your convenience.

Pain. 2014 Dec;155(12):2448-2460. doi: 10.1016/j.pain.2014.08.027. Epub 2014 Aug 27.

Ovarian hormones and chronic pain: A comprehensive review.

Hassan S1, Muere A2, Einstein G3.

Author information

Abstract

Most chronic noncancer pain (CNCP) conditions are more common in women and have been reported to worsen, particularly during the peak reproductive years. This phenomenon suggests that ovarian hormones might play a role in modulating CNCP pain. To this end, we reviewed human literature aiming to assess the potential role of ovarian hormones in modulating the following CNCP conditions: musculoskeletal pain, migraineheadache, temporal mandibular disorder, and pelvic pain. We found 50 relevant clinical studies, the majority of which demonstrated a correlation between hormone changes or treatments and pain intensity, threshold, or symptoms. Taken together, the findings suggest that changes in hormonal levels may well play a role in modulating the severity of CNCP conditions. However, the lack of consistency in study design, methodology, and interpretation of menstrual cycle phases impedes comparison between the studies. Thus, while the literature is highly suggestive of the role of ovarian hormones in modulating CNCP conditions, serious confounds impede a definitive understanding for most conditions except menstrual migraine and endometriosis. It may be that these inconsistencies and the resulting lack of clarity have contributed to the failure of hormonal effects being translated into medical practice for treatment of CNCP conditions.

Copyright © 2014 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

KEYWORDS:

Chronic pain; Chronic pelvic pain; Fibromyalgia; Irritable bowel syndrome; Menstrual cycle; Migraine headache; Ovarian hormones;Temporomandibular joint disorder