TENSION HEADACHE AND TMJ Disorders: Highland Park / Lake Forest NEW OFFICE OPEN December 2014

Tension Headaches are a type of Trigmeminal Nerve innervated muscle contraction headache. They are closely related to TMJ Disorders (TMD) and postural distortions like a forward head position. Tension Headaches and Chronic Daily Headaches are essentially variations of Muscle Contaction Headaches. Frequently severe muscle pain headaches are called Migraines or Atypical Migraines but are in reality primarily caused by muscle trigger points.  My new office dedicated to treatment of TMJ disorders and Sleep apnea  is opening in Highland Park in December 2014

It is important to remember that all muscle contraction headaches are a form of repetitive strain injuries. When there is a postural distortion or bite problem the muscles adapt to protect the whole If there is an acute injury Muscle Splinting will occur. This is where the muscle tighten to protect an injured site.

The good news is that Neuromuscular Dentistry can usually quickly and effectively correct these problems. My new Highland Park office dedicated to treating TMJ disorders, Headaches, Migraines and Sleep Disordered Breathing visitwww.thinkbetterlife.com for more information on TMJ Disorders and Neuromuscular Dentistry. WWW.ihateheadaches.org is another excellent site concerning chronic headaches and correction with Neuromuscular Dentistry.

Muscle Splinting is normal, in fact it is ideal on a short term basis to protect an injured joint, muscle or tendon. Problems arise when Muscle Splinting is no longer needed but Chronic Muscle Contracture occurs. This will often result in Tight Bands in the Muscle and Trigger Points in the tight bands.

Myofascial Pain and Dysfunction is when there is chronic muscle shortening with associated trigger points. It is similar, in many ways to Fibromyalgia but is more regional in nature. TMJ Dysfunction Patients (TMD) frequently have widespread myofascial Pain and Dysfunction throughout the Head, Neck, Shoulders and Upper Back.

Trigger points and muscle problems tend to spread from one area of the body to another as the muscles continually try to adapt to protect the whole. Unfortunately the muscles work past their Adaptive Capacity. When there is widespread muscle pain, taut bands and pain the condition is called Fibromyalgia and it is often treated as a Rheumatic Systemic Disease but frequently it is best addressed one area at a time, correcting function and eventually having the entire system working again as a single unit.

Patients with chronic pain often develop Alpha Intrusion into Delta Sleep which is the marker for Fibromyalgia. The deep sleep is disturbed resulting in increased pain and sympathetic nervous system activity.

Sleep disordered breathing greatly contributes to these problems. Patients may snore loudly or have sleep apnea where they periodically quit breathing but the female patients and younger, thinner heather males and females often have UARS or Upper Airway Resistance Syndrome that leaves them tired and sore and ruins their sleep but without the classic symptoms. Learn more about Sleep Apnea and UARS at www.ihatecpap.com that discusses sleep disordered breathing and comfortable alternatives to CPAP for treating these airway issues.

Sleep Well Illinois is a new company working to do universal sleep screening in Physicians offices to help identify these patients.

TMJ Help Sites; Creating a TMJ Support Group in Highland Park for Chicago and North Suburban TMJ sufferers.

I HATE Headaches.org is the ultimate TMJ Help site for patients with Chronic Headaches.  Patients in the Highland Park/ Lake Forest and Deerfield areas of North Suburban Chicago have a new resource www.thinkbetterlife.com

Dr Shapira would like to create a TMJ support group in the Highland Park Lake Forest area for patients with chronic headaches and/or TMJ disorders.

My new office is at 3500 Western Ave in Highland Park Illinois across from the Fort Sheridan Train Station.  It is dedicated to helping patients with acute and chronic pain problems including headaches, migraines, sleep apnea and TMJ disorders associated with the teeth, jaws, jaw joints and posture

This was originally published as a press release:

Highland Park, IL: Innovative Treatment Protocols for Fast Relief of TMJ (TMD) Disorders: You Deserve a Better Quality of Life

Improving the quality of life of patients from the North Shore and Chicago. You deserve a better life! Thinkbetterlife.com is your doorway to your better life.

Google +0  1  0  7  0

    CHICAGO, IL, October 15, 2014 /24-7PressRelease/ -- Patients who are living with TMJ disorders, TMD and Chronic Tension Headaches, Sinus Pain or Migraines want relief now. http://www.ThinkBetterLife.com is the new website dedicated to patients seeking quick relief and of TMD disorders and headaches. Long term correction of these disorders always starts with quick relief of the current pains.

Many patients think that TMJ (TMD) disorders are only treated with splints. Dr Ira Shapira utilizes a multifaceted approach to giving patients quick and lasting relief from their chronic pain. He utilizes Diagnostic Neuromuscular Orthotics and has over 30 years experience in Neuromuscular Dentistry. He trained with Barney Jankelson the founder of this field and with Bob Jankelson, his son. In addition to utilizing Neuromuscular Dentistry he is one of only a handful of practitioners to utilize SPG Blocks (Sphenopalatine Ganglion Blocks), Trigger Point Injections and Spray and Stretch techniques to treat Myofascial Pain and Muscle pain from Fibromyalgia. He trained with Dr Janet Travell who wrote the book Myofacial Pain and Dysfunction: A Trigger Point Manual.

Dr Shapira spent years doing research into sleep apnea and its connection to jaw position. His early research was done as a Visiting Assistant Professor in the 1980's at Rush Medical School in The Sleep Disorder clinic. He worked closely with Dr Rosalind Cartwright the acknowledged Mother of Dental Sleep Medicine. Dr Cartwright recruited Dr Shapira to return to Rush as an Asst Professor in the 1990's till early this century.

The connections between impaired nasopharyngeal breathing and development of ADD and ADHD in children was the topic of a recent lecture Dr Shapira gave in Buenos Aires, Argentina. The development of chronic TMJ disorders, headaches, migraines and postural distortions were all discussed at his lecture to members of ICCMO, The International College of CranioMandibular Orthopedics of which Dr Shapira is a Fellow and Secretary. Dr Shapira is a representative from ICCMO to the American Alliance of TMD Organizations.

In the 1990's Dr Shapira was a star lecturer for the A4M, The American Academy of Anti-Aging Medicine where he presented his work on the effect of TMJ disorders across ones lifetime. Premature aging and loss of memory and even dementia and Alzheimers disease are part of the same ongoing problem. Sleep Apnea and snoring are types of TMJ disorders according to the National Heart Lung and Blood Institute of the NIH in their report: Cardiovascular and Sleep Related Consequences of Temporomandibular Disorders.

Dr Shapira has been utilizing a multifaceted approach toward relieving chronic pain associated with TMJ disorders for over 30 years and is now bringing his expertise to the North Shore Communities of Chicago. He created www.IHATECPAP.com which addressed Sleep Apnea and snoring and utilizing oral appliances to treat these problems. He also created www.ihateheadaches.org that focuses on many types of headaches and the role of Neuromuscular Dentistry in providing relief of these problems.

The DNA Appliance is offering a possible cure for sleep apnea and TMJ disorders by growing the jaws utilizing Epigenetic Orthodontics. Until recently it was believed these changes could only be accomplished through extensive surgical procedures.

Dr Shapira has also studied Cranial Suture Release techniques and Chirodontics. He inroduced these concepts to a Chiropracter who is his friend and colleague, Dr Mark Freund . Dr Freund has embraced these concepts in totality and has become an expert in these techniques through immersive studying both in the US and Internationally. His primary office is in Lindenhurst but he also sees Cranial patients in Gurnee in Dr Shapira's office www.delanydentalcare.com.

Dr Freund will be treating patients in Dr Shapira's Highland Park office. These techniques treat not only TMJ Dysfunction but also postural distortion such as forward head posture that leads to headaches and neck pain. These postural distortions can have negative effects throughout the entire body.

Dr Ira L Shapira created the I HATE CPAP and I HATE HEADACHE websites to help patients find help with these difficult medical disorders that medicine can frequently not treat adequately without a dental collaboration. Dr Shapira did research in the 1980's as a visiting assistant professor at Rush Medical School where he worked with Rosalind Cartwright PhD who is primarily responsible for the entire field of Dental Sleep Medicine. He also studied with Dr Barney Jankelson who created the initial concepts that neuromuscular dentistry still uses today and created a company Myotronics that is the leading manufacturer of instrumentation used by Neuromuscular Dentistry.

Dr Shapira is a Diplomate of The American Board of Dental Sleep Medicine, a Diplomate of the American Academy of Pain Management, and a Fellow of the International College of CranioMandibular Orthopedics (ICCMO). He is a former national and International Regent of ICCMO, its current Secretary and the representative to the Alliance of TMD organizations or the TMD ALLIANCE has a general dental practice (http://www.delanydentalcare.com) in Gurnee, Il and has recently started Chicagoland Dental Sleep Medicine Associates with offices in Skokie, Schaumburg, Chicago, Vernon Hills and Bannockburn. Patients in Northern Illinois or southern Wisconsin can contact Dr Shapira by phone toll free at 1-8-NO-PAP-MASK OR 1-800-TM-JOINT or thru his websites at http://www.ihateheadaches.org orhttp://www.chicagoland.ihatecpap.com.

Dr Ira L Shapira is an author and section editor of Sleep and Health Journal, President of I HATE CPAP LLC, President Dato-TECH, and has a Dental Practice with his partner Dr Mark Amidei. He has recently formed Chicagoland Dental Sleep Medicine Associates. He is a Regent of ICCMO and its representative to the TMD Alliance, He was a founding and certified member of the Sleep Disorder Dental Society which became the American Academy of Dental Sleep Medicine, A founding member of DOSA the Dental Organization for Sleep Apnea. He is a Diplomate of the American Board of Dental Sleep Medicine, A Diplomat of the American Academy of Pain Management, a graduate of LVI. He is a former assistant professor at Rush Medical School's Sleep Service where he worked with Dr Rosalind Cartwright who is a founder of Sleep Medicine and Dental Sleep Medicine. Dr Shapira is a consultant to numerous sleep centers and teaches courses in Dental Sleep Medicine in his office to doctors from around the U.S. He is the Founder of I HATE CPAP LLC and http://www.ihatecpap.com Dr Shapira also holds several patents on methods and devices for the prophylactic minimally invasive early removal of wisdom teeth and collection of bone marrow and stem cells. He is currently working with Dr Tom Diekwisch at the University of Illinois to prove these stem cells can change peoples lives for the better. Dr Shapira is a licensed general dentist in Illinois and Wisconsin.

Lynette:    
 I can get my headaches at any time of day. They can be minor and then suddenly spike or can stay at the same level but be bad enough to stop me achieving my daily goals. When they get really bad I have the option of going to the hospital for a largactil drip and helps a bit. I've had xray and ct scan and nothing has shown up. Iv had these for 3 1/2 years .Can you help me please


Dr Shapira response:

Lynette,  It is not uncommon to hear stories like yours.  You have done the right initial approach of ruling out organic disease.  Radiographs, CT Scans, MRI's and other diagnostic testing rules out organic disease.  

I look forward to seeing patients just like you because it is usually very easy to get 50-80 percent improvement in the early diagnostic phase of treatment.

I frequently utilize simple techniques to reduce headache at the first consultation appointment.  Many patients report more relief at that first appointment then they have had in years or decades.  

The first visit allows me to understand your problem by temporarily relieving your symptoms.  Once you thoroughly understand your we move on to treatment planning in how to make this temporary relief permanent and how to give you control of your symptoms.

IT IS IMPORTANT TO UNDERSTAND THERE ARE NO MAGIC CURES, DRUGS OR SURGERIES.  YOU MUST UNRAVEL THE PROBLEM BUT LIVING WITH CHRONIC PAIN HAS PERMANENTLY CHANGED BOTH YOU AND YOUR BRAIN.  THE ONLY TRUE "CURE" WOULD TO BE TO HAVE A DO-OVER FOR THE LAST THREE YEARS.

TREATMENT IS TO IMPROVE YOUR QUALITY OF LIFE AS SOON AS POSSIBLE.  I always tell my patients to expect 50-80% improvement initially.  We continually strive to eliminate 50-80% of remaining pain and dysfunction.

Most of my patients begin treatment with a Neuromuscular Diagnostic Orthotic as part of a comprehensive approach to giving you rapid relief of symptoms.

Learning how to use Sphenopalatine Ganglion Blocks as an abortive measure to prevent severe exacerbations may let you quickly eliminate most hospital visits.  Eliminating a long term chronic pain problem is complex and we break it down into small pieces to address specific aspects.  There is sometime changes in lifestyle.

I utilize a whole person approach to therapy and treatment.  The use of trigger point injections and trigger point deactivation utilizing vapocoolants and stretch quickly eliminate much of the myofascial pain, a main cause of headache and gives you techniques to turn headaches off before they become severe.

While you are not close to Chicago I do see long distance patients.  To find a Neuromuscular Dentist near you go to www.iccmo.org.  I would also suggest working with a Diplomat of the American Board of Dental Sleep Medicine is many of these problems have a nocturnal problem associated, especially Sleep Disordered breathing.  The American Academy of Pain Management also has Diplomats trained in treating chronic pain.

I am pleased to announce that my new Highland Park, Il office will be opening in September and it is a tow minute walk from the Fort Sheridan Metra Station for my Chicago and Milwaukee patients who depend on public transportation.

Cluster Headaches and Teeth Grinding

Dan:     I have been diagnosed with Chronic Cluster Headaches. I also grind and clench my teeth at night. My pain is on the right side always.

Dr Shapira Response,

Good News, Neuromuscular Dentistry may help control or eliminate your cluster headaches.

Sorry to hear about your headaches.  While the causes of Cluster Headaches are not well understood they are unquestionably related to the Trigeminal Nerve, the same nerve responsible for TMJ disorders and headache, sinus pain, facial pain and related symptoms.

We know that 100% oxygen can relieve classic cluster headaches.  We also know that almost all nocturnal  clenching and grinding of the teeth is related to sleep disordered breathing that causes oxygen desaturation and disturbs hormonal systems.  The connection is critical.

Much of the literature on cluster headaches point to a hormonal link.  When sleep is disturbed most of the bodies hormonal systems go into malfunction.  Especially Growth hormone, melatonin, thyroid, sex hormones, insulin resistance and cortisol.

TMJ disorders and sleep disorders both upset the functions of our circadian clocks that are also implicated in cluster headaches.  

A thorough diagnosis by a trained Neuromuscular Dentist(ideally a Fellow or Master of ICCMO due to advanced  training and commitment to the science) would be an excellent first step.  The use of a Neurmucular Diagnostic Orthotic may by itself eliminate or greatly improve your symptoms. I would strongly suggest you take a broader approach and also seek out a Board certified Diplomat in Dental Sleep Medicine trained in treating sleep disordered breathing and sleep apnea.  Correcting sleep disordered breathing whether it is snoring or sleep apnea or anything between can have dramatic effects on your cluster headaches.

This will address the trigeminal nervous system which contributes over 50% of input to the brain after the reticular activating system.  The sleep treatment will eliminate or minimize circadian disruptions.  It will also allow hormonal systems to be properly regulated and will eliminate the oxidative stress of repeated hypoxias (drops in oxygen).

A doctor trained in Sphenopalatine Ganglion blocks and trigger point injections can offer additional methods of eliminating your cluster headaches.  Diplomats of the American Academy of Pain Management understand the complex nature of chronic pain.  Be wary of doctors who only "throw medications" at the problem because they often only treat the symptoms and not the underlying causes of the disorder.

Good Luck

Ira L Sahpira DDS, D,ABDSM, D,AAPM, FICCMO

This new abstract from PUBMED.gov explains how Trigeminal Nerves can be affected by reactive oxygen, exactly as created by sleep disordered breathing.

Headache. 2014 Mar;54(3):472-84. doi: 10.1111/head.12301. Epub 2014 Feb 11.

Reactive oxygen species induce procalcitonin expression in trigeminal ganglia glia.

Raddant AC1, Russo AF.

Author information

Abstract

OBJECTIVE:

To examine calcitonin gene-related peptide (CGRP) gene expression under inflammatory conditions using trigeminal ganglia organ cultures as an experimental system. These cultures have increased proinflammatory signaling that may mimic neurogenic inflammation in the migraine state.

BACKGROUND:

The trigeminal nerve sends peripheral pain signals to the central nervous system during migraine. Understanding the dynamic processes that occur within the trigeminal nerve and ganglion may provide insights into events that contribute to migraine pain. A neuropeptide of particular interest is CGRP, which can be elevated and play a causal role in migraine. However, most studies have overlooked a second splice product of the Calca gene that encodes calcitonin (CT), a peptide hormone involved in calcium homeostasis. Importantly, a precursor form of CT called procalcitonin (proCT) can act as a partial agonist at the CGRP receptor and elevated proCT has recently been reported during migraine.

METHODS:

We used a trigeminal ganglion whole organ explant model, which has previously been demonstrated to induce pro-inflammatory agents in vitro. Quantitative polymerase chain reaction and immunohistochemistry were used to evaluate changes in messenger ribonucleic acid (mRNA) and protein levels of CGRP and proCT.

RESULTS:

Whole mouse trigeminal ganglia cultured for 24 hours showed a 10-fold increase in CT mRNA, with no change in CGRP mRNA. A similar effect was observed in ganglia from adult rats. ProCT immunoreactivity was localized in glial cells. Cutting the tissue blunted the increase in CT, suggesting that induction required the close environment of the intact ganglia. Consistent with this prediction, there were increased reactive oxygen species in the ganglia, and the elevated CT mRNA was reduced by antioxidant treatment. Surprisingly, reactive oxygen species were increased in neurons, not glia.

CONCLUSIONS:

These results demonstrate that reactive oxygen species can activate proCT expression from the CGRP gene in trigeminal glia by a paracrine regulatory mechanism. We propose that this glial recruitment pathway may occur following cortical spreading depression and neurogenic inflammation to increase CGRP nociceptive actions in migraine.

© 2014 American Headache Society.

KEYWORDS:

calcitonin gene-related peptide; migraine; procalcitonin; reactive oxygen species; trigeminal ganglion

PMID:

 

24512072

 

[PubMed - indexed for MEDLINE] 

PMCID:

 

PMC3947709

 [Available on 2015/3/1]

Related citations

TMJ Disorders, Headaches, Migraines treated in Dr Ira Shapira's new Highland Park, Illinois office.

I have been treating TMJ Disorders  and associated tension headaches, chronic daily headaches and migraines for over 30 years in my Gurnee office.  My new office at 3500 Western Ave in Highland Park will be dedicated to the treatment of chronic pain and sleep disorders.

I have been practicing and teaching the art and science of Neuromuscular Dentistry and Sleep Disorder Dentistry long before it became well known.

Doing research at Rush MedicalSchool in the mid 1980's I discovered the physiologic similarities in the bires of patients with sleep apnea and TMD.

While I will continue my general practice in Gurnee the new office will be dedicated to treatment and elimination of pain and sleep disorders.  The DNA Appliance and Epigenetic Orthodontics actually offer an non-surgical cure for obstructive sleep apnea.

The new office website is still under construction but is www.thinkbetterlife.com.

This name was chosen to because the goal of our treatment is to offer solutions that lead to a better life.  The location in Highland Park  will make it easier for my Chicago patients to visit as it is across the street from the Fort Sheridan Metra Station.

I will announce the Grand Opening Soon

Thank You Dr Ira L Shapira

Surgical Options For Treatment of Cluster Headaches: The Trigeminal Nerve Connection

Patrick :    What are the surgical options for treating my severe cluster headaches?

Dr Shapira response: Dear Patrick,

 am not a big advocate of surgery for cluster headaches.  Treatment of the Trigeminal Nerve  " microvascular decompression of the trigeminal nerve with section of the nervus intermedius compares very favorably to other destructive techniques without the accompanying neurologic deficits" (see below) is probably the best surgical treatment but do not expect success.  There is a significant risk of very negative outcomes.  As there is unquestionably a Trigeminal Nerve  basis in cluster headaches I would first  attempt a diagnostic neuromuscular orthotic (ie Neuromuscular Dentistry ) and/or sphenopalatine ganglion (SPG) block as prophylactic method.  Patients can learn to self administer the intranasal  SPG block quickly and easily at home with special hollow tube cotton applicators. Surgery of the Sphenopalatine Ganglion has been attempted but is not recommended.

There is a new study out of South Africa that showed good results on 4 out of 5 patients (short term study) but the surgery is relatively atraumatic.  (see below)  There is also a study on implantable neurostimulation of the Spenopalatine Ganglon (SPG) but I would certainly try the intranasal approach first.

 Many Cluster headaches respond rapidly to 100% oxygen as an emergency treatment.

What have you previously attempted to treat your cluster headachers?

I have included three excerpts from PubMed abstracts but all conclude surgery is not a first line approach and the newest article concludes " We do not recommend trigeminal nerve radiosurgery for treatment of cluster headache."

It has been said that: "There is no disease or disorder known to man that cannot be made worse by sticking a knife in it."  This does not mean surgery is bad but you should approach it with caution and be aware of possible negative outcomes.

Ira L Shapira DDS, D,ABDSM, D,AAPM, FICCMO

SEE ABSTRACTS BELOW FOR MORE INFORMATION

Headache. 1998 Sep;38(8):590-4.

The surgical management of chronic cluster headache.

Chronic cluster headache remains a debilitating and poorly controlled syndrome. Although various surgical treatments have had limited success, microvascular decompression of the trigeminal nerve with section of the nervus intermedius compares very favorably to other destructive techniques without the accompanying neurologic deficits. It is, therefore, our recommendation as the first-line operative treatment of chronic cluster headache.

Curr Pain Headache Rep. 2002 Feb;6(1):57-64.

Interventional treatment for cluster headache: a review of the options.

Rozen TD.

Source

Cleveland Clinic Headache Center, 9500 Euclid Avenue, Cleveland, OH 44195, USA. RozenT@ccf.org

Abstract

There is no more severe pain than that sustained by a cluster headache sufferer. Surgical treatment of cluster headache should only be considered after a patient has exhausted all medical options or when a patient's medical history precludes the use of typical cluster abortive and preventive medications. Once a cluster patient is deemed a medical failure only those who have strictly side-fixed headaches should be considered for surgery. Other criteria for cluster surgery include pain localizing to the ophthalmic division of the trigeminal nerve, a psychologically stable individual, and absence of addictive personality traits. To understand the rationale behind the surgical treatment strategies for cluster, one must have a general understanding of the anatomy of cluster pathogenesis. The most frequently used surgical techniques for cluster are directed toward the sensory trigeminal nerve and the cranial parasympathetic system.

Cephalalgia. 2012 Jun;32(8):635-40. doi: 10.1177/0333102412445219. Epub 2012 Apr 23.

Predilection to deafferentation pain syndrome after radiosurgery in cluster headache.

Donnet A, Carron R, Régis J.

Source

Department of Neurology, Timone Hospital, Marseille, France. adonnet@ap-hm.fr

Abstract

Cluster-tic syndrome is a rare, disabling disorder. We report the first case of cluster-tic syndrome with a successful response to stereotactic radiosurgery. After failing optimal medical treatment, a 58-year-old woman suffering from cluster-tic syndrome was treated with gamma knife radiosurgery. The trigeminal nerve and sphenopalatine ganglion were targeted with a maximum dose of 85 and 90 Gy respectively. The patient experienced a complete resolution of the initial pain, but developed, as previously described after radiosurgical treatment for cluster headache, a trigeminal nerve dysfunction. This suggests that trigeminal nerve sensitivity to radiosurgery can be extremely different depending on the underlying pathological condition, and that there is an abnormal sensitivity of the trigeminal nerve in cluster headache patients. We do not recommend trigeminal nerve radiosurgery for treatment of cluster headache.

Other relevant articles show short term relief:

Neurosurgery. 2006 Dec;59(6):1258-62; discussion 1262-3.

Long-term results of radiosurgery for refractory cluster headache.

McClelland S 3rd, Tendulkar RD, Barnett GH, Neyman G, Suh JH.

Source

Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.

Abstract

OBJECTIVE:

Medically refractory cluster headache (CH) is a debilitating condition for which few surgical modalities have proven effective. Previous reports involving short-term follow-up of CH patients have reported modest degrees of pain relief after radiosurgery of the trigeminal nerve ipsilateral to symptom onset. With the recent success of deep brain stimulation as a surgical modality for these patients, it becomes imperative for the long-term risks and benefits of radiosurgery to be more extensively delineated. To address this issue, we present our findings from the largest retrospective series of patients undergoing radiosurgery for CH with extended follow-up periods.

METHODS:

Between 1997 and 2001, 10 patients with CH underwent gamma knife radiosurgery at our institution. All patients fulfilled clinical criteria for treatment, including complete resistance to pharmacotherapy (usually methysergide, verapamil, and lithium), pain primarily localized to the ophthalmic division of the trigeminal nerve, and psychological stability. The mean age at radiosurgery was 40.3 years (range, 26-62 yr), and the average CH duration was 11.3 years (range, 2-21 yr). Patients received 75 Gy to the 100% isodose line delivered to the most proximal part of the trigeminal nerve where the 50% isodose line was outside the brainstem (4-mm collimator), with a mean follow-up period of 39.7 months (range, 5-88 mo). Pain relief was defined as excellent (free of CH with minimal or no medications), good (50% reduction of CH severity and frequency with medications), fair (25% reduction of CH severity and frequency with medications), or poor (less than 25% reduction of CH severity and frequency with medications).

RESULTS:

After radiosurgery, pain relief was poor in nine patients and fair in one patient. Six patients with poor to fair relief initially experienced excellent to good relief (range, 2 wk-2 yr after treatment) before regressing. Five patients (50%) experienced trigeminal nerve dysfunction, manifesting predominantly as facial numbness after treatment.

CONCLUSION:

Although some patients may experience short-term pain relief, none had relief sustainable for longer than 2 years. The results from this series indicate that radiosurgery of the trigeminal nerve does not provide long-term pain relief for medically refractory CH.

PMID:

  

17277688

 

[PubMed - indexed for MEDLINE]

This article consider the treatment worse than the disease:

J Neurol Neurosurg Psychiatry. 2005 February; 76(2): 218–221.

doi:  10.1136/jnnp.2004.041202

PMCID: PMC1739520

Gamma knife treatment for refractory cluster headache: prospective open trial

A Donnet, D Valade, and J Regis

Abstract

Background: Since the initial report of Ford et al in 1998 no further study has evaluated radiosurgery of the trigeminal nerve in chronic cluster headache (CCH).

Methods: We carried out a prospective open trial of neurosurgery and enrolled 10 patients (nine men, one woman; mean age 49.8 years, range 32–77) presenting with severe and drug resistant CCH (mean duration 9 years, range 2–33). The cisternal segment of the nerve was targeted with a single 4 mm collimator (80–85 Gy max).

Results: The mean follow up was 13.2 months. No improvement was observed in two patients and three patients had no further attacks. Three patients showed dramatic improvement with a few attacks per month or very few attacks over the last six months. Two patients were pain free for only one and two weeks and their headaches recurred with the same severity as before. Three patients developed paraesthesia with no hypoaesthesia, one developed hypoaesthesia, and one developed deafferentation pain.

Conclusions: The rate and severity of trigeminal nerve injury appeared to be significantly higher than in trigeminal neuralgia, and this study does not support the positive results of the study of Ford et al. We consider the morbidity to be significant for the low rate of pain cessation, making this procedure less attractive even for the more severely affected subgroup of patients.

This article considers Cluster Headaches to be internally generated within the brain therefore not amenable to surgery but it did report good results in one case with Sumatriptan

Brain. 2002 May;125(Pt 5):976-84.

Persistence of attacks of cluster headache after trigeminal nerve root section.

Matharu MS, Goadsby PJ.

Source

Headache Group, Institute of Neurology, University College London, UK.

Abstract

Cluster headache is a strictly unilateral headache that occurs in association with cranial autonomic features. We report a patient with a trigeminal nerve section who continued to have attacks. A 59-year-old man described a 14-year history of left-sided episodes of excruciating pain centred on the retro-orbital and orbital regions. These episodes lasted 1-4 h, recurring 2-3 times daily. The attacks were associated with ipsilateral ptosis, conjunctival injection, lacrimation, rhinorrhoea and facial flushing. From 1986 to 1988, he had trials of medications without any benefit. In February 1988, he had complete surgical section of the left trigeminal sensory root that shortened the attacks in length for 1 month without change in their frequency or character. In April 1988, he had further surgical exploration and the root was found to be completely excised; post-operatively, there was no change in the symptoms. From 1988 to 1999, he had a number of medications, including verapamil and indomethacin, all of which were ineffective. Prednisolone 30 mg orally daily rendered the patient completely pain free. Sumatriptan 100 mg orally and 6 mg subcutaneously aborted the attack after approximately 45 and 15 min, respectively. He was completely anaesthetic over the entire left trigeminal distribution. Left corneal reflex was absent. Motor function of the left trigeminal nerve was preserved. Neurological and physical examination was otherwise normal. MRI scan showed a marked reduction in the calibre of the left trigeminal nerve from the nerve root exit zone in the pons to Meckel's cave. An ECG-gated three-dimensional multislab MRI inflow angiogram was performed. No dilatation was observed in the left internal carotid artery during the cluster attack. Blink reflexes were elicited with a standard electrode and stimulus. Stimulation of the left supraorbital nerve produced neither ipsilateral nor contralateral blink reflex response. Stimulation of the right supraorbital nerve produced an ipsilateral response with a mean R2 onset latency of 36 ms and a contralateral response with a mean R2 onset latency of 32 ms. Lack of ipsilateral vessel dilatation makes the role of vascular factors in the initiation of cluster attacks questionable. With complete section of the left trigeminal sensory root the brain would perceive neither vasodilatation nor a peripheral neural inflammatory process; however, the patient continued to have an excellent response to sumatriptan. The case illustrates that cluster headache may be generated primarily from within the brain, and that triptans may have anti-headache effects through an entirely central mechanism.

A more positive result was shown in this study from Mayo but does not discuss length of relief only short term results.

Mayo Clin Proc. 1986 Jul;61(7):537-44.

Surgical treatment of chronic cluster headache.

Onofrio BM, Campbell JK.

Abstract

Chronic cluster headache, also known as chronic migrainous neuralgia, is frequently unresponsive to medical management. Although neuronal factors may be involved in the pathogenesis of this form of recurrent hemicranial pain, vasodilatation within the distribution of the trigeminal nerve is believed to be important. Attempts to provide relief by surgical means have primarily involved interruption of the vasodilator pathways of the greater superficial petrosal nerve and the sphenopalatine ganglion. A more direct approach of interrupting the pain pathways of the trigeminal nerve has been attempted sporadically for more than 50 years. Recent interest in the role of substance P in the production of pain in cluster headache suggests that trigeminal ablative procedures might have a dual role in the relief of medically intractable cases. Among 26 patients who underwent posterior fossa trigeminal sensory rhizotomy or percutaneous radio-frequency trigeminal gangliorhizolysis at our institution, relief of pain was excellent in 14 (54%), fair to good in 4 (15%), and poor in 8 (31%)

The next article (a case study) discusses brain stimulation of the hypothalamus as a treatment alternative:

Cephalalgia. 2011 Jan;31(1):112-5. doi: 10.1177/0333102410373157. Epub 2010 May 17.

Mere surgery will not cure cluster headache--implications for neurostimulation.

Hidding U, May A.

Source

Department of Systems Neuroscience, University Medical Centre Hamburg-Eppendorf (UKE), Martinistrasse 52, Hamburg, Germany.

Abstract

This case study concerns a patient with primary chronic cluster headache, who was unresponsive to all treatments and consecutively underwent hypothalamic deep brain stimulation (DBS). DBS had no effect on the cluster attacks, but cured an existing polydipsia as well as restlessness. However, hypothalamic DBS produced a constant, dull headache without concomitant symptoms and a high-frequent tremor. All of these effects were repeated when the stimulation was stopped and than started again. DBS had no effect on a pathological weight gain from 70 kg to 150 kg due to bulimia at night, usually during headache attacks. This case illustrates that cluster headache is, in some patients, only one symptom of a complex hypothalamic syndrome. This case also underlines that the stimulation parameters and anatomical target area for hypothalamic DBS may be too unspecific to do justice to the clinical variety of patients and concomitant symptoms. Hypothalamic DBS is an exquisite and potentially life-saving treatment method in otherwise intractable patients, but needs to be better characterised and should only be considered when other stimulation methods, such as stimulation of the greater occipital nerve, are unsuccessful.

J Oral Maxillofac Surg. 2013 Apr;71(4):677-81. doi: 10.1016/j.joms.2012.12.001.

A new minimally invasive technique for cauterizing the maxillary artery and its application in the treatment ofcluster headache.

Shevel E.

Source

The Headache Clinic, Johannesburg, South Africa. drshevel@headclin.com

Abstract

PURPOSE:

To describe a new, relatively atraumatic method of cauterizing the maxillary artery and its effectiveness in treating cluster headache.

MATERIALS AND METHODS:

Five patients with cluster headache were treated with arterial ligation of certain terminal branches of the external carotid artery. A new, atraumatic method of cauterizing the maxillary artery is described.

RESULTS:

The success rate and postoperative morbidity are presented. In four out of five patients the cluster attacks ceased immediately following surgery.

CONCLUSION:

A new intraoral technique for maxillary artery cauterization and the effectiveness of cauterization of the terminal branches of the external carotid artery in the treatment of cluster headache are described. Although the sample is small, the results are encouraging, and may offer permanent relief of cluster headache pain.

Cephalalgia. 2013 Jul;33(10):816-30. doi: 10.1177/0333102412473667. Epub 2013 Jan 11.

Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: A randomized, sham-controlled study.

Schoenen J, Jensen RH, Lantéri-Minet M, Láinez MJ, Gaul C, Goodman AM, Caparso A, May A.

Source

Headache Research Unit, Department of Neurology, CHR Citadelle, Liège University, B-4000 Liège, Belgium. jschoenen@ulg.ac.be

Abstract

BACKGROUND:

The pain and autonomic symptoms of cluster headache (CH) result from activation of the trigeminal parasympathetic reflex, mediated through the sphenopalatine ganglion (SPG). We investigated the safety and efficacy of on-demand SPG stimulation for chronic CH (CCH).

METHODS:

A multicenter, multiple CH attack study of an implantable on-demand SPG neurostimulator was conducted in patients suffering from refractory CCH. Each CH attack was randomly treated with full, sub-perception, or sham stimulation. Pain relief at 15 minutes following SPG stimulation and device- or procedure-related serious adverse events (SAEs) were evaluated.

FINDINGS:

Thirty-two patients were enrolled and 28 completed the randomized experimental period. Pain relief was achieved in 67.1% of full stimulation-treated attacks compared to 7.4% of sham-treated and 7.3% of sub-perception-treated attacks ( P  < 0.0001). Nineteen of 28 (68%) patients experienced a clinically significant improvement: seven (25%) achieved pain relief in ≥50% of treated attacks, 10 (36%), a ≥50% reduction in attack frequency, and two (7%), both. Five SAEs occurred and most patients (81%) experienced transient, mild/moderate loss of sensation within distinct maxillary nerve regions; 65% of events resolved within three months.

INTERPRETATION:

On-demand SPG stimulation using the ATI Neurostimulation System is an effective novel therapy for CCH sufferers, with dual beneficial effects, acute pain relief and observed attack prevention, and has an acceptable safety profile compared to similar surgical procedures.