Monday, April 12, 2010
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Saturday, April 10, 2010
Sphenopalatine (nasal) Ganglion (SPG) can be responsible for much more than headaches.
I came across this interesting abstract (below) on the spenopalatine ganglion and how it can cause remote effects. According to the article published in Arch Phys Med Rehabil. 1979 Aug;60(8):353-9 it can be responsible for wide ranging disorders. "Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others." I must disagree that the symptoms are "psychosomatic", I would venture that doctors facing idiopathic conditions sometimes label what they do not understand as psychosomatic. I have not read the original article only the abstract at this time and I am not sure how the authors are using the term psychosomatic.
All of the symptoms are mediated by the autonomic nervous system. The authors point out the connections to the Trigeminal Nerve, facial nerve and to the internal carotid artery plexus of the sympathetic nervous system. these connections could explain how the SPG is ntimately involved in TMD (TMJ) disorders and facial pain, migraines, tension headaches and other problems.
Neuromuscular dentistry will have effects on the trigeminal and facial nerves that travel thru the SPG but use of intranasal spenopalatine blocks will be a valuable tool in treating these autonomic aspects of chronic pain. Neuromuscular Dentists and all physicians and dentists treating chronic pain should be well versed in utilization of intranasal SPG blocks.
The rage reaction may also be affected by the SPG which may explain chemical changes seen in the brains of chronic pain patients. The connections to the pituitary gland could have effects on a wide variety of hormonal conditions.
I have seen remarkable results in some patients while utilizing SPG intranasal blocks while in other patients they seem ineffective. This may actually constitute a diagnostic evaluation for how large an autonomic effect is in a given patient.
Neuromuscular dentistry can evaluate the changes that take place in the masticatory muscles by utilizing EMG measurements of the masticatory muscles before and after SPG blocks. However we will only be able to measure the effects on voluntary muscles but not on visceral muscles or autonomic function. The field of neuromuscular dentistry has tremendous effects on the trigeminal nerve input to the brain. The Trigemnal nerve (fifth cranial nerve) is responsible for over 50% of the total input to the brain. the autonomic components are still not well understood by clinicians treating migraines, tension headaches, TMD, myofascial pain and other disorders. RSD (Reflex sympathetic Dystrophy) or CRPS (complex regional pain syndrome) are autonomic manifestations are some some of the most troubling in clinical treatment of pain.
The authors presents arguments supporting the following hypotheses:" 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered."
I am sometimes amazed at the effectiveness that we achieve utilizing a neuromuscular orthotic while we still do not have a good grasp on the underlying neurology. I believe why we are so successful in eliminating, preventing and treating chronic migraines and headaches is that the correction of the proprioceptive input accomplished by neuromuscular dental orthotics or occlusal corrections is such an emormous reduction in noxious neural input that we accidentally produce vast beneficial effects throughout the trigeminovascular system, the autonomic nervous system, the hormonal systems influenced by the pituitary gland and in the part of the brain (retained) that is involved in rage reflexes found in lower animals.
Arch Phys Med Rehabil. 1979 Aug;60(8):353-9.
Sphenopalatine (nasal) ganglion: remote effects including "psychosomatic" symptoms, rage reaction, pain, and spasm.
Ruskin AP.
Many articles implicate the nasal ganglion in the production of remote symptoms and discuss treatment. Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others. All these symptoms appear to have 2 common denominators. They are mediated by the autonomic nervous system and at least in some instances can be "psychosomatic." The sphenopalatine ganglion (SPG) is a major autonomic ganglion located superficially in the pterygopalatine fossa, with major afferent distribution to the entire nasopharynx and important connections with the trigeminal nerve, facial nerve, internal carotid artery plexus of the sympathetic nervous system and, as shown in the rat, direct connection with the anterior pituitary gland. This paper presents arguments supporting the following hypotheses: 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered.20
PMID: 464779 [PubMed - indexed for MEDLINE]
All of the symptoms are mediated by the autonomic nervous system. The authors point out the connections to the Trigeminal Nerve, facial nerve and to the internal carotid artery plexus of the sympathetic nervous system. these connections could explain how the SPG is ntimately involved in TMD (TMJ) disorders and facial pain, migraines, tension headaches and other problems.
Neuromuscular dentistry will have effects on the trigeminal and facial nerves that travel thru the SPG but use of intranasal spenopalatine blocks will be a valuable tool in treating these autonomic aspects of chronic pain. Neuromuscular Dentists and all physicians and dentists treating chronic pain should be well versed in utilization of intranasal SPG blocks.
The rage reaction may also be affected by the SPG which may explain chemical changes seen in the brains of chronic pain patients. The connections to the pituitary gland could have effects on a wide variety of hormonal conditions.
I have seen remarkable results in some patients while utilizing SPG intranasal blocks while in other patients they seem ineffective. This may actually constitute a diagnostic evaluation for how large an autonomic effect is in a given patient.
Neuromuscular dentistry can evaluate the changes that take place in the masticatory muscles by utilizing EMG measurements of the masticatory muscles before and after SPG blocks. However we will only be able to measure the effects on voluntary muscles but not on visceral muscles or autonomic function. The field of neuromuscular dentistry has tremendous effects on the trigeminal nerve input to the brain. The Trigemnal nerve (fifth cranial nerve) is responsible for over 50% of the total input to the brain. the autonomic components are still not well understood by clinicians treating migraines, tension headaches, TMD, myofascial pain and other disorders. RSD (Reflex sympathetic Dystrophy) or CRPS (complex regional pain syndrome) are autonomic manifestations are some some of the most troubling in clinical treatment of pain.
The authors presents arguments supporting the following hypotheses:" 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered."
I am sometimes amazed at the effectiveness that we achieve utilizing a neuromuscular orthotic while we still do not have a good grasp on the underlying neurology. I believe why we are so successful in eliminating, preventing and treating chronic migraines and headaches is that the correction of the proprioceptive input accomplished by neuromuscular dental orthotics or occlusal corrections is such an emormous reduction in noxious neural input that we accidentally produce vast beneficial effects throughout the trigeminovascular system, the autonomic nervous system, the hormonal systems influenced by the pituitary gland and in the part of the brain (retained) that is involved in rage reflexes found in lower animals.
Arch Phys Med Rehabil. 1979 Aug;60(8):353-9.
Sphenopalatine (nasal) ganglion: remote effects including "psychosomatic" symptoms, rage reaction, pain, and spasm.
Ruskin AP.
Many articles implicate the nasal ganglion in the production of remote symptoms and discuss treatment. Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others. All these symptoms appear to have 2 common denominators. They are mediated by the autonomic nervous system and at least in some instances can be "psychosomatic." The sphenopalatine ganglion (SPG) is a major autonomic ganglion located superficially in the pterygopalatine fossa, with major afferent distribution to the entire nasopharynx and important connections with the trigeminal nerve, facial nerve, internal carotid artery plexus of the sympathetic nervous system and, as shown in the rat, direct connection with the anterior pituitary gland. This paper presents arguments supporting the following hypotheses: 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered.20
PMID: 464779 [PubMed - indexed for MEDLINE]
Sunday, April 4, 2010
Sphenopalatine (nasal) Ganglion (SPG) can be responsible for much more than headaches.
I came across this interesting abstract (below) on the spenopalatine ganglion and how it can cause remote effects. According to the article published in Arch Phys Med Rehabil. 1979 Aug;60(8):353-9 it can be responsible for wide ranging disorders. "Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others." I must disagree that the symptoms are "psychosomatic", I would venture that doctors facing idiopathic conditions sometimes label what they do not understand as psychosomatic. I have not read the original article only the abstract at this time and I am not sure how the authors are using the term psychosomatic.
All of the symptoms are mediated by the autonomic nervous system. The authors point out the connections to the Trigeminal Nerve, facial nerve and to the internal carotid artery plexus of the sympathetic nervous system. these connections could explain how the SPG is ntimately involved in TMD (TMJ) disorders and facial pain, migraines, tension headaches and other problems.
Neuromuscular dentistry will have effects on the trigeminal and facial nerves that travel thru the SPG but use of intranasal spenopalatine blocks will be a valuable tool in treating these autonomic aspects of chronic pain. Neuromuscular Dentists and all physicians and dentists treating chronic pain should be well versed in utilization of intranasal SPG blocks.
The rage reaction may also be affected by the SPG which may explain chemical changes seen in the brains of chronic pain patients. The connections to the pituitary gland could have effects on a wide variety of hormonal conditions.
I have seen remarkable results in some patients while utilizing SPG intranasal blocks while in other patients they seem ineffective. This may actually constitute a diagnostic evaluation for how large an autonomic effect is in a given patient.
Neuromuscular dentistry can evaluate the changes that take place in the masticatory muscles by utilizing EMG measurements of the masticatory muscles before and after SPG blocks. However we will only be able to measure the effects on voluntary muscles but not on visceral muscles or autonomic function. The field of neuromuscular dentistry has tremendous effects on the trigeminal nerve input to the brain. The Trigemnal nerve (fifth cranial nerve) is responsible for over 50% of the total input to the brain. the autonomic components are still not well understood by clinicians treating migraines, tension headaches, TMD, myofascial pain and other disorders. RSD (Reflex sympathetic Dystrophy) or CRPS (complex regional pain syndrome) are autonomic manifestations are some some of the most troubling in clinical treatment of pain.
The authors presents arguments supporting the following hypotheses:" 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered."
I am sometimes amazed at the effectiveness that we achieve utilizing a neuromuscular orthotic while we still do not have a good grasp on the underlying neurology. I believe why we are so successful in eliminating, preventing and treating chronic migraines and headaches is that the correction of the proprioceptive input accomplished by neuromuscular dental orthotics or occlusal corrections is such an emormous reduction in noxious neural input that we accidentally produce vast beneficial effects throughout the trigeminovascular system, the autonomic nervous system, the hormonal systems influenced by the pituitary gland and in the part of the brain (retained) that is involved in rage reflexes found in lower animals.
Arch Phys Med Rehabil. 1979 Aug;60(8):353-9.
Sphenopalatine (nasal) ganglion: remote effects including "psychosomatic" symptoms, rage reaction, pain, and spasm.
Ruskin AP.
Many articles implicate the nasal ganglion in the production of remote symptoms and discuss treatment. Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others. All these symptoms appear to have 2 common denominators. They are mediated by the autonomic nervous system and at least in some instances can be "psychosomatic." The sphenopalatine ganglion (SPG) is a major autonomic ganglion located superficially in the pterygopalatine fossa, with major afferent distribution to the entire nasopharynx and important connections with the trigeminal nerve, facial nerve, internal carotid artery plexus of the sympathetic nervous system and, as shown in the rat, direct connection with the anterior pituitary gland. This paper presents arguments supporting the following hypotheses: 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered.20
PMID: 464779 [PubMed - indexed for MEDLINE]
All of the symptoms are mediated by the autonomic nervous system. The authors point out the connections to the Trigeminal Nerve, facial nerve and to the internal carotid artery plexus of the sympathetic nervous system. these connections could explain how the SPG is ntimately involved in TMD (TMJ) disorders and facial pain, migraines, tension headaches and other problems.
Neuromuscular dentistry will have effects on the trigeminal and facial nerves that travel thru the SPG but use of intranasal spenopalatine blocks will be a valuable tool in treating these autonomic aspects of chronic pain. Neuromuscular Dentists and all physicians and dentists treating chronic pain should be well versed in utilization of intranasal SPG blocks.
The rage reaction may also be affected by the SPG which may explain chemical changes seen in the brains of chronic pain patients. The connections to the pituitary gland could have effects on a wide variety of hormonal conditions.
I have seen remarkable results in some patients while utilizing SPG intranasal blocks while in other patients they seem ineffective. This may actually constitute a diagnostic evaluation for how large an autonomic effect is in a given patient.
Neuromuscular dentistry can evaluate the changes that take place in the masticatory muscles by utilizing EMG measurements of the masticatory muscles before and after SPG blocks. However we will only be able to measure the effects on voluntary muscles but not on visceral muscles or autonomic function. The field of neuromuscular dentistry has tremendous effects on the trigeminal nerve input to the brain. The Trigemnal nerve (fifth cranial nerve) is responsible for over 50% of the total input to the brain. the autonomic components are still not well understood by clinicians treating migraines, tension headaches, TMD, myofascial pain and other disorders. RSD (Reflex sympathetic Dystrophy) or CRPS (complex regional pain syndrome) are autonomic manifestations are some some of the most troubling in clinical treatment of pain.
The authors presents arguments supporting the following hypotheses:" 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered."
I am sometimes amazed at the effectiveness that we achieve utilizing a neuromuscular orthotic while we still do not have a good grasp on the underlying neurology. I believe why we are so successful in eliminating, preventing and treating chronic migraines and headaches is that the correction of the proprioceptive input accomplished by neuromuscular dental orthotics or occlusal corrections is such an emormous reduction in noxious neural input that we accidentally produce vast beneficial effects throughout the trigeminovascular system, the autonomic nervous system, the hormonal systems influenced by the pituitary gland and in the part of the brain (retained) that is involved in rage reflexes found in lower animals.
Arch Phys Med Rehabil. 1979 Aug;60(8):353-9.
Sphenopalatine (nasal) ganglion: remote effects including "psychosomatic" symptoms, rage reaction, pain, and spasm.
Ruskin AP.
Many articles implicate the nasal ganglion in the production of remote symptoms and discuss treatment. Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others. All these symptoms appear to have 2 common denominators. They are mediated by the autonomic nervous system and at least in some instances can be "psychosomatic." The sphenopalatine ganglion (SPG) is a major autonomic ganglion located superficially in the pterygopalatine fossa, with major afferent distribution to the entire nasopharynx and important connections with the trigeminal nerve, facial nerve, internal carotid artery plexus of the sympathetic nervous system and, as shown in the rat, direct connection with the anterior pituitary gland. This paper presents arguments supporting the following hypotheses: 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered.20
PMID: 464779 [PubMed - indexed for MEDLINE]
HEADACHE AND SLEEP APNEA TREATMENT IN SCHAUMBURG,MCHENRY, BARRINGTON, ELGIN AND CRYSTAL LAKE
I HAVE BEEN TRETING PATIENTS WITH CHRONIC HEAD AND NECK PAIN, FACIAL PAIN, MIGRAINES TENSION-TYPE HEADACHES FOR 30 YEARS. I SEE PATIENTS PRIMARILY IN MY GURNEE OFFICE AND OVER THE YEARS PATIENTS HAVE FOUND THAT IT WAS WORTH THE DRIVE FOR RELIEF OF PAIN. I HAVE RECENTLY CREATED CICAGOLAND DENTAL SLEEP MEDICINE ASSOCIATES AND I AM ABLE TO SEE PATIENTS IN SCHAUMBURG IN THE OFFICES OF DR ALAN ACIERNO AN EXCELLENT GENERAL DENTIST.
PATIENTS WITH HEADACHES AND SLEEP DISORDERS CAN MAKE APPOINTMENTS TO SEE ME IN SCHAUMBURG BY CONTACTING ME AT DELANY DENTAL CARE LTD IN GURNEE. CALL TOLL FREE AT 1-800-TM-JOINT OR 1-8-NO-PAP-MASK OR VISIT MY WEBSITE @ http://www.delanydentalcare.com/neuromuscular.html
PATIENTS WITH HEADACHES AND SLEEP DISORDERS CAN MAKE APPOINTMENTS TO SEE ME IN SCHAUMBURG BY CONTACTING ME AT DELANY DENTAL CARE LTD IN GURNEE. CALL TOLL FREE AT 1-800-TM-JOINT OR 1-8-NO-PAP-MASK OR VISIT MY WEBSITE @ http://www.delanydentalcare.com/neuromuscular.html
Long-standing history of chronic daily headaches? SINUS HEADACHE MAY BE A TMJ DISORDER!
The article "emporomandibular dysfunction: an often overlooked cause of chronic headaches" published in Ann Allergy Asthma Immunol. 2007 Oct;99(4):314-8 recommends evaluating patients with chronic daily headaches for TMJ disorders. This interesting article looks at 25 years of Pub Med searches of the keywords " temporomandibular dysfunction, temporomandibular disorder, temporomandibular joint, and chronic headache". The article concludes "The disorder should be suspected in individuals with a long-standing history of chronic daily headaches and facial pain without objective evidence of sinus, neurologic, or intracranial abnormalities."
The article is directed to ENT and allergy physicians and notes "Allergists and immunologists are frequently called on to evaluate patients with chronic headaches and facial pain. TMD is known to cause recurrent facial discomfort and headaches. Many individuals with the disorder present with headache or facial discomfort as their only chief complaint. They mistakenly think it is a "sinus" headache. Nearly 10 million Americans are affected by the disorder, and early studies estimate that TMD pain is the cause of chronic headaches in 14% to 26% of individuals with recurrent headaches"
NEUROMUSCULAR DENTISTRY CAN DIAGNOSE AND TREAT CHRONIC DAILY HEADACHES BY UTILIZING A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC. A DIAGNOSTIC ORTHOTIC , WHEN SUCCESSFUL IN ELIMINATING PAIN NOT ONLY IS THE FIRST STEP OF TREATING OR CURING THE DISORDER BUT ALSO GUIDES THE PRACTITIONER IN THE BEST MEANS OF TREATMENT.
ACCORDING TO THIS ARTICLE "As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy"
This is not uncommon. TMJ or TMD is frequently called "THE GREAT IMPOSTER" because patients are frequently given multiple courses of antibiotics to treat non-existent infections, given migraine medications for headaches that are myofascial in orgin or subjected to multiple CAT scans and MRI's that are essentially normal. Please see the Sleep and Health Article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" to leatn more about how neuromuscular dentistry can help eliminate, prevent or alleviate migraines, tension-type headaches, chronic daily headaches, facial pain or sinus pain and/or pressure. These are all frequently symptoms of TMJ disorders.
Additional information on Neuromuscular Dentistry can be found in "Neuromuscular Dentistry" an article originally published by the American Equilibration Society that has been republished in Sleep and Health Journal @ http://www.sleepandhealth.com/neuromuscular-dentistry
'
PubMed abstract below
Ann Allergy Asthma Immunol. 2007 Oct;99(4):314-8.
Temporomandibular dysfunction: an often overlooked cause of chronic headaches.
Lupoli TA, Lockey RF.
Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, University of South Florida College of Medicine, James A. Haley Veteran's Hospital, Tampa, Florida 33612, USA. tlupoli@hsc.usf.edu
OBJECTIVE: To review and discuss the role of temporomandibular dysfunction (TMD) as a cause of chronic headaches and facial pain. DATA SOURCES AND STUDY SELECTION: A literature review was performed using the PubMed database for English-language articles published between January 1, 1981, and August 31, 2006, using the following keywords: temporomandibular dysfunction, temporomandibular disorder, temporomandibular joint, and chronic headache. Additional information was obtained from a review of current medical texts. RESULTS:. CONCLUSIONS: TMD is a likely underdiagnosed cause of chronic headache and facial discomfort. As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy. TMD can be readily diagnosed by a careful history and physical examination. Patients typically respond well to conservative therapy, which includes behavioral modification and nonsteroidal anti-inflammatory drugs. The disorder should be suspected in individuals with a long-standing history of chronic daily headaches and facial pain without objective evidence of sinus, neurologic, or intracranial abnormalities.
PMID: 17941277 [PubMed - indexed for MEDLINE]
The article is directed to ENT and allergy physicians and notes "Allergists and immunologists are frequently called on to evaluate patients with chronic headaches and facial pain. TMD is known to cause recurrent facial discomfort and headaches. Many individuals with the disorder present with headache or facial discomfort as their only chief complaint. They mistakenly think it is a "sinus" headache. Nearly 10 million Americans are affected by the disorder, and early studies estimate that TMD pain is the cause of chronic headaches in 14% to 26% of individuals with recurrent headaches"
NEUROMUSCULAR DENTISTRY CAN DIAGNOSE AND TREAT CHRONIC DAILY HEADACHES BY UTILIZING A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC. A DIAGNOSTIC ORTHOTIC , WHEN SUCCESSFUL IN ELIMINATING PAIN NOT ONLY IS THE FIRST STEP OF TREATING OR CURING THE DISORDER BUT ALSO GUIDES THE PRACTITIONER IN THE BEST MEANS OF TREATMENT.
ACCORDING TO THIS ARTICLE "As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy"
This is not uncommon. TMJ or TMD is frequently called "THE GREAT IMPOSTER" because patients are frequently given multiple courses of antibiotics to treat non-existent infections, given migraine medications for headaches that are myofascial in orgin or subjected to multiple CAT scans and MRI's that are essentially normal. Please see the Sleep and Health Article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" to leatn more about how neuromuscular dentistry can help eliminate, prevent or alleviate migraines, tension-type headaches, chronic daily headaches, facial pain or sinus pain and/or pressure. These are all frequently symptoms of TMJ disorders.
Additional information on Neuromuscular Dentistry can be found in "Neuromuscular Dentistry" an article originally published by the American Equilibration Society that has been republished in Sleep and Health Journal @ http://www.sleepandhealth.com/neuromuscular-dentistry
'
PubMed abstract below
Ann Allergy Asthma Immunol. 2007 Oct;99(4):314-8.
Temporomandibular dysfunction: an often overlooked cause of chronic headaches.
Lupoli TA, Lockey RF.
Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, University of South Florida College of Medicine, James A. Haley Veteran's Hospital, Tampa, Florida 33612, USA. tlupoli@hsc.usf.edu
OBJECTIVE: To review and discuss the role of temporomandibular dysfunction (TMD) as a cause of chronic headaches and facial pain. DATA SOURCES AND STUDY SELECTION: A literature review was performed using the PubMed database for English-language articles published between January 1, 1981, and August 31, 2006, using the following keywords: temporomandibular dysfunction, temporomandibular disorder, temporomandibular joint, and chronic headache. Additional information was obtained from a review of current medical texts. RESULTS:. CONCLUSIONS: TMD is a likely underdiagnosed cause of chronic headache and facial discomfort. As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy. TMD can be readily diagnosed by a careful history and physical examination. Patients typically respond well to conservative therapy, which includes behavioral modification and nonsteroidal anti-inflammatory drugs. The disorder should be suspected in individuals with a long-standing history of chronic daily headaches and facial pain without objective evidence of sinus, neurologic, or intracranial abnormalities.
PMID: 17941277 [PubMed - indexed for MEDLINE]
Retro-orbital pain and TMD (TMJ) explained anatomically in this article.
A mechanism for retro-orbital pain and TMD is presented in this anatomical dissection of the the temporal branch of the zygomatic nerve passing through an accessory canal in the sphenozygomatic suture. This anatomical placement of the nerve would allow temporal muscle tension to cause nerve irritation and retro-orbital pain. Utilization of a diagnostic neuromuscular orthotic could differentiate retro-orbital pain that is best treated by neuromuscular dentistry.
Surg Radiol Anat. 2002 May;24(2):113-6.
Nervous branch passing through an accessory canal in the sphenozygomatic suture: the temporal branch of the zygomatic nerve.
Akita K, Shimokawa T, Tsunoda A, Sato T.
Unit of Functional Anatomy, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. akita.fana@tmd.ac.jp
A nervous branch which passes through a small canal in the sphenozygomatic suture is sometimes observed during dissection. To examine the origin, course and distribution of this nervous branch, 42 head halves of 21 Japanese cadavers (11 males, 10 females) and 142 head halves of 71 human dry skulls were used. The branch was observed in seven sides (16.7%); it originated from the communication between the lacrimal nerve and the zygomaticotemporal branch of the zygomatic nerve or from the trunk of the zygomatic nerve. In two head halves (4.8%), the branch pierced the anterior part of the temporalis muscle during its course to the skin of the anterior part of the temple. The small canal in the suture was observed in 31 head halves (21.8%) of the dry skulls. Although this nervous branch is inconstantly observed, it should be called the temporal branch of the zygomatic nerve according to the constant positional relationship to the sphenoid and zygomatic bones. According to its origin, course and distribution, this nervous branch may be considered to be influential in zygomatic and retro-orbital pain due to entrapment and tension from the temporalis muscle and/or the narrow bony canal. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0027-4.
PMID: 12197019 [PubMed - indexed for MEDLINE]
Surg Radiol Anat. 2002 May;24(2):113-6.
Nervous branch passing through an accessory canal in the sphenozygomatic suture: the temporal branch of the zygomatic nerve.
Akita K, Shimokawa T, Tsunoda A, Sato T.
Unit of Functional Anatomy, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. akita.fana@tmd.ac.jp
A nervous branch which passes through a small canal in the sphenozygomatic suture is sometimes observed during dissection. To examine the origin, course and distribution of this nervous branch, 42 head halves of 21 Japanese cadavers (11 males, 10 females) and 142 head halves of 71 human dry skulls were used. The branch was observed in seven sides (16.7%); it originated from the communication between the lacrimal nerve and the zygomaticotemporal branch of the zygomatic nerve or from the trunk of the zygomatic nerve. In two head halves (4.8%), the branch pierced the anterior part of the temporalis muscle during its course to the skin of the anterior part of the temple. The small canal in the suture was observed in 31 head halves (21.8%) of the dry skulls. Although this nervous branch is inconstantly observed, it should be called the temporal branch of the zygomatic nerve according to the constant positional relationship to the sphenoid and zygomatic bones. According to its origin, course and distribution, this nervous branch may be considered to be influential in zygomatic and retro-orbital pain due to entrapment and tension from the temporalis muscle and/or the narrow bony canal. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0027-4.
PMID: 12197019 [PubMed - indexed for MEDLINE]
NEW STUDY SHOWS TMD COMORBIDITY IN OVER 50% OF CHRONIC HEADACHES AND CHRONIC MIGRAINES
A new study Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study in Headache. 2010 Feb 12 is very revealing. It was evaluating chronic daily headaches, pschiatric disorders and TMD. In the study "Individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH (chronic daily headache) were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2).
Of the 1631 subjects 57 (3.6%) had CDH. Chronic migraine comprised represented 36.8% and Chronic tension-type headache represented 17.5%. Medication overuse headache was also common representing 22.8% and probable medication overuse headache representing another 17.5% were also common combined totaling 40.3% of Chronic daily headaches
There were TMD comorbidities observed in 58.1% of the patients. This is no surprise as the trigeminal nerve is almost universally involved in chronic headaches. If a thorough neuromuscular detistry evaluation was done it is likely the percentage of patients with TMD signs or symptoms would be much higher. There were also psychiatric disorders were observed in a large percentage of these patients but living with chronic pain can frequently manifest itself in secondary psychiatric problems.
I frequently find that patients who are in chronic pain, not sleeping well and overutilizing medications change ramatically after they begin using a diagnostic orthotic. I sometimes feel I don't meet the patients until their second or third visit after significant pain reduction.
It is normal to be depressed when you are in constant non-remiting pain. I have frequently said that patients in constant pain who do not become depressed are "certifiable".
When considering comorbidities it is important to understand that TMD is a causitive comorbidity that helps create the chronic headaches while the psychiatric comorbidity may be a result of the pain or not related to the pain problem.
If one was to consider medication overuse a comorbidity then the data would skew considerably. Is the medication overuse headache a symptom of the underlying TMD or psychiatric disorder. Patients with TMD are prone to seeing a wide variety of health practitioners before being diagnosed with tmd (TMJ) disorders. TMD is know as "The Great Imposter" for that reason. Please see the Sleep and Health article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor
TMD IS SUCH A MAJOR COMORBIDITY IN HEADACHES THAT EVERY PATIENT WITH CHRONIC HEADACHES OR MIGRAINES SHOULD BE EVALUATED FOR TMD PRIOR TO INITIATING MEDICATION. A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC MAY ELIMINATE THE PAIN PROBLEMS THEREBY AVOIDING FUTURE MEDICATION OVERUSE HEADACHES AND ASSOCIATED PSYCHIATRIC PROBLEMS FROM BOTH PAIN AND MEDICATION OVERUSE.
PUBMED ABSTRACT below
Headache. 2010 Feb 12. [Epub ahead of print]
Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study.
da Silva Jr A, Costa EC, Gomes JB, Leite FM, Gomez RS, Vasconcelos LP, Krymchantowski A, Moreira P, Teixeira AL.
From the UFMG - Headache Clinic, Belo Horizonte, Brazil (A. da Silva Jr, E.C. Costa, J.B. Gomes, and F.M. Leite); University Hospital, Federal University of Minas Gerais - Headache Clinic, Neurology Division, Belo Horizonte, Brazil (R.S. Gomez); Federal University of Minas Gerais (UFMG) - Internal Medicine, Belo Horizonte, Brazil (L.P. Vasconcelos and A.L. Teixeira); Universidade Federal Fluminense - Neurology, Rio de Janeiro, Brazil (A. Krymchantowski); Universidade Federal Fluminense - Headache Clinic, University Hospital, Rio de Janeiro, Brazil (P. Moreira); Federal University of Minas Gerais (UFMG) - Laboratory of Immunopharmacology, Belo Horizonte, Brazil (A.L. Teixeira).
Background.- Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking. Objectives.- To estimate the 1-year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil. Methods.- This was a cross-sectional, population-based, 2-phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2). Medication overuse headache was diagnosed, as per the ICHD-2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM-IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively. Results.- A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension-type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them. Conclusions.- The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers. (Headache 2010;**:**-**).
PMID: 20163479 [PubMed - as supplied by publisher
Of the 1631 subjects 57 (3.6%) had CDH. Chronic migraine comprised represented 36.8% and Chronic tension-type headache represented 17.5%. Medication overuse headache was also common representing 22.8% and probable medication overuse headache representing another 17.5% were also common combined totaling 40.3% of Chronic daily headaches
There were TMD comorbidities observed in 58.1% of the patients. This is no surprise as the trigeminal nerve is almost universally involved in chronic headaches. If a thorough neuromuscular detistry evaluation was done it is likely the percentage of patients with TMD signs or symptoms would be much higher. There were also psychiatric disorders were observed in a large percentage of these patients but living with chronic pain can frequently manifest itself in secondary psychiatric problems.
I frequently find that patients who are in chronic pain, not sleeping well and overutilizing medications change ramatically after they begin using a diagnostic orthotic. I sometimes feel I don't meet the patients until their second or third visit after significant pain reduction.
It is normal to be depressed when you are in constant non-remiting pain. I have frequently said that patients in constant pain who do not become depressed are "certifiable".
When considering comorbidities it is important to understand that TMD is a causitive comorbidity that helps create the chronic headaches while the psychiatric comorbidity may be a result of the pain or not related to the pain problem.
If one was to consider medication overuse a comorbidity then the data would skew considerably. Is the medication overuse headache a symptom of the underlying TMD or psychiatric disorder. Patients with TMD are prone to seeing a wide variety of health practitioners before being diagnosed with tmd (TMJ) disorders. TMD is know as "The Great Imposter" for that reason. Please see the Sleep and Health article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor
TMD IS SUCH A MAJOR COMORBIDITY IN HEADACHES THAT EVERY PATIENT WITH CHRONIC HEADACHES OR MIGRAINES SHOULD BE EVALUATED FOR TMD PRIOR TO INITIATING MEDICATION. A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC MAY ELIMINATE THE PAIN PROBLEMS THEREBY AVOIDING FUTURE MEDICATION OVERUSE HEADACHES AND ASSOCIATED PSYCHIATRIC PROBLEMS FROM BOTH PAIN AND MEDICATION OVERUSE.
PUBMED ABSTRACT below
Headache. 2010 Feb 12. [Epub ahead of print]
Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study.
da Silva Jr A, Costa EC, Gomes JB, Leite FM, Gomez RS, Vasconcelos LP, Krymchantowski A, Moreira P, Teixeira AL.
From the UFMG - Headache Clinic, Belo Horizonte, Brazil (A. da Silva Jr, E.C. Costa, J.B. Gomes, and F.M. Leite); University Hospital, Federal University of Minas Gerais - Headache Clinic, Neurology Division, Belo Horizonte, Brazil (R.S. Gomez); Federal University of Minas Gerais (UFMG) - Internal Medicine, Belo Horizonte, Brazil (L.P. Vasconcelos and A.L. Teixeira); Universidade Federal Fluminense - Neurology, Rio de Janeiro, Brazil (A. Krymchantowski); Universidade Federal Fluminense - Headache Clinic, University Hospital, Rio de Janeiro, Brazil (P. Moreira); Federal University of Minas Gerais (UFMG) - Laboratory of Immunopharmacology, Belo Horizonte, Brazil (A.L. Teixeira).
Background.- Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking. Objectives.- To estimate the 1-year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil. Methods.- This was a cross-sectional, population-based, 2-phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2). Medication overuse headache was diagnosed, as per the ICHD-2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM-IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively. Results.- A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension-type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them. Conclusions.- The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers. (Headache 2010;**:**-**).
PMID: 20163479 [PubMed - as supplied by publisher
Saturday, April 3, 2010
TMJ and Sleep Apnea
All patients with TMJ disorders especially if they get morning headaches or are tired during the day should be evaluated for sleep apnea. Sleep apnea (see www.ihatecpap.com) is a collapse of the airway during sleep.
Patients with clicking or popping TM joints will frequently have resolution of the TM Joint (temporomandibular joint) clicking if they wear a sleep apnea oral appliance.
The appliance stabilizes the condyle of the TMJ forward and if the disc is reduced allows time for the soft tissues to heal and stabilze the disc.
This stabilization will require the use of a daytime neuromuscular (splint) orthotic to maintain joint stability during the day.
Patients with clicking or popping TM joints will frequently have resolution of the TM Joint (temporomandibular joint) clicking if they wear a sleep apnea oral appliance.
The appliance stabilizes the condyle of the TMJ forward and if the disc is reduced allows time for the soft tissues to heal and stabilze the disc.
This stabilization will require the use of a daytime neuromuscular (splint) orthotic to maintain joint stability during the day.
Neuromuscular Dentistry: The basic Premises and history of the science of Neuromuscular Dentistry
Much of this material is taken from my delanydentalcare.com website and from Sleep and Health's article on Neuromuscular Dentistry http://www.sleepandhealth.com/neuromuscular-dentistry which I highly suggest you read for a more detailed explanation of neuromuscular dentistry science and physiological principles.
Neuromuscular Dentistry is founded on the basic premise that healthy physiologic muscle function is basic to all of dentistry and medicine. The health of the underlying neurological systems, particularly those of the Trigeminal Nerve including the sympathetic and parasympathetic divisions. A corollary to this concept of healthy nerves and muscles is: Doctors do not heal their patients but rather they remove the impediments to healing and the body heals itself.
The second premise is that occlusion is important in neuromuscular dentistry as a resetting mechanism of the trigeminal nervous system’s control of the stomatognathic muscles. Myocentric occlusion is ideally a position in which the muscles move the mandible from a non-torqued rest position into full occlusion with minimal muscle accommodation and no interferences of occlusal contacts until full closure is attained thus eliminating all torque (and pathological muscle adaptation) during closure. This means that there are no noxious contacts to the teeth that are received by the periodontal ligaments or the muscular proprioceptors that must be avoided by the muscles (accommodation) but rather allow “free” entry into myocentric occlusion. The jaw muscles will return to rest position after closure with the muscles maintaining their healthy low tonicity. Relaxed healthy musculature is the gold standard of neuromuscular dentistry.
I founded Ihateheadaches.org, as a resource dedicated to educating and assisting those in need of headache, migraine and TMD diagnosis and treatment.
Neuromuscular dentistry is one of the most exciting fields of dentistry. The history of dental treatment has always been mechanical and primarily involved in repairing diseased and damaged tissues. This changed in 1934 when Dr. Costen, an otolaryngologist, in St Louis, Missouri described a series of problems in denture patients that eventually grew to become know as TMD or TMJ disorders. True to the mechanical background of dentists, they treated these problems as mechanical problems.
Centric Relation was a major concept in the background of treatment of TMD (TMJ) disorders (temporomandibular disorders). Centric Relation was a terminal hinge point of the TM Joints as determined by manipulation of the lower jaw by the dentist. There is stgill a large group of doctors who cling to this concept. There have been over 26 different definitions of centric relation over the years.
Wikipedia defines centric relation as "In dentistry, centric relation is the mandibular jaw position in which the head of the condyle is situated as far superior and anterior as it possibly can within the mandibular fossa. This position is used when restoring edentulous patients with removable or either implant-supported hybrid or fixed prostheses. Because the dentist wants to be able to reproducibly relate the patient's maxilla and mandible, but the patient does not have teeth with which to establish his or her own vertical dimension of occlusion, another method has been devised to achieve this goal. The condyle can only be in the same place as it was the last time it was positioned by the dentist if it is consistently moved to the most superior and anterior position within the fossa."
The problem with the entire concept of centric relation is that it makes the musclesand nerves secondary players in occlusion. The treating doctors muscles become more important than the patients normal nerve and muscle physiology and function. This all changed due a giant in dentistry Dr Barney Jankelson considered the father of Neuromuscular Dentistry.
Dr. Barney Jankelson, a board certified prosthodontist (specialty dentist), changed dentistry by making the muscles and neuromusculqr function of patients the center of treatment. He realized that while mechanics were important in treatment of headaches, TMj disorders and other painful conditions, the underlying muscle physiology was most important. Dr. Jankelson (or Dr J) as his friends called him developed methods of relaxing muscles and measuring physiologic parameters . His work was done in Seattle, Washington now known world-wide as the birthplace of Neuromuscular dentistry. The method to create healthy musculature depended on a dental occlusion
Due to the Knowledge of Dr. J. and many other great innovators, neuromuscular dentistry became the preeminent treatment for TMJ problems.
There was a major split in dentistry with many dentists clinging to their outdated mechanical views. These dentists still believe that the jaw joint or the temporomandibular joint is the most important aspect of treatment . They consider themselves to be Centric Relation dentists. Centric relation is the description of a joint position. The fallacy of this belief is reflected in the fact that the definition of centric relation continuously changes, and there are over 20 different definitions. The main belief of this group is that the muscles of the treating dentist's hands know better where the patients jaw should function than the patient's own relaxed healthy muscles. There is a third group of dentists who do not believe in the physical nature of these disorders and believe that pschotherapy, medication and biofeedback are the best way to treat all headaches and TMJ problems. They do not believe that the teeth and occlusion are involved in the development of TMD problems or are useful in treating these problems. They believe it is primarily a psychological problem though they frequently do not communicate this fact to their patients.
Neuromuscular Dentistry recognizes that the muscles, bones, joints and nerves of the masticatory system are the same in the masticatory region as in other areas of the body and that creating a healthy system by eliminating pathological function is basic to health.
There are other greats in Neuromuscular Dentistry.
Dr. Jim Garry was a pedodontist who described how airway and facial development affected the normal formation of the jaws and face. He was a great advocate of breastfeeding, and his work has changed the lives of tens of thousands of children.
Dr. Norman Thomas is an anatomist, physiologist and dentist who understood the science behind neuromuscular dentistry and how it related to total body health and posture. He is the brilliant man that still enables clinicians to integrate their clinical skills with the underlying basic science. He continues to do some of the most important work in all of dentistry at the Las Vegas Institute (LVI).
Robert Jankelson, Barney's son, carried on his father's work and wrote the first textbook on neuromuscular dentistry.
Janet Travell, who is one of the all time medical greats in the field of pain management and is known for her textbook Myofascial Pain and Dysfunction: A Trigger Point Manual. She was President Kennedy's personal physician. He had severe chronic pain and walked with a limp and cane due to war injuries. Dr. Travell changed his life by letting him live without severe pain.
Jackie Kennedy built the Rose Garden at the White House in her honor because Dr. Travell loved Roses.
I am Dr. Ira Shapira and I was fortunate to be students of these greats of neuromuscular dentistry. I have been practicing the art and science of neuromuscular dentistry for over 30 years . My partner Dr. Mark Amidei, has been with me for over 20 years and also practices using neuromuscular dentistry.
The Las Vegas Institute, considered the premier learning institute, was founded by Dr. Bill Dickerson. His background was from the Centric Relation mechanical school of thought but 10 years ago he had the great courage to abandon the outdated ideas and teach cosmetic reconstruction using neuromuscular ideals. Thousands of dentists around the world are now embracing the science of neuromuscular dentistry. Bill is one of the great men in cosmetic dentistry but he will be best remembered for his work in making neuromuscular dentistry available to the world. Dr Norman Thomas is now leading LVI in teaching and researching Neuromusclar dentistry. He is a great inspiration to his students who will represent the future of neuromuscular dentistry and research in this important field.
Traditional dentistry operates under the assumption that your jaw's acquired position is its optimum position. Neuromuscular dentistry, on the other hand is focused on finding the ideal position or range of positions for ideal health. This optimum position for your jaw is the basis for future work. This ideal position continually resets the neuromuscular system to a healthy physiologic condition.
My goal in utilizing Neuromuscular Dentistry is not just to treat a single tooth to solve a complex problem. Instead, we examine the entire neuromuscular and anatomical system of the head and neck in order to treat the whole patient, alleviating pain throughout the mouth and body.
We strive to treat the whole problem and give our patients a higher quality of life by aligning your jaw in the most comfortable position possible. Posture throughout the body is affected by the jaw and jaw function. The lower jaw acts like a counter balance for the skull as it sits atop of the spine much like the weights that are used in a doctors scale. You set the 50 and the 10 pound weights and the when you get the 1 pound weight perfectly adjusted the scale rests perfectly centered. If you move that weight even slightly in either direction the scale does not go slightly out of balance but rather it goes clunk. That is the effect disruptions in jaw function has on the entire body's postural balance. I tell my patients, You've been clunked.
Neuromuscular Dentistry;
Diagnostic and treatment modalities: There are two manufactures who make diagnostic equipment used by Neuromuscular Dentists, Myotronics and BioResearch. Myotronics was founded by Dr Barney Jankelson.
Warning!! All doctors that use these modalities do not practice neuromuscular dentistry. Some use the information as a baseline only!
MKG- Computerized Mandibular Scan
The mkg was invented by Dr. Barney Jankelson, DR. J, and it is designed to measure mandibular movement in 3 dimensions and track the jaw to understand both function and dysfunction. The name actually means study of mandibular movement. The name was changed to differentiate between neuromuscular dentistry and kinesiology, the study of movement elsewhere in the body. The scanner works by tracking a small magnet to the lower front teeth and tracking the magnets movement by sensors that do not touch the lower jaw. This allows the study of mandibular motion free of any interfering forces. Dr Shapira has been using an MKG for 28 years starting with an early model that utilized an ossciliscope to today's modern computerized scans. I The understanding based on ossciliscope findings have been verified by today's computers. Clinicians who learned on the ossciliscope usually have a deeper understanding than doctors learning on computers today. Today's computers do give a wealth of information that was not available in the past.
EMG or electromyography is utilized in conjunction with the MKG or CMS to evaluate the physiologic state and function of the masticatory (jaw) muscles and neck postural muscles. The EMG can be used to evaluate bilateral symmetry of the muscles, the health during rest and function, and can be used for incredibly accurate adjustments to the bite.
Emg is also used to measure the effectiveness of TENS in relaxing muscles. Neuromuscular dentistry typically uses bipolar adhesive skin electrodes that measure activity only. There is no discomfort involved during EMG testing. Effectiveness of muscle relaxation can be determined by EMG following use of TENS.
Dr Shapira and Dr Amidei have recently upgraed their myotronic equipment from the K6 to two new K7diagnostic systems.
TENS or transcutaneous electrical neural stimulation is at the heart of all neuromuscular dentistry. It is used to create a healthy relaxed state in unhealthy, diseased or spastic muscles. The Myomonitor is a specific type of TENS unit invented by Dr. Barney Jankelson that is used to relax masticatory and cervical musculature. The unit uses a very small electrical impulse to gently stimulate the muscles through a single synapse reflex (similar to the knee jerk done by physicians) repeatedly over an extended time. This action naturally relaxes the muscles. While some people don't think the process sounds natural I describe it as such because the repeated pulsing and relaxation pumps metabolic wastes out of the muscle cells and brings in blood with oxygen and nutrition, and the muscle relaxes as it heals versus the unnatural relaxation occurring by dumping chemicals or drugs into the system.
The pulses occur every 1.5 seconds and last only a 500th of a second. This time is set because it is the length of time it takes the cellular membrane to return to normal after stimulation. It is for this reason the muscles can be pulsed for an extended time without fatigue.
Borer associates have a similar TENS unit that is used for the same purposes but is slightly different in design. The slight differences usually do not matter, but for difficult long-term patients, each unit has its own peculiar advantages usually only appreciated by the very skilled and adept neuromuscular practitioner.
Both types of TENS are used in conjunction with the MKG and EMG to evaluate changes in mandibular position and function as the muscles are made healthier. Most problems are associated with long term accommodation pf muscle to less than ideal conditions. This results in a repetitive strain injury as the muscles must overcompensate for long periods of time.
The best way is to look at the diagnostic information gathered with these devices as aids that help the doctor make a more accurate diagnosis and plan effective treatment. If you go to the mall and look for a store, you will look up the store on the map and then look for the you are here arrow to figure out where you are in relation to where you are going. This information is vital to prevent treatment going in the wrong direction.
Transcranial neural transmitter modulation is a very unique type of TENS unit that is designed to stimulate the brain and create neurotransmitter changes in the brain similar to potent antidepressants without the chemical side effects.
Dr. Ira Shapira has been using this instrument as part of a diagnostic protocol to help understand and differentiate between peripheral disorders and problems arising from the CNS or central nervous system.
TENSing (Transcutaneous Electrical Neuromuscular Stimulation) muscles works out the lactic acid in your jaw muscles while working in fresh blood, oxygen, and nourishment for your jaw muscles. This helps relax your muscles and helps neuromuscular dentist Dr. Shapira to re-align your jaw to its relaxed neuromuscular rest position and establish an occlusion that lets the patients muscles return to a healthy state after use. The corrective alignment is usually done by a diagnostic orthotic. This allows initial treatment that is reversible until accurate diagnosis and successful phase 1 treatment is accomplished.
Phase 1 treatment is designed to find a functional position that stabilizes the jaw and allows healthy function in which the muscles naturally return to their relaxed state. Phase 2 treatment is long term stabilization with a more permanent orthotic cosmetic reconstruction orthodontic or surgical intervention. Avoidance of surgery is a top concern of Dr. shapira because there are so many complications related to surgery.
Neuromuscular dentist, Dr. Shapira, has been working with chronic head and neck pain patients for 30 years. His practice is dedicated to non-surgical alternatives to Temporomandibular Joint Dysfunction and drug-free pain management. He is certified to treat sleep apnea with FDA approved appliances as non-surgical alternatives to UP3 and Tracheotomy. He is a Diplomate of The American Board of Dental Sleep Medicine and TYhe American Academy of Pain Management. He understands the relation of jaw position and sleep apnea to all of the physical and biochemical disorder patients deal with. He has successfully treated hundreds of patients with a multitude of TM Joint problems, TMD and the myriad of related conditions. As a former sufferer of chronic pain, Dr Shapira made it a personal crusade to not only relieve his pain but to give patients a quality of life they never thought was possible.
Dr Shapira trained with Dr Janet Travell, the world's expert on myofascial pain and dysfunction and uses the techniques he learned from her to alleviate pain and restore normal function to his patients. Many experts consider fibromyalgia and myofascial dysfunction to be different subsets of the same disorder.
The I HATE Headaches website has a find a Dentist area that will continue to grow. If there is not a dentist in your area on the site currently contact Dr Shapira and he will help you locate a Neuromuscular Dentist in your area.
Neuromuscular Dentistry is founded on the basic premise that healthy physiologic muscle function is basic to all of dentistry and medicine. The health of the underlying neurological systems, particularly those of the Trigeminal Nerve including the sympathetic and parasympathetic divisions. A corollary to this concept of healthy nerves and muscles is: Doctors do not heal their patients but rather they remove the impediments to healing and the body heals itself.
The second premise is that occlusion is important in neuromuscular dentistry as a resetting mechanism of the trigeminal nervous system’s control of the stomatognathic muscles. Myocentric occlusion is ideally a position in which the muscles move the mandible from a non-torqued rest position into full occlusion with minimal muscle accommodation and no interferences of occlusal contacts until full closure is attained thus eliminating all torque (and pathological muscle adaptation) during closure. This means that there are no noxious contacts to the teeth that are received by the periodontal ligaments or the muscular proprioceptors that must be avoided by the muscles (accommodation) but rather allow “free” entry into myocentric occlusion. The jaw muscles will return to rest position after closure with the muscles maintaining their healthy low tonicity. Relaxed healthy musculature is the gold standard of neuromuscular dentistry.
I founded Ihateheadaches.org, as a resource dedicated to educating and assisting those in need of headache, migraine and TMD diagnosis and treatment.
Neuromuscular dentistry is one of the most exciting fields of dentistry. The history of dental treatment has always been mechanical and primarily involved in repairing diseased and damaged tissues. This changed in 1934 when Dr. Costen, an otolaryngologist, in St Louis, Missouri described a series of problems in denture patients that eventually grew to become know as TMD or TMJ disorders. True to the mechanical background of dentists, they treated these problems as mechanical problems.
Centric Relation was a major concept in the background of treatment of TMD (TMJ) disorders (temporomandibular disorders). Centric Relation was a terminal hinge point of the TM Joints as determined by manipulation of the lower jaw by the dentist. There is stgill a large group of doctors who cling to this concept. There have been over 26 different definitions of centric relation over the years.
Wikipedia defines centric relation as "In dentistry, centric relation is the mandibular jaw position in which the head of the condyle is situated as far superior and anterior as it possibly can within the mandibular fossa. This position is used when restoring edentulous patients with removable or either implant-supported hybrid or fixed prostheses. Because the dentist wants to be able to reproducibly relate the patient's maxilla and mandible, but the patient does not have teeth with which to establish his or her own vertical dimension of occlusion, another method has been devised to achieve this goal. The condyle can only be in the same place as it was the last time it was positioned by the dentist if it is consistently moved to the most superior and anterior position within the fossa."
The problem with the entire concept of centric relation is that it makes the musclesand nerves secondary players in occlusion. The treating doctors muscles become more important than the patients normal nerve and muscle physiology and function. This all changed due a giant in dentistry Dr Barney Jankelson considered the father of Neuromuscular Dentistry.
Dr. Barney Jankelson, a board certified prosthodontist (specialty dentist), changed dentistry by making the muscles and neuromusculqr function of patients the center of treatment. He realized that while mechanics were important in treatment of headaches, TMj disorders and other painful conditions, the underlying muscle physiology was most important. Dr. Jankelson (or Dr J) as his friends called him developed methods of relaxing muscles and measuring physiologic parameters . His work was done in Seattle, Washington now known world-wide as the birthplace of Neuromuscular dentistry. The method to create healthy musculature depended on a dental occlusion
Due to the Knowledge of Dr. J. and many other great innovators, neuromuscular dentistry became the preeminent treatment for TMJ problems.
There was a major split in dentistry with many dentists clinging to their outdated mechanical views. These dentists still believe that the jaw joint or the temporomandibular joint is the most important aspect of treatment . They consider themselves to be Centric Relation dentists. Centric relation is the description of a joint position. The fallacy of this belief is reflected in the fact that the definition of centric relation continuously changes, and there are over 20 different definitions. The main belief of this group is that the muscles of the treating dentist's hands know better where the patients jaw should function than the patient's own relaxed healthy muscles. There is a third group of dentists who do not believe in the physical nature of these disorders and believe that pschotherapy, medication and biofeedback are the best way to treat all headaches and TMJ problems. They do not believe that the teeth and occlusion are involved in the development of TMD problems or are useful in treating these problems. They believe it is primarily a psychological problem though they frequently do not communicate this fact to their patients.
Neuromuscular Dentistry recognizes that the muscles, bones, joints and nerves of the masticatory system are the same in the masticatory region as in other areas of the body and that creating a healthy system by eliminating pathological function is basic to health.
There are other greats in Neuromuscular Dentistry.
Dr. Jim Garry was a pedodontist who described how airway and facial development affected the normal formation of the jaws and face. He was a great advocate of breastfeeding, and his work has changed the lives of tens of thousands of children.
Dr. Norman Thomas is an anatomist, physiologist and dentist who understood the science behind neuromuscular dentistry and how it related to total body health and posture. He is the brilliant man that still enables clinicians to integrate their clinical skills with the underlying basic science. He continues to do some of the most important work in all of dentistry at the Las Vegas Institute (LVI).
Robert Jankelson, Barney's son, carried on his father's work and wrote the first textbook on neuromuscular dentistry.
Janet Travell, who is one of the all time medical greats in the field of pain management and is known for her textbook Myofascial Pain and Dysfunction: A Trigger Point Manual. She was President Kennedy's personal physician. He had severe chronic pain and walked with a limp and cane due to war injuries. Dr. Travell changed his life by letting him live without severe pain.
Jackie Kennedy built the Rose Garden at the White House in her honor because Dr. Travell loved Roses.
I am Dr. Ira Shapira and I was fortunate to be students of these greats of neuromuscular dentistry. I have been practicing the art and science of neuromuscular dentistry for over 30 years . My partner Dr. Mark Amidei, has been with me for over 20 years and also practices using neuromuscular dentistry.
The Las Vegas Institute, considered the premier learning institute, was founded by Dr. Bill Dickerson. His background was from the Centric Relation mechanical school of thought but 10 years ago he had the great courage to abandon the outdated ideas and teach cosmetic reconstruction using neuromuscular ideals. Thousands of dentists around the world are now embracing the science of neuromuscular dentistry. Bill is one of the great men in cosmetic dentistry but he will be best remembered for his work in making neuromuscular dentistry available to the world. Dr Norman Thomas is now leading LVI in teaching and researching Neuromusclar dentistry. He is a great inspiration to his students who will represent the future of neuromuscular dentistry and research in this important field.
Traditional dentistry operates under the assumption that your jaw's acquired position is its optimum position. Neuromuscular dentistry, on the other hand is focused on finding the ideal position or range of positions for ideal health. This optimum position for your jaw is the basis for future work. This ideal position continually resets the neuromuscular system to a healthy physiologic condition.
My goal in utilizing Neuromuscular Dentistry is not just to treat a single tooth to solve a complex problem. Instead, we examine the entire neuromuscular and anatomical system of the head and neck in order to treat the whole patient, alleviating pain throughout the mouth and body.
We strive to treat the whole problem and give our patients a higher quality of life by aligning your jaw in the most comfortable position possible. Posture throughout the body is affected by the jaw and jaw function. The lower jaw acts like a counter balance for the skull as it sits atop of the spine much like the weights that are used in a doctors scale. You set the 50 and the 10 pound weights and the when you get the 1 pound weight perfectly adjusted the scale rests perfectly centered. If you move that weight even slightly in either direction the scale does not go slightly out of balance but rather it goes clunk. That is the effect disruptions in jaw function has on the entire body's postural balance. I tell my patients, You've been clunked.
Neuromuscular Dentistry;
Diagnostic and treatment modalities: There are two manufactures who make diagnostic equipment used by Neuromuscular Dentists, Myotronics and BioResearch. Myotronics was founded by Dr Barney Jankelson.
Warning!! All doctors that use these modalities do not practice neuromuscular dentistry. Some use the information as a baseline only!
MKG- Computerized Mandibular Scan
The mkg was invented by Dr. Barney Jankelson, DR. J, and it is designed to measure mandibular movement in 3 dimensions and track the jaw to understand both function and dysfunction. The name actually means study of mandibular movement. The name was changed to differentiate between neuromuscular dentistry and kinesiology, the study of movement elsewhere in the body. The scanner works by tracking a small magnet to the lower front teeth and tracking the magnets movement by sensors that do not touch the lower jaw. This allows the study of mandibular motion free of any interfering forces. Dr Shapira has been using an MKG for 28 years starting with an early model that utilized an ossciliscope to today's modern computerized scans. I The understanding based on ossciliscope findings have been verified by today's computers. Clinicians who learned on the ossciliscope usually have a deeper understanding than doctors learning on computers today. Today's computers do give a wealth of information that was not available in the past.
EMG or electromyography is utilized in conjunction with the MKG or CMS to evaluate the physiologic state and function of the masticatory (jaw) muscles and neck postural muscles. The EMG can be used to evaluate bilateral symmetry of the muscles, the health during rest and function, and can be used for incredibly accurate adjustments to the bite.
Emg is also used to measure the effectiveness of TENS in relaxing muscles. Neuromuscular dentistry typically uses bipolar adhesive skin electrodes that measure activity only. There is no discomfort involved during EMG testing. Effectiveness of muscle relaxation can be determined by EMG following use of TENS.
Dr Shapira and Dr Amidei have recently upgraed their myotronic equipment from the K6 to two new K7diagnostic systems.
TENS or transcutaneous electrical neural stimulation is at the heart of all neuromuscular dentistry. It is used to create a healthy relaxed state in unhealthy, diseased or spastic muscles. The Myomonitor is a specific type of TENS unit invented by Dr. Barney Jankelson that is used to relax masticatory and cervical musculature. The unit uses a very small electrical impulse to gently stimulate the muscles through a single synapse reflex (similar to the knee jerk done by physicians) repeatedly over an extended time. This action naturally relaxes the muscles. While some people don't think the process sounds natural I describe it as such because the repeated pulsing and relaxation pumps metabolic wastes out of the muscle cells and brings in blood with oxygen and nutrition, and the muscle relaxes as it heals versus the unnatural relaxation occurring by dumping chemicals or drugs into the system.
The pulses occur every 1.5 seconds and last only a 500th of a second. This time is set because it is the length of time it takes the cellular membrane to return to normal after stimulation. It is for this reason the muscles can be pulsed for an extended time without fatigue.
Borer associates have a similar TENS unit that is used for the same purposes but is slightly different in design. The slight differences usually do not matter, but for difficult long-term patients, each unit has its own peculiar advantages usually only appreciated by the very skilled and adept neuromuscular practitioner.
Both types of TENS are used in conjunction with the MKG and EMG to evaluate changes in mandibular position and function as the muscles are made healthier. Most problems are associated with long term accommodation pf muscle to less than ideal conditions. This results in a repetitive strain injury as the muscles must overcompensate for long periods of time.
The best way is to look at the diagnostic information gathered with these devices as aids that help the doctor make a more accurate diagnosis and plan effective treatment. If you go to the mall and look for a store, you will look up the store on the map and then look for the you are here arrow to figure out where you are in relation to where you are going. This information is vital to prevent treatment going in the wrong direction.
Transcranial neural transmitter modulation is a very unique type of TENS unit that is designed to stimulate the brain and create neurotransmitter changes in the brain similar to potent antidepressants without the chemical side effects.
Dr. Ira Shapira has been using this instrument as part of a diagnostic protocol to help understand and differentiate between peripheral disorders and problems arising from the CNS or central nervous system.
TENSing (Transcutaneous Electrical Neuromuscular Stimulation) muscles works out the lactic acid in your jaw muscles while working in fresh blood, oxygen, and nourishment for your jaw muscles. This helps relax your muscles and helps neuromuscular dentist Dr. Shapira to re-align your jaw to its relaxed neuromuscular rest position and establish an occlusion that lets the patients muscles return to a healthy state after use. The corrective alignment is usually done by a diagnostic orthotic. This allows initial treatment that is reversible until accurate diagnosis and successful phase 1 treatment is accomplished.
Phase 1 treatment is designed to find a functional position that stabilizes the jaw and allows healthy function in which the muscles naturally return to their relaxed state. Phase 2 treatment is long term stabilization with a more permanent orthotic cosmetic reconstruction orthodontic or surgical intervention. Avoidance of surgery is a top concern of Dr. shapira because there are so many complications related to surgery.
Neuromuscular dentist, Dr. Shapira, has been working with chronic head and neck pain patients for 30 years. His practice is dedicated to non-surgical alternatives to Temporomandibular Joint Dysfunction and drug-free pain management. He is certified to treat sleep apnea with FDA approved appliances as non-surgical alternatives to UP3 and Tracheotomy. He is a Diplomate of The American Board of Dental Sleep Medicine and TYhe American Academy of Pain Management. He understands the relation of jaw position and sleep apnea to all of the physical and biochemical disorder patients deal with. He has successfully treated hundreds of patients with a multitude of TM Joint problems, TMD and the myriad of related conditions. As a former sufferer of chronic pain, Dr Shapira made it a personal crusade to not only relieve his pain but to give patients a quality of life they never thought was possible.
Dr Shapira trained with Dr Janet Travell, the world's expert on myofascial pain and dysfunction and uses the techniques he learned from her to alleviate pain and restore normal function to his patients. Many experts consider fibromyalgia and myofascial dysfunction to be different subsets of the same disorder.
The I HATE Headaches website has a find a Dentist area that will continue to grow. If there is not a dentist in your area on the site currently contact Dr Shapira and he will help you locate a Neuromuscular Dentist in your area.
Friday, April 2, 2010
Medication overuse headaches, Living Without Pain and how Neuromuscular Dentistry Can Help Change Lives
It is an intresthing phenomenon that medication overuse headaches are an enormous problem in neuromuscular dentistry even though most neuromuscular dentists use very little medication. By the time patients have been seen by a neuromuscular dentist they have frequently seen numerous physicians and other medical specialists and are using multiple perscription and over the counter medications.
Breaking the cycle of medication overuse headache by STEWART J. TEPPER, MD in the Cleveland Clinic Journal of Medicine reported:
"(Abstract) When patients who have frequent, disabling migraines take medications to relieve their symptoms, they run the risk that the attacks will increase in frequency to daily or near-daily as a rebound effect comes into play. This pattern, called medication overuse headache, is more likely to happen with butalbital and opioids than with migraine-specific drugs, as partial responses lead to recurrence, repeat dosing, and, eventually, overuse. Breaking the cycle involves weaning the patient from the overused medications, setting up a preventive regimen, and setting strict limits on the use of medications to relieve acute symptoms."
Medication overuse headaches are a frequent event with neuromuscular problems that frequently caue chronic daily tension headaches. These medications to not correct the underlying problem and the paient now has a layer cake of headaches that are often frosted with vascular headaches. The tirgeminal nervous system and the related trigeminovascular system is primarily responsible for the majority of headaches. I frequently find weaning my patients off narcotic and pschoactive medications is much harder than eliminating their pain. This is especially true because I advise patients to follow their physicians guidance when weaning off medication. Physicians who have heavily prescribe drugs are not always the best influence to convince patients that overuse headaches are a problem.
Many patients who suffer from medication overuse headaches originally had either migraines, tension-type headaches or a combination of headaches. They frequently also have anxiety and depression as comorbidities. Chronic daily headaches usualy is defined by 3 months with over 15 days/month of headaches that last 4 or more hours if not treated with medication.
According to Dr Tepper "In a large population-based study,3 2.5% of patients who began with episodic migraine (headaches on fewer than 15 days per month) had “transformed migraine” (headaches on 15 or more days per month) 1 year later. The prevalence of chronic daily headache is almost 5% of the general population and may account for up to 70% of the initial diagnoses seen in headache centers." This is what I would call iatrogenic medicine where the treatment of episodic migraine can result in the development of transformed migraine. What is probably more common is that patients with headaches due to nociceptive trigeminal impulses which create migraine and Episoic Tension-Type Headaches are treated with medication rather than correction of the root causes of the headache.
Treatment of headaches must always consider the time of day when headaches occur. Morning headaches are almost universally a result of sleep apnea and/or trigeminal headaches as a result of TMJ disorders and clenching, grinding or other parafunction. The NHLBI considers sleep apnea to be a TMJ disorder so almost 100% of morning headaches are related to abnormal jaw and trigeminal nervous system input.
Denture Patients with morning headachjes represent a special population that may have an easy solution. Historically, dentists have told patients to sleep with their dentures out. this has been shown to cause drastic increases in sleep apnea (and probably morning headaches). Wearing dentures may not only relieve headaches, neck pain and sleep apnea but also help avoid heart attacks, strokes and memory loss. Denture patients with chronic head and neck pain should seek out a neuromuscular dentist who can idealize the physiology of the masticatory system. When patients wear dentures to long without replacement or refitting they may be prone to neck pain and cervicogenic headaches due to changes in head posture.
Dr Tepper describes medication overuse headaches as follow: "Medication overuse headache is a subset of chronic daily headache, also occurring on 15 or more days per month but with the added criterion of medication overuse, ie, regular overuse for more than 3 months of at least one acute treatment drug:
Ergotamine, triptans, opioids, or combination analgesic medications on 10 or more days per month on a regular basis for more than 3 months, or
Simple analgesics or any combination of ergotamine, triptans, analgesics, or opioids on 15 or more days per month on a regular basis for more than 3 months without overuse of any single class alone.
Another criterion is that the patient’s headaches must worsen in some way (usually frequency) as the use of acute medications becomes more frequent.
Medication overuse headache is the most common form of secondary chronic daily headache seen in headache practice, and probably accounts for about half of cases of chronic daily headache."
His article states that this is the most common form of secondary chronic daily headaches. An iatrogenic disorder is one that is caused by the medical treatment. Secondary headaches from meication overuse are definitely iatrogenid and are frequently accompanied by other iatrogenic problems such as bleeding ulcers, narcotic addictions and numerous medication side effects.
THERE ARE TIMES WHEN IT IS ABSOLUTELY NECESSARY TO CONTROL SEVERE PAIN WITH HEAVY DOSES OF MEDICATION. IT IS NOT ACCEPTABLE THAT CORRECTION OF THE UNDERLYING CONDITIONS THAT MAKE PATIENTS REQUIRE THESE DRUGS ARE NOT ADDRESSED. A PREVIOUS POST DISCUSSED IDENTIFICATION OF MYOFASCIAL TRIGGER POINTS VASTLY IMPOVING MIGRAINE TREATMENT SUCCESS.
NEUROMUSCULAR DENTISTS ARE A VALUABLE ASSET TO ALL HEADACHE PATIENTS. Many neurologists are not familiar with the science(http://www.sleepandhealth.com/neuromuscular-dentistry) behind Neuromuscular Dentistry. An excellent approach for all patients with any type of chronic migraine or tension headache to utilize a neuromuscular diagnostic orthotic for a period of about 6 -12 weeks. A neuromuscular orthotic must be worn 24 hours/day and seven days a week and therefore must be comfortable for normal daily life functions.
Most patients respond amazingly well to the diagnostic orthotic and it is rare to not see a minimum of 50% improvement in chronic daily and tension type headaches. Patients with migraines associated with ovulation and/or menstrual cycle may still have exaccerbations during those times. Patients should continue to avoid known headache triggers.
Cervicogenic headaches also respond to neuromuscular dentistry due to changes in forward head posture that gradually occur while wearing the diagnostic orthotic. As the body posture corrects it is frequently necessary to reshape and resurface the diagnostic orthotic over time. I usually start with adjustments one time a week and gradually increase the time between visits. Each patient is unique and some patients need more frequent adjustments. Other patients have "miracle relief" with complete elimination of all migraine and muscle pain after the first visit. Often the "miracle relief" patient is not cured but just has so much relief and never felt so good that they report complete relief. When they get used to this new feeling (not having pain is often a totally new sensation) there are often still residual problems to address.
Patients discuss feeling a lightness or sense of energy because they are no longer utilizing so many physiologic and psychologic processes to cover up the pain and cope.
I often find that a few visits into treatment I "meet the paient for the first time" because they have changed in dramatic ways that are far more complex than presence of absence of pain. There is a "lightness to their soul" or a new hope not of pain relief but of resuming their life. One patient described her orthotic as ending "Life Interruptess" and I have had spouses tell me that they have rediscovered the person who was lost in a sea of pai.
This does not always translate into total cures, frequently a patient in constant pain for years findsa large bulk of pain gone and they can then begin the process of solving remaining problems that are now discrete entities. Prior, when drowning in pain they could not see the forest for the trees. As overall pain relief occurs they can now actually have proper diagnosis of other problems.
Depression and pschological disorders frequently disappear. I describe as the difference between psychosomatic pain and Somatophsycic pai.
In simplest terms psychosomtic pain translates into "I HURT BECAUSE I'M CRAZY" while Somatopsychic pain translates into "MY PAIN IS MAKING ME CRAZY". Relieve the pain and the "CRAZY" is gone. It is normal to be depressed when you are in constant pain, in fact, "IF YOU ARE IN CONSTANT TERRIBLE PAIN AND DO NOT BECOME DEPRESSED YOU ARE CERTIFIABLE" Depression is a normal outcome of chronic pain.
There is no true cure for long term pain because the pain has changed your past, who you were and what you did. Relief of pain lets you move forward without the weight of a 1000 pound albatross around your neck but the only true cure would be " A DO-OVER ON THE YEARS WHERE CHRONIC PAIN RULED YOUR LIFE" and unfortunately no one can roll back the clock and make you the person you would have been without your pain.
Dr Tepper discusses the many names given to these medication overuse headaches in his article: "Many terms have been used to describe medication overuse headache in the past, such as analgesic-rebound headache (or just rebound headache), transformed migraine with medication overuse, and even chronic migraine. The lack of uniformity in terminology makes for confusion in the literature and difficulty in communicating with patients and colleagues. Some authors mean medication overuse headache when they say chronic daily headache." He spells out why so many patients cannot find answers to their problems. Clearly identifying both the cause and the symptoms is vital in treatment. A essential element in identifying the cause is ruling out other causes. This is why a neuromuscular dental orthotic is so vital not just for treatment but as an essential element of the diagnostic protocol.
Dr Tepper goes on to state: "Complicating this diagnostic confusion is a debate as to whether chronic daily headache in general should be treated as a primary or secondary headache disorder." THIS IS EXTREMELY IMPORTANT! IF WE ARE NOT CLEAR IF WE ARE TREATING THE UNDERLYING CONDITION OR THE IATROGENIC SYMPTOMS OR MEDICATION OVERUSE, MORE HARM CAN BE DONE TO THE PATIENT. ACCORDING TO DR TEPPER " Some European headache specialists insist on a strict division between primary and secondary daily headaches, and medication overuse headache is one of the latter. Many American specialists believe that chronic daily headache is a collective description or phenotype rather than a diagnostic category, and that it is usually associated with and exacerbated by medication overuse. The International Classification of Headache Disorders uses the term “chronic migraine” for primary daily headache, and “medication overuse headache” for secondary daily headache or rebound." THIS LACK OF CLARITY IN DIAGNOSIS IS A MAJOR FAULT IN TREATMENT OF CHRONIC DAILY HEADACHE.
It is important to remember that the meication is used primarily to alter changes caused by the trigeminovascular system. The easies and safest method of altering the Trigeminal nervous system is thru altering afferent impulses that create noxious results. The NTI-TSS appliance is considered an extremely effective, if not most effective migraine treatment. Unfortunately is may complicate achieving a long-term health position. I frequently will use the NTI or a version of it in nocturnal (night-time) appliances but find that for patients looking for long -term complete relief have better results with neuromuscular orthotics. It is postulated that part of the effect of the NTI is on sleep apnea by increasing tongue space and reducing apnea. It is well known that when patients have apneic eventsthat result in changes in sleep stage clenching frequently results. When patients with sleep apnea are treated via Dental Sleep Medicine (http://www.ihatecpap.com) complete or partial headache and migraine relief is frequently reported.
Central Sensitization is a major factor in acute problems becoming chronic and in the development of RSD or CRPS. According to Dr Tepper "Complicating the dilemma, acute migraine-specific medications such as triptans and dihydroergotamine (Migranal) work better when taken early in migraine attacks, before central sensitization and allodynia develop with attendant photophonophobia and sensitivity to other stimuli. On the other hand, overuse will lead to medication overuse headache."
The use of Neuromuscular Dentistry can help prevent central sensitization and even reduce the changes caused by neural plasticity. Central sensitization or changes to the CNS may be reversible if noxious input to the system is reduced. This is the same whether using NTI-TSS or Neuromuscular Orthotics. The difference is NTI uses a new pathological input to turn off or overide a more powerful noxious input whereas a neuromuscular orthotic is used to reduce all noxious input and to return to a normal physiologic state. When sleep apnea is present it is advisable to treat daytime and nightime conditions with distinct appliances.
The next section of Dr Tepper's article I have some points of Disagreement and I will use all capitals for my comments.
"SYMPTOMS VARY (from article)
The symptoms of medication overuse headache vary in frequency, severity, location, quality, and associated features, both among patients and in the same patient. This is because the disease itself varies and also because of differences in the type and frequency of medication intake. Still, some features help to define this problem, and failing to recognize them may account for a widely held clinical feeling that these patients are “difficult.” THIS WIDE VARIETY OF PROBLEMS WILL FAIL TO SEPERATE PRIMARY FROM SECONDARY HEADACHES.
History of episodic migraine. Generally, medication overuse headache does not occur in nonmigraineurs. THE ACTUAL DIAGNOSIS OF MIGRAINE IS FREQUENTLY SUSPECT AND CHRONIC USE OF DRUGS LIKE EXCEDRIN FREQUENTLY OCCURS IN PATIENTS WITH TMD, CERVICAL PAIN AND MUSCULAR TENSION-TYPE HEADACHES.
Headache on most days of the month. Whenever a migraineur starts having headaches on more days than not, the diagnosis of medication overuse should be considered. REMEMBER THERE CAN BE MIGRAINES MIXED WITH TENSION TYPE HEADACHES AND FREQUENTLY THEY BLEND TOGETHER IN THE PATIENTS MIND AS MORE SEVERE AND LESS SEVER MIGRAINE WHEN IN REALITY THEY HAVE TENSION-TYPE HEADACHES OR TMD HEADCHES WITH PERIODIC MIGRAINE.
Overuse of acute medications. The criteria (see above) allow for combining days of acute medication use. For example, if a patient takes a combination analgesic on 5 days and a triptan on 5 different days, that would still be enough days of acute treatment to trigger medication overuse headache.
Variable pain location (THIS IS ALSO CONSISTENT WITH TMD OR MYOFASCIAL PAIN) is a particular characteristic of medication overuse headache. Although the location may differ from day to day (front or back, rostral or caudal, unilateral or bilateral), it is the quantity not the quality or location of the headaches that suggests the diagnosis.
A drug-dependent rhythm. Predictably, the headaches come on in the early morning or awaken the patient from sleep. This may be due to variable drug withdrawal. AS DISCUSSED PREVIOUSLY TMD AND SLEEP APNEA ARE THE PRIMARY CAUSES OF MORNING HEADACHES.
Neck pain. Medication overuse headache frequently involves the neck, and patients often seek and receive treatments such as muscle relaxants or injections to the neck. When patients are weaned from their acute migraine medications, neck pain generally dissipates. The neck pain, however, can recur episodically with their remaining, now-episodic acute migraines. Neck pain associated with medication overuse headache is not usually a sign of a primary neck disorder; rather, it is a symptom of medication overuse headache itself. NEUROLOGISTS FREQUENTLY DO NOT CONSIDER MANUAL OR ANATOMICAL CAUSES OF NECK PAIN IN RELATION TO HEADACHES. PATIENTS WHO ARE OVERCLOSED TEND TO HAVE FORWARD HEAD POSITION THAT CAUSES NECK PAIN AND CERVICOGENIC HEADACHES. THE QUADRANT THEOREM OF GUZAY EXPLAINS WHY THIS HAPPENS. ROCOBADO HAS SHOWN THAT EVERY CM OF FORWARD HEAD POSTURE REQUIRES TWICE THE EFFORT TO MAINTAIN POSTURE. A TWO INCH FORWARD HEAD POSTURE WOULD RESULT IN 3200% INCREASE IN TONIC MUSCLE ACTIVITY TO LOW BACK.
Concomitant depression and anxiety are comorbid with episodic migraine, but appear to be more common with medication overuse headache. Treating the depression or anxiety does not restore an episodic pattern of migraine; weaning from the overused medications remains the most important intervention. A frequent clinical error is to diagnose and treat the psychiatric issues without recognizing medication overuse as the primary problem. A FREQUENT PROBLEM IS WHEN ONE ASSUMES THE DEPRESSION IS THE CAUSE OF PAIN INSTEAD A SECONDARY RESULT OF PAIN. SLEEP DISTURBANCES ASSOCIATED WITH DEPRESSION CAN CERTAINLY INCREASE BOTH MUSCLE PAIN AND HEADACHES. DEPRESION IS FREQUENTLY SEEN WITH UNDIAGNOSED SLEEP APNEA.
Nonrestorative sleep is almost always reported by patients with medication overuse headache. This is often due to the caffeine contained in combination analgesics or to excessive dietary caffeine intake, but it may also be part of the daily acute drug withdrawal syndrome. The sleep problems are also associated with the concomitant depression. Sleep often improves after weaning from the offending substance or substances. As with neck pain, patients do not have a primary sleep disorder—the sleep disturbance is a symptom of medication overuse headache. MANY OF THESE PATIENTS, ESPECIALLY WOMEN DO HAVE AN UNDERLYING SLEEP DISORDER, UARS OR UPPER AIRWAY RESISTAANCE SYNDROME BUT IT DOES NOT MEET THE DIAGNOSTIC CRITERIA TO BE CONSIDERD SLEEP APNEA SYNDROME. THE DEFINITIONS FOR APNEA WERE DEVELOPED ON OLD FAT MEN AND TEND TO UNDERSCORE OF MISS THE DIAGNOOSIS IN FEMALES AND YOUNGER THINNER HEALTHIER PATIENTS IN GENERAL.
ALPHA-INTRUSION INTO DELTA SLEEP IS THE MARKER FOR FIBROMYALGIA BUT IS ALSO FREQUENTLY SEEN WITH TMD DUE TO AIRWAY PROBLEMS.
Vasomotor instability. Autonomic features are commonly associated with medication overuse headache. Rhinorrhea, nasal stuffiness, and lacrimation are features of medication withdrawal, especially from opioids, and are frequently attributed to sinus disease or “sinus headaches.” Many patients undergo unnecessary sinus procedures or are given antibiotics, decongestants, and other wrong medications for incorrect diagnoses. Decongestants can cause and exacerbate medication overuse headache, so they need to be withdrawn. The sinus features generally remit when the overused migraine medications are eliminated. MANY OF THESE PROBLEMS ARE RELATED TO THE NASAL CYCLE AND THE SWITCHING OF SYMPATHETIC AND PARASYMPATHETIC PROCESSES THAT OCCUR ON A REGULAR BASIS AT NIGHT. THERE IS AN EXCELLENT ARTICLE THAT DESCRIBES SOME OF THESE PROCESSES AT: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=1163 THESE SYMPTOMS MAY BE MORE RELATED TO A NORMAL PHYSIOLOGIC PROCESS AND ACTUALLY SERVE AS A CUASE OF MEDICATION OVERUSE.
Preventive medications are less effective or ineffective until the acute medications are withdrawn. Thus, prescribing prevention without weaning is usually futile, and the patients are often dismissed as having a refractory problem. At the same time, migraine-specific acute treatments, ie, triptans and ergots, are usually also less effective. When patients complain that “nothing works,” either preventively or acutely, medication overuse headache should spring to mind. THE SAME HOLDS TRU WHEN TREATING PATIENTS WITH A NEUROMUSCULAR ORTHOTIC. EVEN THOUGH THE UNDERLYING PROBLEM MAY BE CORRECTED AND WILL PREVENT FUTURE HEADACHES THE PATIENT STILL SUFFERS WITHRAWAL SYMPTOMS THAT MAKE THEM FEEL THERAPY IS INEFFECTIVE. IN REALITY THE DRUG PROBLEM (IATROGENIC) ACTUALLY HIDES THE EFFECTIVENESS OF TREATMENT.
I TELL MY PATIENTS TO NOT CHANGE DRUG REGIMEN INITIALLY BUT TO CONTINUE ON THEIR CURRENT MEDS WHILE GOING THRU THE FIRST PHASE OF TREATMENT. ONCE STABILITY IS REACHED THEY CAN THEN GO THRU DRUG WITHDRAWAL THERAPY WHICH WILL BE EASIER BUT STILL UNPLEASANT.
Weaning from overused medications can restore the efficacy of previously ineffective treatments at the same time that a patient is restored to an episodic headache pattern. Thus, complete weaning is the pivotal clinical intervention. Clinically, there is no spontaneous remission from rebound without absolute detoxification, maintained for months. ONCE WEANED FROM MEDICATIONS THEY FREQUENTLY WILL NO LONGER NEED THESE MEDICATIONS ANY LONGER. IF THERE ARE STILL ISOLATED EVENTS THAT CONTINUE MEDICATION USE WILL PROBABLY BE GREATLY REDUCED.
THE FOLLOWING PARAGRAPH IS WHAT I FIND TRULY FIGHTENING ABOUT THIS PAPER. ASSUMING THE HEADACHE IS DUE TO MEDICATION OVERUSE IGNORES WHY OVERUSE OCCURED INITIALLY. THE LIST OF DIFFERENTIAL DIAGNOSIS ARE ALL POSSIBLE CUASES AND SHOULD BE INDIVIDUALLY AND COLLECTIVELY CONSIDERED BEFORE PATIENTS REACH TOXIC LEVELS OF MEDICATIONS THAT CAUSE IATROGENIC PROBLEMS. ALMOST ALL HEADACHES ARE RELATED TO TRIGEMINAL NERVOUS INPUT FROM THE JAWS AND TEETH AND IT ACCOUNTS FOR OVER 50% OF THE TOTAL INPUT TO THE BRAIN. SLEEP APNEA IS A SECONDARY CONDITION ALSO RELATING TO THE JAW POSITION.
"Other diagnoses entertained. The more diagnoses suggested for daily headache, and the more treatments tried unsuccessfully, the more likely the diagnosis is actually medication overuse headache. Because this condition is protean, patients and caregivers alike make more and more fanciful diagnoses such as allergies, cervicogenic headache, temperomandibular disorder, occipital neuralgia, chronic Lyme disease, and systemic candidiasis. A useful strategy is to assume that daily headache is likely due to medication overuse. And since medication overuse headache is generally treatable, patients labeled as having refractory headaches often are dramatically improved by appropriate intervention."
MEDICATION OVERUSE IS REAL AND A SERIOUS PROBLEM BUT TO DISCOUNT WHAT ARE POSSIBLY KEY ELEMENTS IN TREATMENT IS NOT ONLY FLWED BUT DANGEROUS BECAUSE FREQUENTLY PATIENTS WILL IN DESPERATION SEEK OUT NON-PROFESSIONALLY PRESCRIBED DRUG ALERNATIVES. NEUROMUSCULAR DENTISTRY, NUCCA, A?O CHIROPRACTIC, PHYSICAL THERAPY, MASSAGE THERAPY, TRIGGER PONT INJECTIONS AND NUMEROUS OTHER PHYSICAL MEDICINE MODALITIES SHOULD BE USED TO DECREASE PAIN AS AN ESSENTIAL PART OF MEDICATION CONTROL.
THE USE OF NON-INVASIVE INTRANASAL SPHENOPLATINE GANGLION BLOCKS CAN MAKE THE PROCESS MUCH SMOOTHER.
THE STATEMNTS "Episodic migraine attacks appear to be generated in the upper brainstem. This region in turn activates a set of peripheral pain mechanisms, ie, meningeal inflammation and vasodilation. The peripheral pain processes turn on afferent circuits that carry the pain signals to the lower brainstem, where these signals are integrated. Finally, the central signals ascend the brainstem, stimulating autonomic nuclei that account for nausea and other vasomotor changes, proceed through the thalamus, and terminate in the cortex where pain is perceived. Thus, migraine without aura consists of three steps—a central generator, a set of peripheral pain mechanisms, and a series of steps culminating in central integration. (Aura involves other steps, not outlined here.)" DESCRIBES WHAT HAPPENS TO PATIENTS BUT PLEASE NOTE THE TRIGEMINAL NERVE CONTROLS BLOOD FLOW TO THE ANTERIOR 2/3 OF THE MENINGES OF THE BRAIN. A NEUROMUSCULAR ORTHOTIC CAN HELP ADDRESS THAT INFLAMATORY/VASCULAR DILATION PROCESS. THE AFFERENTS THAT CARRY PAIN ARE PRIMARILY RELATED TO THE TRIGEMINAL NERVOUS SYSTEM WHICH IS DIRECTLY ADDRESSED BY A NEUROMUSCULAR ORTHOTIC. THE AUTONOMIC CONDITIONS ARE DISCUSSED IN THE PREVIOUSLY REFERENCED ARTICLE
I WOULD REDEFINE MIGRAINE WITHOUT AURA AS A PERIPHERAL TRIGGERS (USUALLY TRIGEMINAL NERVE BUT CAN BE OLFACTORY OR VISUAL)WHICKH THEN SETS OFF CENTRAL MECHANISM WHICH INCREASES PERIPHERAL PAIN MECHANISMS.
THE TRIGEMINAL NERVE IS THE MAJR SWITCH THAT STARTS THE PROCESS. THERE MAY ACTUALLY BE MANY PERIPHERAL SWITCHES IN ADDITION TO THE TRIGEMINAL NERVE AND WHEN THE RIGHT COMBINATION AND INTENSITY OF INPUT REACHES THRESHOLD THAN THE CENTRAL PROCESS BEGINS.
NEUROMUSCULAR DENTISTRY DEALS WITH PREVENTING INITIATING THRESHOLD FROM BEING REACHED.
Breaking the cycle of medication overuse headache by STEWART J. TEPPER, MD in the Cleveland Clinic Journal of Medicine reported:
"(Abstract) When patients who have frequent, disabling migraines take medications to relieve their symptoms, they run the risk that the attacks will increase in frequency to daily or near-daily as a rebound effect comes into play. This pattern, called medication overuse headache, is more likely to happen with butalbital and opioids than with migraine-specific drugs, as partial responses lead to recurrence, repeat dosing, and, eventually, overuse. Breaking the cycle involves weaning the patient from the overused medications, setting up a preventive regimen, and setting strict limits on the use of medications to relieve acute symptoms."
Medication overuse headaches are a frequent event with neuromuscular problems that frequently caue chronic daily tension headaches. These medications to not correct the underlying problem and the paient now has a layer cake of headaches that are often frosted with vascular headaches. The tirgeminal nervous system and the related trigeminovascular system is primarily responsible for the majority of headaches. I frequently find weaning my patients off narcotic and pschoactive medications is much harder than eliminating their pain. This is especially true because I advise patients to follow their physicians guidance when weaning off medication. Physicians who have heavily prescribe drugs are not always the best influence to convince patients that overuse headaches are a problem.
Many patients who suffer from medication overuse headaches originally had either migraines, tension-type headaches or a combination of headaches. They frequently also have anxiety and depression as comorbidities. Chronic daily headaches usualy is defined by 3 months with over 15 days/month of headaches that last 4 or more hours if not treated with medication.
According to Dr Tepper "In a large population-based study,3 2.5% of patients who began with episodic migraine (headaches on fewer than 15 days per month) had “transformed migraine” (headaches on 15 or more days per month) 1 year later. The prevalence of chronic daily headache is almost 5% of the general population and may account for up to 70% of the initial diagnoses seen in headache centers." This is what I would call iatrogenic medicine where the treatment of episodic migraine can result in the development of transformed migraine. What is probably more common is that patients with headaches due to nociceptive trigeminal impulses which create migraine and Episoic Tension-Type Headaches are treated with medication rather than correction of the root causes of the headache.
Treatment of headaches must always consider the time of day when headaches occur. Morning headaches are almost universally a result of sleep apnea and/or trigeminal headaches as a result of TMJ disorders and clenching, grinding or other parafunction. The NHLBI considers sleep apnea to be a TMJ disorder so almost 100% of morning headaches are related to abnormal jaw and trigeminal nervous system input.
Denture Patients with morning headachjes represent a special population that may have an easy solution. Historically, dentists have told patients to sleep with their dentures out. this has been shown to cause drastic increases in sleep apnea (and probably morning headaches). Wearing dentures may not only relieve headaches, neck pain and sleep apnea but also help avoid heart attacks, strokes and memory loss. Denture patients with chronic head and neck pain should seek out a neuromuscular dentist who can idealize the physiology of the masticatory system. When patients wear dentures to long without replacement or refitting they may be prone to neck pain and cervicogenic headaches due to changes in head posture.
Dr Tepper describes medication overuse headaches as follow: "Medication overuse headache is a subset of chronic daily headache, also occurring on 15 or more days per month but with the added criterion of medication overuse, ie, regular overuse for more than 3 months of at least one acute treatment drug:
Ergotamine, triptans, opioids, or combination analgesic medications on 10 or more days per month on a regular basis for more than 3 months, or
Simple analgesics or any combination of ergotamine, triptans, analgesics, or opioids on 15 or more days per month on a regular basis for more than 3 months without overuse of any single class alone.
Another criterion is that the patient’s headaches must worsen in some way (usually frequency) as the use of acute medications becomes more frequent.
Medication overuse headache is the most common form of secondary chronic daily headache seen in headache practice, and probably accounts for about half of cases of chronic daily headache."
His article states that this is the most common form of secondary chronic daily headaches. An iatrogenic disorder is one that is caused by the medical treatment. Secondary headaches from meication overuse are definitely iatrogenid and are frequently accompanied by other iatrogenic problems such as bleeding ulcers, narcotic addictions and numerous medication side effects.
THERE ARE TIMES WHEN IT IS ABSOLUTELY NECESSARY TO CONTROL SEVERE PAIN WITH HEAVY DOSES OF MEDICATION. IT IS NOT ACCEPTABLE THAT CORRECTION OF THE UNDERLYING CONDITIONS THAT MAKE PATIENTS REQUIRE THESE DRUGS ARE NOT ADDRESSED. A PREVIOUS POST DISCUSSED IDENTIFICATION OF MYOFASCIAL TRIGGER POINTS VASTLY IMPOVING MIGRAINE TREATMENT SUCCESS.
NEUROMUSCULAR DENTISTS ARE A VALUABLE ASSET TO ALL HEADACHE PATIENTS. Many neurologists are not familiar with the science(http://www.sleepandhealth.com/neuromuscular-dentistry) behind Neuromuscular Dentistry. An excellent approach for all patients with any type of chronic migraine or tension headache to utilize a neuromuscular diagnostic orthotic for a period of about 6 -12 weeks. A neuromuscular orthotic must be worn 24 hours/day and seven days a week and therefore must be comfortable for normal daily life functions.
Most patients respond amazingly well to the diagnostic orthotic and it is rare to not see a minimum of 50% improvement in chronic daily and tension type headaches. Patients with migraines associated with ovulation and/or menstrual cycle may still have exaccerbations during those times. Patients should continue to avoid known headache triggers.
Cervicogenic headaches also respond to neuromuscular dentistry due to changes in forward head posture that gradually occur while wearing the diagnostic orthotic. As the body posture corrects it is frequently necessary to reshape and resurface the diagnostic orthotic over time. I usually start with adjustments one time a week and gradually increase the time between visits. Each patient is unique and some patients need more frequent adjustments. Other patients have "miracle relief" with complete elimination of all migraine and muscle pain after the first visit. Often the "miracle relief" patient is not cured but just has so much relief and never felt so good that they report complete relief. When they get used to this new feeling (not having pain is often a totally new sensation) there are often still residual problems to address.
Patients discuss feeling a lightness or sense of energy because they are no longer utilizing so many physiologic and psychologic processes to cover up the pain and cope.
I often find that a few visits into treatment I "meet the paient for the first time" because they have changed in dramatic ways that are far more complex than presence of absence of pain. There is a "lightness to their soul" or a new hope not of pain relief but of resuming their life. One patient described her orthotic as ending "Life Interruptess" and I have had spouses tell me that they have rediscovered the person who was lost in a sea of pai.
This does not always translate into total cures, frequently a patient in constant pain for years findsa large bulk of pain gone and they can then begin the process of solving remaining problems that are now discrete entities. Prior, when drowning in pain they could not see the forest for the trees. As overall pain relief occurs they can now actually have proper diagnosis of other problems.
Depression and pschological disorders frequently disappear. I describe as the difference between psychosomatic pain and Somatophsycic pai.
In simplest terms psychosomtic pain translates into "I HURT BECAUSE I'M CRAZY" while Somatopsychic pain translates into "MY PAIN IS MAKING ME CRAZY". Relieve the pain and the "CRAZY" is gone. It is normal to be depressed when you are in constant pain, in fact, "IF YOU ARE IN CONSTANT TERRIBLE PAIN AND DO NOT BECOME DEPRESSED YOU ARE CERTIFIABLE" Depression is a normal outcome of chronic pain.
There is no true cure for long term pain because the pain has changed your past, who you were and what you did. Relief of pain lets you move forward without the weight of a 1000 pound albatross around your neck but the only true cure would be " A DO-OVER ON THE YEARS WHERE CHRONIC PAIN RULED YOUR LIFE" and unfortunately no one can roll back the clock and make you the person you would have been without your pain.
Dr Tepper discusses the many names given to these medication overuse headaches in his article: "Many terms have been used to describe medication overuse headache in the past, such as analgesic-rebound headache (or just rebound headache), transformed migraine with medication overuse, and even chronic migraine. The lack of uniformity in terminology makes for confusion in the literature and difficulty in communicating with patients and colleagues. Some authors mean medication overuse headache when they say chronic daily headache." He spells out why so many patients cannot find answers to their problems. Clearly identifying both the cause and the symptoms is vital in treatment. A essential element in identifying the cause is ruling out other causes. This is why a neuromuscular dental orthotic is so vital not just for treatment but as an essential element of the diagnostic protocol.
Dr Tepper goes on to state: "Complicating this diagnostic confusion is a debate as to whether chronic daily headache in general should be treated as a primary or secondary headache disorder." THIS IS EXTREMELY IMPORTANT! IF WE ARE NOT CLEAR IF WE ARE TREATING THE UNDERLYING CONDITION OR THE IATROGENIC SYMPTOMS OR MEDICATION OVERUSE, MORE HARM CAN BE DONE TO THE PATIENT. ACCORDING TO DR TEPPER " Some European headache specialists insist on a strict division between primary and secondary daily headaches, and medication overuse headache is one of the latter. Many American specialists believe that chronic daily headache is a collective description or phenotype rather than a diagnostic category, and that it is usually associated with and exacerbated by medication overuse. The International Classification of Headache Disorders uses the term “chronic migraine” for primary daily headache, and “medication overuse headache” for secondary daily headache or rebound." THIS LACK OF CLARITY IN DIAGNOSIS IS A MAJOR FAULT IN TREATMENT OF CHRONIC DAILY HEADACHE.
It is important to remember that the meication is used primarily to alter changes caused by the trigeminovascular system. The easies and safest method of altering the Trigeminal nervous system is thru altering afferent impulses that create noxious results. The NTI-TSS appliance is considered an extremely effective, if not most effective migraine treatment. Unfortunately is may complicate achieving a long-term health position. I frequently will use the NTI or a version of it in nocturnal (night-time) appliances but find that for patients looking for long -term complete relief have better results with neuromuscular orthotics. It is postulated that part of the effect of the NTI is on sleep apnea by increasing tongue space and reducing apnea. It is well known that when patients have apneic eventsthat result in changes in sleep stage clenching frequently results. When patients with sleep apnea are treated via Dental Sleep Medicine (http://www.ihatecpap.com) complete or partial headache and migraine relief is frequently reported.
Central Sensitization is a major factor in acute problems becoming chronic and in the development of RSD or CRPS. According to Dr Tepper "Complicating the dilemma, acute migraine-specific medications such as triptans and dihydroergotamine (Migranal) work better when taken early in migraine attacks, before central sensitization and allodynia develop with attendant photophonophobia and sensitivity to other stimuli. On the other hand, overuse will lead to medication overuse headache."
The use of Neuromuscular Dentistry can help prevent central sensitization and even reduce the changes caused by neural plasticity. Central sensitization or changes to the CNS may be reversible if noxious input to the system is reduced. This is the same whether using NTI-TSS or Neuromuscular Orthotics. The difference is NTI uses a new pathological input to turn off or overide a more powerful noxious input whereas a neuromuscular orthotic is used to reduce all noxious input and to return to a normal physiologic state. When sleep apnea is present it is advisable to treat daytime and nightime conditions with distinct appliances.
The next section of Dr Tepper's article I have some points of Disagreement and I will use all capitals for my comments.
"SYMPTOMS VARY (from article)
The symptoms of medication overuse headache vary in frequency, severity, location, quality, and associated features, both among patients and in the same patient. This is because the disease itself varies and also because of differences in the type and frequency of medication intake. Still, some features help to define this problem, and failing to recognize them may account for a widely held clinical feeling that these patients are “difficult.” THIS WIDE VARIETY OF PROBLEMS WILL FAIL TO SEPERATE PRIMARY FROM SECONDARY HEADACHES.
History of episodic migraine. Generally, medication overuse headache does not occur in nonmigraineurs. THE ACTUAL DIAGNOSIS OF MIGRAINE IS FREQUENTLY SUSPECT AND CHRONIC USE OF DRUGS LIKE EXCEDRIN FREQUENTLY OCCURS IN PATIENTS WITH TMD, CERVICAL PAIN AND MUSCULAR TENSION-TYPE HEADACHES.
Headache on most days of the month. Whenever a migraineur starts having headaches on more days than not, the diagnosis of medication overuse should be considered. REMEMBER THERE CAN BE MIGRAINES MIXED WITH TENSION TYPE HEADACHES AND FREQUENTLY THEY BLEND TOGETHER IN THE PATIENTS MIND AS MORE SEVERE AND LESS SEVER MIGRAINE WHEN IN REALITY THEY HAVE TENSION-TYPE HEADACHES OR TMD HEADCHES WITH PERIODIC MIGRAINE.
Overuse of acute medications. The criteria (see above) allow for combining days of acute medication use. For example, if a patient takes a combination analgesic on 5 days and a triptan on 5 different days, that would still be enough days of acute treatment to trigger medication overuse headache.
Variable pain location (THIS IS ALSO CONSISTENT WITH TMD OR MYOFASCIAL PAIN) is a particular characteristic of medication overuse headache. Although the location may differ from day to day (front or back, rostral or caudal, unilateral or bilateral), it is the quantity not the quality or location of the headaches that suggests the diagnosis.
A drug-dependent rhythm. Predictably, the headaches come on in the early morning or awaken the patient from sleep. This may be due to variable drug withdrawal. AS DISCUSSED PREVIOUSLY TMD AND SLEEP APNEA ARE THE PRIMARY CAUSES OF MORNING HEADACHES.
Neck pain. Medication overuse headache frequently involves the neck, and patients often seek and receive treatments such as muscle relaxants or injections to the neck. When patients are weaned from their acute migraine medications, neck pain generally dissipates. The neck pain, however, can recur episodically with their remaining, now-episodic acute migraines. Neck pain associated with medication overuse headache is not usually a sign of a primary neck disorder; rather, it is a symptom of medication overuse headache itself. NEUROLOGISTS FREQUENTLY DO NOT CONSIDER MANUAL OR ANATOMICAL CAUSES OF NECK PAIN IN RELATION TO HEADACHES. PATIENTS WHO ARE OVERCLOSED TEND TO HAVE FORWARD HEAD POSITION THAT CAUSES NECK PAIN AND CERVICOGENIC HEADACHES. THE QUADRANT THEOREM OF GUZAY EXPLAINS WHY THIS HAPPENS. ROCOBADO HAS SHOWN THAT EVERY CM OF FORWARD HEAD POSTURE REQUIRES TWICE THE EFFORT TO MAINTAIN POSTURE. A TWO INCH FORWARD HEAD POSTURE WOULD RESULT IN 3200% INCREASE IN TONIC MUSCLE ACTIVITY TO LOW BACK.
Concomitant depression and anxiety are comorbid with episodic migraine, but appear to be more common with medication overuse headache. Treating the depression or anxiety does not restore an episodic pattern of migraine; weaning from the overused medications remains the most important intervention. A frequent clinical error is to diagnose and treat the psychiatric issues without recognizing medication overuse as the primary problem. A FREQUENT PROBLEM IS WHEN ONE ASSUMES THE DEPRESSION IS THE CAUSE OF PAIN INSTEAD A SECONDARY RESULT OF PAIN. SLEEP DISTURBANCES ASSOCIATED WITH DEPRESSION CAN CERTAINLY INCREASE BOTH MUSCLE PAIN AND HEADACHES. DEPRESION IS FREQUENTLY SEEN WITH UNDIAGNOSED SLEEP APNEA.
Nonrestorative sleep is almost always reported by patients with medication overuse headache. This is often due to the caffeine contained in combination analgesics or to excessive dietary caffeine intake, but it may also be part of the daily acute drug withdrawal syndrome. The sleep problems are also associated with the concomitant depression. Sleep often improves after weaning from the offending substance or substances. As with neck pain, patients do not have a primary sleep disorder—the sleep disturbance is a symptom of medication overuse headache. MANY OF THESE PATIENTS, ESPECIALLY WOMEN DO HAVE AN UNDERLYING SLEEP DISORDER, UARS OR UPPER AIRWAY RESISTAANCE SYNDROME BUT IT DOES NOT MEET THE DIAGNOSTIC CRITERIA TO BE CONSIDERD SLEEP APNEA SYNDROME. THE DEFINITIONS FOR APNEA WERE DEVELOPED ON OLD FAT MEN AND TEND TO UNDERSCORE OF MISS THE DIAGNOOSIS IN FEMALES AND YOUNGER THINNER HEALTHIER PATIENTS IN GENERAL.
ALPHA-INTRUSION INTO DELTA SLEEP IS THE MARKER FOR FIBROMYALGIA BUT IS ALSO FREQUENTLY SEEN WITH TMD DUE TO AIRWAY PROBLEMS.
Vasomotor instability. Autonomic features are commonly associated with medication overuse headache. Rhinorrhea, nasal stuffiness, and lacrimation are features of medication withdrawal, especially from opioids, and are frequently attributed to sinus disease or “sinus headaches.” Many patients undergo unnecessary sinus procedures or are given antibiotics, decongestants, and other wrong medications for incorrect diagnoses. Decongestants can cause and exacerbate medication overuse headache, so they need to be withdrawn. The sinus features generally remit when the overused migraine medications are eliminated. MANY OF THESE PROBLEMS ARE RELATED TO THE NASAL CYCLE AND THE SWITCHING OF SYMPATHETIC AND PARASYMPATHETIC PROCESSES THAT OCCUR ON A REGULAR BASIS AT NIGHT. THERE IS AN EXCELLENT ARTICLE THAT DESCRIBES SOME OF THESE PROCESSES AT: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=1163 THESE SYMPTOMS MAY BE MORE RELATED TO A NORMAL PHYSIOLOGIC PROCESS AND ACTUALLY SERVE AS A CUASE OF MEDICATION OVERUSE.
Preventive medications are less effective or ineffective until the acute medications are withdrawn. Thus, prescribing prevention without weaning is usually futile, and the patients are often dismissed as having a refractory problem. At the same time, migraine-specific acute treatments, ie, triptans and ergots, are usually also less effective. When patients complain that “nothing works,” either preventively or acutely, medication overuse headache should spring to mind. THE SAME HOLDS TRU WHEN TREATING PATIENTS WITH A NEUROMUSCULAR ORTHOTIC. EVEN THOUGH THE UNDERLYING PROBLEM MAY BE CORRECTED AND WILL PREVENT FUTURE HEADACHES THE PATIENT STILL SUFFERS WITHRAWAL SYMPTOMS THAT MAKE THEM FEEL THERAPY IS INEFFECTIVE. IN REALITY THE DRUG PROBLEM (IATROGENIC) ACTUALLY HIDES THE EFFECTIVENESS OF TREATMENT.
I TELL MY PATIENTS TO NOT CHANGE DRUG REGIMEN INITIALLY BUT TO CONTINUE ON THEIR CURRENT MEDS WHILE GOING THRU THE FIRST PHASE OF TREATMENT. ONCE STABILITY IS REACHED THEY CAN THEN GO THRU DRUG WITHDRAWAL THERAPY WHICH WILL BE EASIER BUT STILL UNPLEASANT.
Weaning from overused medications can restore the efficacy of previously ineffective treatments at the same time that a patient is restored to an episodic headache pattern. Thus, complete weaning is the pivotal clinical intervention. Clinically, there is no spontaneous remission from rebound without absolute detoxification, maintained for months. ONCE WEANED FROM MEDICATIONS THEY FREQUENTLY WILL NO LONGER NEED THESE MEDICATIONS ANY LONGER. IF THERE ARE STILL ISOLATED EVENTS THAT CONTINUE MEDICATION USE WILL PROBABLY BE GREATLY REDUCED.
THE FOLLOWING PARAGRAPH IS WHAT I FIND TRULY FIGHTENING ABOUT THIS PAPER. ASSUMING THE HEADACHE IS DUE TO MEDICATION OVERUSE IGNORES WHY OVERUSE OCCURED INITIALLY. THE LIST OF DIFFERENTIAL DIAGNOSIS ARE ALL POSSIBLE CUASES AND SHOULD BE INDIVIDUALLY AND COLLECTIVELY CONSIDERED BEFORE PATIENTS REACH TOXIC LEVELS OF MEDICATIONS THAT CAUSE IATROGENIC PROBLEMS. ALMOST ALL HEADACHES ARE RELATED TO TRIGEMINAL NERVOUS INPUT FROM THE JAWS AND TEETH AND IT ACCOUNTS FOR OVER 50% OF THE TOTAL INPUT TO THE BRAIN. SLEEP APNEA IS A SECONDARY CONDITION ALSO RELATING TO THE JAW POSITION.
"Other diagnoses entertained. The more diagnoses suggested for daily headache, and the more treatments tried unsuccessfully, the more likely the diagnosis is actually medication overuse headache. Because this condition is protean, patients and caregivers alike make more and more fanciful diagnoses such as allergies, cervicogenic headache, temperomandibular disorder, occipital neuralgia, chronic Lyme disease, and systemic candidiasis. A useful strategy is to assume that daily headache is likely due to medication overuse. And since medication overuse headache is generally treatable, patients labeled as having refractory headaches often are dramatically improved by appropriate intervention."
MEDICATION OVERUSE IS REAL AND A SERIOUS PROBLEM BUT TO DISCOUNT WHAT ARE POSSIBLY KEY ELEMENTS IN TREATMENT IS NOT ONLY FLWED BUT DANGEROUS BECAUSE FREQUENTLY PATIENTS WILL IN DESPERATION SEEK OUT NON-PROFESSIONALLY PRESCRIBED DRUG ALERNATIVES. NEUROMUSCULAR DENTISTRY, NUCCA, A?O CHIROPRACTIC, PHYSICAL THERAPY, MASSAGE THERAPY, TRIGGER PONT INJECTIONS AND NUMEROUS OTHER PHYSICAL MEDICINE MODALITIES SHOULD BE USED TO DECREASE PAIN AS AN ESSENTIAL PART OF MEDICATION CONTROL.
THE USE OF NON-INVASIVE INTRANASAL SPHENOPLATINE GANGLION BLOCKS CAN MAKE THE PROCESS MUCH SMOOTHER.
THE STATEMNTS "Episodic migraine attacks appear to be generated in the upper brainstem. This region in turn activates a set of peripheral pain mechanisms, ie, meningeal inflammation and vasodilation. The peripheral pain processes turn on afferent circuits that carry the pain signals to the lower brainstem, where these signals are integrated. Finally, the central signals ascend the brainstem, stimulating autonomic nuclei that account for nausea and other vasomotor changes, proceed through the thalamus, and terminate in the cortex where pain is perceived. Thus, migraine without aura consists of three steps—a central generator, a set of peripheral pain mechanisms, and a series of steps culminating in central integration. (Aura involves other steps, not outlined here.)" DESCRIBES WHAT HAPPENS TO PATIENTS BUT PLEASE NOTE THE TRIGEMINAL NERVE CONTROLS BLOOD FLOW TO THE ANTERIOR 2/3 OF THE MENINGES OF THE BRAIN. A NEUROMUSCULAR ORTHOTIC CAN HELP ADDRESS THAT INFLAMATORY/VASCULAR DILATION PROCESS. THE AFFERENTS THAT CARRY PAIN ARE PRIMARILY RELATED TO THE TRIGEMINAL NERVOUS SYSTEM WHICH IS DIRECTLY ADDRESSED BY A NEUROMUSCULAR ORTHOTIC. THE AUTONOMIC CONDITIONS ARE DISCUSSED IN THE PREVIOUSLY REFERENCED ARTICLE
I WOULD REDEFINE MIGRAINE WITHOUT AURA AS A PERIPHERAL TRIGGERS (USUALLY TRIGEMINAL NERVE BUT CAN BE OLFACTORY OR VISUAL)WHICKH THEN SETS OFF CENTRAL MECHANISM WHICH INCREASES PERIPHERAL PAIN MECHANISMS.
THE TRIGEMINAL NERVE IS THE MAJR SWITCH THAT STARTS THE PROCESS. THERE MAY ACTUALLY BE MANY PERIPHERAL SWITCHES IN ADDITION TO THE TRIGEMINAL NERVE AND WHEN THE RIGHT COMBINATION AND INTENSITY OF INPUT REACHES THRESHOLD THAN THE CENTRAL PROCESS BEGINS.
NEUROMUSCULAR DENTISTRY DEALS WITH PREVENTING INITIATING THRESHOLD FROM BEING REACHED.
I HATE HEADACHES IS YOUR SOURCE FOR INFORMATION AND NEUROMUSCULAR DENTISTRY
I am currently working very diligently to make the I Hate Headaches site the most comprehensive source for Neuromuscular Dentistry and to help the public "find a Neuromuscular Dentist" While there are a few doctors who are early members of our site I will help patients find neuromuscular dentists in their area.
I frequently find that patients wish to come to my office to see me personally. My office can make arrangements for out of town patients who want to experience the changes neuromuscular dentistry can accomplish. I currently have several out of stat patients with sleep disorders, headaches, migraines and other types of TMD who travel to my office.
Please bookmark my blog and also watch for new content about neuromuscular dentistry on this site.
I frequently find that patients wish to come to my office to see me personally. My office can make arrangements for out of town patients who want to experience the changes neuromuscular dentistry can accomplish. I currently have several out of stat patients with sleep disorders, headaches, migraines and other types of TMD who travel to my office.
Please bookmark my blog and also watch for new content about neuromuscular dentistry on this site.
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