A recent study (pubmed abstract below) in the Journal Cephalgia showed that "Less than 15% of subjects received more than one triptan product in the 2 years." Triptans which are very successful for a small percentage of patients are not a panacea. The reasons for discontinuation may be numerous. I suspect that many patients treated for "migraines" of various types actually have headaches (albeit severe) of muscular or myofascial orgin often associated with craniomandibular disorders, TMD, Temporomandibular Joint Dysfunction, or other primary disorders of the Trigeminal Nerve related to masticatory function. The study also showed that 80% of patients only received one or two packages of Triptan medication. These patients obviously did not obtain significant relief or the side effects caused them to discontinue treatment.
Drug therapy of chronic daily headaches, atypical migraine, chronic migraine, tension-type headaches and other disorders may be useful as a interim measure but I content that removing the underlying cause of migraines and headaches is the optimum long term solution for chronic headache pain. The basis of Neuromuscular Dentistry is to eliminate the noxious input to the Trigeminal Nervous System that is responsible for headache propagation.
Sleep and Health Journal has my article on Neuromuscular Dentistry that was originally published by the American Equilibration Society. It is an excellent resource for all patients with headaces, migraines and TMJ disorders that are considering Neuromuscular Dental Treatment. The Neuromuscular Dentistry article is available @ http://www.sleepandhealth.com/neuromuscular-dentistry
The use of BOTOX to treat migraines and Tenion-Type headaches actually proves the validity of Neuromuscular Dentistry. The long term block with botulism toxin of neurojunctions in masticatory muscles clearly demonstrate that the pain and headache/ migraines are coming either directly from the musces, ie referred or myofascial pain or that noxious input from these muscles is causing central sensitization of the Trigeminal Nerve and Central Nervous system.
Neuromuscular Dentistry creates a healthy homeostasis where long term healing can occur. Neuromuscular Dentistry is frequently criticised for being expensive. This is actually a falsehood. Initial therapy with a diagnostic orthotic is usually done over a period of a few months and can run several thousan dolars but pales when compared to the costs of MRI's CAT SCANS, Chronic medication use with associated side effects and rebound headaches and awful effects on family and friends as well as patients quality of life. Chronic pain patients frequenty suffer sever guilt for the effects of their pain on the lives of their loved ones.
The reason Neuromuscular Dentistry has a reputation of being extremely expensive is that many patients elect to do full mouth reconstruction as long term stabilzation after their pain is eliminated or substantially reduced. They prefer not to have a long term stabilization appliance. The second phase of Neuromuscular Dental Treatment of Migraines and/or Tension Headaches and TMJ disorders requires stabilization so improvements in quality of life are maintained.
Cast removable orthotics, orthodontics and semi-permanent oral orthotics are alternatives to expensive reconstruction. The quality of life of the patient is what is key not the method of long term stabilization.
There are some dental groups that are involved in treatment of TMJ disorders that chose to ignore widespread clinical success from occlusal therapy and prefer to ebrace the pscho-social approach to these problems. They prefer the medication approach and believe this is more a mental problem than a physical problem. they strongly embrace the use of psychoactive medications and other drugs that frequently have dangerous side effects. Evidenced based medicine is the new watchword in research and drug therapy naturally lends itself to randomized clinical trials. These doctors frequently site these drug studies.
Drug studies are not bad but they are the most pervasive due to billions spent by Big Pharma looking to score big in the market place. Recent studies have shown that positive studies are published as much as two years earlier than studies that show negative results and problematic side effects. It has become common place to see the FDA recall products completely or place dire warnings about drug safety after they have been available for years. Even "safe" drugs like Acetaminophen often have dangerous side effects. The following is from WebMD:
""July 1, 2009 -- The FDA should put new restrictions on acetaminophen, an advisory committee recommended Tuesday, saying the move would protect people from the potential toxicity that can cause liver failure and even death.
The FDA does not have to follow its advisory committees’ recommendations, but it usually does. It will likely be months before the FDA makes a final decision on the drug.
You might not know "acetaminophen," because that's the drug's generic name. One of the nation’s top drugs for pain relief, acetaminophen is found in many over-the-counter products -- including Tylenol, aspirin-free Anacin, Excedrin, and numerous cold medicines. It's also found in many prescription drugs." (end Web MD info)
Many negative studies are never published because funding is discontinued when the results are negative and nobody is that interested in drugs that don't work. When those drugs are already on the market and the initial studies show promise physicians are not always aware of later studies.
Another study (abstract below) used experimental mechanical stimulation to induce hyperaemia associated with cortical spreading depression (CSD) the underlying mechanism behind the aura is associated with neurological disorders that 30% of migraine patients patients additionally suffering from. The most common of the focal neurological disturbances is the aura.
What I find most interesting about the experiment is that proves that Cortical Spreading Depression associated with Aura can be mechanically induced which is exactly the philosophy of Neuromuscular Dentistry. Obviously if you read the study it is designed to find new drugs to treat migraine. It is certainly not their intention to show that migraines are primarily central effect of peripheral stimulation. But as I stated previously Botox is an excellent example of peripherally caused migraines being controlled by changing neurolical input to the trigeminal system. I maintain that if possible removing noxious stimuli is preferable to injection of dangerous toxins.
Some of the dangers and General Side Effects associated with Botox injections follow:
* Bruising (Common)
* Dizziness
* Skin rash
* Tiredness
* Muscle spasm
* Numbness
* General Weaknes
* Drowsines
* Flu-like syndrome 2%
* Feeling generally unwell
* Dryness of the mouth
* Sickness
* Headache 13.3%
* Stiffness
Injections around the eye often have one or more the following side effects:
*Drooping upper eyelid 3.2%
* Drooping brow
* Mild inflammation of the surface of the eye
* Difficulty in completely closing the eye
* Overflow of tears
* Dry eye
* Sensitivity to light
Less Frequent side effects include:
* Inflammation of the surface of the eye
* Turning out or Eversion of the eyelid
* Turning in or Inversion of the eyelid
* Double vision
* Facial weakness
* Facial droop
* Blurred vision
The following side effects are rare but do occur:
* Swelling of the eyelids
* Ulcers develop on the surface of the eye
* Eye pressure increase (Glaucoma)
I do feel that there is a definite role of Botox in the treatment of migraines for some patients but I would advise that initiating treatment with a diagnostic neuromuscular orthotic may prove vastly more successful and safer for the patient and provide a better long term quality of life.
Cephalalgia. 2010 May;30(5):576-81. Epub 2010 Feb 11.
Triptans: low utilization and high turnover in the general population.
Panconesi A, Pavone E, Franchini M, Mennuti N, Bartolozzi M, Guidi L, Banfi R.
Health Authority 11, Empoli, Florence, Italy. a.panconesi@virgilio.it
Abstract
Studies performed in selected populations have shown a poor utilization of triptans for migraine. Our study was aimed at establishing patterns of triptans utilization in a large community using the pharmaceutical prescriptions database of two consecutive years in a regional Health Authority in Italy. About 0.5% of the population observed received triptans prescriptions in a year, but > 50% of the cases received only one prescription. On the other hand, 46% of triptan users did not receive a triptan prescription in the following year (past users): in 80% of cases, patients received only 1-2 triptan packages. The evaluation of the discontinued triptan type has shown percentages varying between 30 and 70%. The percentage of triptan users who received a triptan prescription for the first time in the successive year of study (new users) was 52%. These findings together highlight a high turnover in triptans utilization. Less than 15% of subjects received more than one triptan product in the 2 years. In conclusion, we observed a low percentage of triptan users and a low rate of utilization, associated with a high percentage of discontinuation and new utilization (high turnover), without any substantial increase in triptans utilization during the years. All these data probably do not support optimal satisfaction with triptan therapy.
PMID: 19732070 [PubMed - indexed for MEDLINE]
Sunday, January 30, 2011
Saturday, January 29, 2011
TREAT HEADACHES, MIGRAINES AND FACIAL PAIN WITHOUT DANGEROUS DRUGS AND ASSOCIATED SIDE EFFECTS. NEUROMUSCULAR DENTISTRY IS A SAFE AND EFFECTIVE.
Neuromuscular Dentistry may be one of the most effective treatments for a wide variety of conditions including various types of "migraine", tension-type headaches, facial pain, trigeminal neuralgia, TMJ disorders, myofascial ain and muscular and neurogenic headaches. Drugs do not cure the underlying problems that cause the problems and frequently their mechanism of action is unknown. Many drugs are recalled due to dangerous or deadly side effects and a large number of patients experience rebound headaches. These patients frequently require higher doses of medication over time.
There are many varied and diverse advantages to neuromuscular dentistry over standard medical approaches. The single biggest problem in treating headaches utilizing neuromuscular dental technology is that it can be expensive. Insurance companies are aware that 50% reduction in symptoms almost always occurs with treatment. This is a higher positive respone than almost any drug regimens. Insurance companies frequently chose to deny coverage to increase profits to shareholders. Patients who have undergone numerous CAT Scans, MRI's ,Drug therapies and surgeries without adequate control of their pain frequently find that Neuromuscular Dentistry gives amazing relief and improves the quality of their lives and the lives of their loved ones and are then denied coverage for treatment. Many of these patients have exhausted their resources on unsuccessful therapies prior to learning about and experiencing relief thru neuromuscular dentistry.
The Alliance of TMD Organizations is working to address the unfair practices of insurance companies relative to the treatment of TMJ disorders and Headaches related to the masticatory system. They are also the primary group protecting the rights of TMJ patients. There is a large group of clinicians in dentistry who believe the problems patients experience are psychosocial and not physical and want medication to become the only treatment available to most patients. They would like to take away patients right to chose non-drug alternative treatments. Unfortunately this group has enormous political influence and exert control over most research funds often to the detriment of patients. This remains true even after scandals in FDA hearings led removal of some of their members from FDA panels. There are also numerous instances of unethical conflicts of interest that were not disclosed to the FDA. Additional information on the TMD alliance is available at: http://www.tmdalliance.org/
I would like to disclose that I am a representative of ICCMO to the Alliance and that I am a long term member of The American Equilibration Society, The American Academy of CranioFacial Pain and a member of The International Academy of Comprehensive Aesthetics. I am also a Diplomate of the American Academy of Pain Management. These are member organizations of the TMD Alliance. I am the chair of the insurance reimbursement commitee.
Neuromuscular Dental Treatment of headaches is usually divided into two phases: the initial treatment phase (pain reduction and elimination) and long term stabilization (long term maintenance of improved quality of life).
The initial treatment phase includes the diagnostic protocols established by the particular neuromuscular dentist, comprehensive exam including medical histroy review (extremely important), muslce palpation exam, range of motion evaluation radiographs. The use of EMG (electomyography) and computerized mandibular scans (CMS or MKG), sonography, ultra low frequency TENS and transcranial neurostimulation are frequently useful in understanding the variable in the course of the doctor establishing a working diagnosis. More advanced practitioners frequently wil do diagnostic trigger point injections, nerve blocks or autonomic blocks such as spenopalatine ganglion blocks.
The mainstay in neuromuscular dental treatment of TMJ disorders (TMD), migraines, tension-type headaches, atypical migraine, chronic daily headaches and facial pain is the diagnostic neuromuscular orthotic. THIS ORTHOTIC IS UTILIZED TO ESTABLISH A HEALTHY "LANDING POINT" THAT HAS MINIMAL MUSCULAR AND NEUROMUSCULAR ADAPTATION. This allows the body and all of the neuromuscular components a healthy environment to heal.
Doctors do not cure patients! The best doctors remove the impediments to healing! The body than returns to a healthy homeostatic condition. This is what is accomplished with the neuromuscular orthotic over a series of several appointment. If the patient experiences complete relief and /or total elimination of symptoms for an extended period the stabilization phase can be initiated. When patient have substantial relief but still have remaining symptoms they will determine whether they are ready for stabilization.
Long term stabilization can be a very expensive full mouth reconstruction but this is usually one of many possible treatments. Long term removable orthotics, orthodontics and semi-permanent appiances allow pain control without the expense of a reconstruction. WHAT IS IMPORTANT IS THAT THE PATIENT IS READY FOR LONG TERM STABILIZATION. The diagnostic orthotic is not a long term treatment. Frequently patients have dramatic improvements with their orthotics but do not precede to long term stabilization and see their symptoms return as the appliance wears down or breaks.
Sleep disturbances frequently accompany craniomandibular disorders and headaches. Patients with tiredness, morning headaches, nocturnal headaches, high blood pressur and memory problems usuallly need to be evaluated at a sleep lab utilizing a full polysomnograph array.
There are many varied and diverse advantages to neuromuscular dentistry over standard medical approaches. The single biggest problem in treating headaches utilizing neuromuscular dental technology is that it can be expensive. Insurance companies are aware that 50% reduction in symptoms almost always occurs with treatment. This is a higher positive respone than almost any drug regimens. Insurance companies frequently chose to deny coverage to increase profits to shareholders. Patients who have undergone numerous CAT Scans, MRI's ,Drug therapies and surgeries without adequate control of their pain frequently find that Neuromuscular Dentistry gives amazing relief and improves the quality of their lives and the lives of their loved ones and are then denied coverage for treatment. Many of these patients have exhausted their resources on unsuccessful therapies prior to learning about and experiencing relief thru neuromuscular dentistry.
The Alliance of TMD Organizations is working to address the unfair practices of insurance companies relative to the treatment of TMJ disorders and Headaches related to the masticatory system. They are also the primary group protecting the rights of TMJ patients. There is a large group of clinicians in dentistry who believe the problems patients experience are psychosocial and not physical and want medication to become the only treatment available to most patients. They would like to take away patients right to chose non-drug alternative treatments. Unfortunately this group has enormous political influence and exert control over most research funds often to the detriment of patients. This remains true even after scandals in FDA hearings led removal of some of their members from FDA panels. There are also numerous instances of unethical conflicts of interest that were not disclosed to the FDA. Additional information on the TMD alliance is available at: http://www.tmdalliance.org/
I would like to disclose that I am a representative of ICCMO to the Alliance and that I am a long term member of The American Equilibration Society, The American Academy of CranioFacial Pain and a member of The International Academy of Comprehensive Aesthetics. I am also a Diplomate of the American Academy of Pain Management. These are member organizations of the TMD Alliance. I am the chair of the insurance reimbursement commitee.
Neuromuscular Dental Treatment of headaches is usually divided into two phases: the initial treatment phase (pain reduction and elimination) and long term stabilization (long term maintenance of improved quality of life).
The initial treatment phase includes the diagnostic protocols established by the particular neuromuscular dentist, comprehensive exam including medical histroy review (extremely important), muslce palpation exam, range of motion evaluation radiographs. The use of EMG (electomyography) and computerized mandibular scans (CMS or MKG), sonography, ultra low frequency TENS and transcranial neurostimulation are frequently useful in understanding the variable in the course of the doctor establishing a working diagnosis. More advanced practitioners frequently wil do diagnostic trigger point injections, nerve blocks or autonomic blocks such as spenopalatine ganglion blocks.
The mainstay in neuromuscular dental treatment of TMJ disorders (TMD), migraines, tension-type headaches, atypical migraine, chronic daily headaches and facial pain is the diagnostic neuromuscular orthotic. THIS ORTHOTIC IS UTILIZED TO ESTABLISH A HEALTHY "LANDING POINT" THAT HAS MINIMAL MUSCULAR AND NEUROMUSCULAR ADAPTATION. This allows the body and all of the neuromuscular components a healthy environment to heal.
Doctors do not cure patients! The best doctors remove the impediments to healing! The body than returns to a healthy homeostatic condition. This is what is accomplished with the neuromuscular orthotic over a series of several appointment. If the patient experiences complete relief and /or total elimination of symptoms for an extended period the stabilization phase can be initiated. When patient have substantial relief but still have remaining symptoms they will determine whether they are ready for stabilization.
Long term stabilization can be a very expensive full mouth reconstruction but this is usually one of many possible treatments. Long term removable orthotics, orthodontics and semi-permanent appiances allow pain control without the expense of a reconstruction. WHAT IS IMPORTANT IS THAT THE PATIENT IS READY FOR LONG TERM STABILIZATION. The diagnostic orthotic is not a long term treatment. Frequently patients have dramatic improvements with their orthotics but do not precede to long term stabilization and see their symptoms return as the appliance wears down or breaks.
Sleep disturbances frequently accompany craniomandibular disorders and headaches. Patients with tiredness, morning headaches, nocturnal headaches, high blood pressur and memory problems usuallly need to be evaluated at a sleep lab utilizing a full polysomnograph array.
Friday, January 28, 2011
Continuous headache with earache and eye ache.
David: I have had continous Headaches for 3-4 months now. sides and back of head mainly. Earache and eye ache as well
Dr Shapira: David, you have given me only minimal infformation on what treatment you have received or any special circumstances when the pain started. The good news is the symptoms you describe indicate that you probably have headaches of muscular orgins. Tension-Type Headaches (TTH) are commononly associated with the jaw and neck muscles. Achy type pain as you describe in your ears and eyes is nearly always referred muscualar pain.
An excellent approach is to visit a Neuromuscular Dentist who is also trained in using Vapocoolant spray to treat Myofascial pain. If stretch and spray gives relief of the headache, earache and eye ache you will confirm the muscular component.
Because almost all Tension Type Headaches are influences by the Trigeminal Nervous system you will probably do well by tring a Diagnostic Neuromuscular Orthotic as a non-invasive safe diagnostic and treatment entity. If yo get complete relief you will confirm that the headache is muscular and trigeminally modulated.
Occasionally trigger point injections are needed to break-up long standing muscle issues.
Dr Shapira: David, you have given me only minimal infformation on what treatment you have received or any special circumstances when the pain started. The good news is the symptoms you describe indicate that you probably have headaches of muscular orgins. Tension-Type Headaches (TTH) are commononly associated with the jaw and neck muscles. Achy type pain as you describe in your ears and eyes is nearly always referred muscualar pain.
An excellent approach is to visit a Neuromuscular Dentist who is also trained in using Vapocoolant spray to treat Myofascial pain. If stretch and spray gives relief of the headache, earache and eye ache you will confirm the muscular component.
Because almost all Tension Type Headaches are influences by the Trigeminal Nervous system you will probably do well by tring a Diagnostic Neuromuscular Orthotic as a non-invasive safe diagnostic and treatment entity. If yo get complete relief you will confirm that the headache is muscular and trigeminally modulated.
Occasionally trigger point injections are needed to break-up long standing muscle issues.
Monday, January 24, 2011
CONTINUOS HEADACHE FOR MONTHS!
DEBBIE: i have had a headache non stop for 21 months. i need help now!!!!!!
The doctdors can not tell me what is causing thsi, they just keep giving me drugs.
DR SHAPIRA RESPONSE: Debbie, I frequently hear stories like yours. The fact that the physicians cannot find a cause is good news. It means there isn't a brain tumor or similar organic disorder. The majority of headaches are neuromuscular in orgin and you are probably an excellent canidate for diagnostic blocks, trigger pint deactivation and a neuuromuscular orthotic that addresses the trigeminal nerve and the muscles it feeds.
You did not discuss what tests you have had or your history prior to the headache. I advise that you continual to lookfor the underlying causes of your pain.
Long term like you are experiencing can creat permanent brain changes thru central sensitization.
The doctdors can not tell me what is causing thsi, they just keep giving me drugs.
DR SHAPIRA RESPONSE: Debbie, I frequently hear stories like yours. The fact that the physicians cannot find a cause is good news. It means there isn't a brain tumor or similar organic disorder. The majority of headaches are neuromuscular in orgin and you are probably an excellent canidate for diagnostic blocks, trigger pint deactivation and a neuuromuscular orthotic that addresses the trigeminal nerve and the muscles it feeds.
You did not discuss what tests you have had or your history prior to the headache. I advise that you continual to lookfor the underlying causes of your pain.
Long term like you are experiencing can creat permanent brain changes thru central sensitization.
Thursday, January 20, 2011
intense jaw pain on left side, swollen jaw and cheek, no dental issues per dentist and endodontist...tmj or trigeminal neuralgia?
I recently received a e-mail from a patient with the following complaint:
intense jaw pain on left side, swollen jaw and cheek, no dental issues per dentist and endodontist...tmj or trigeminal neuralgia?
The question TMJ or Trigeminal Neuralgia is very limited. 95% of all pain that patients experience is muscle pain. Many patients have severe or even excruciating pain but their TM Joints are normal. These are neuromuscular problems and may have many contributing factors. Trigeminal Neuralgia is rarely the cause of pain and when it is there is usually very specific triggers. The pain usually comes and goes going from normal to intense pain after stimulating trigger.
KI have seen patients with similar symptoms that are later tracked back to cracked toooth syndrome that was not evident early on. Vacumn sinusits can also give similar symptoms.
That said, the most common cause of pain is myofascial pain acute muscle spasm, myositis or other pain of muscular orgin.
A simple test that all general dentists and/or endodontists should know is how to do trigger point deactivation with a vapocoolant and stretch that can often give instanyt pain relief. Use of a diagnostic block to the muscle can also correct these problems when used to make a differential diagnosis.
The patient did not describe whether the pain was affected by jaw movement, if there was limited opening, or many other vital facts to know if there was joint involvement.
The correct approach is to make an accurate diagnosis. This involves a thorough evaluation of the jaw musclesand (TMJ) joints but also the head and neck musculature.
The best route is to seek out a neuromuscular dentist who is trained to evaluate and correct these problems.
I frequently see patients in Chicago who have not found help locally.
Diagnosis is the key to successful treatment. Treatment should be reversible until significant pain relief is accomplished and both the patient and the doctor are comfortable with primary and secondary diagnosis.
intense jaw pain on left side, swollen jaw and cheek, no dental issues per dentist and endodontist...tmj or trigeminal neuralgia?
The question TMJ or Trigeminal Neuralgia is very limited. 95% of all pain that patients experience is muscle pain. Many patients have severe or even excruciating pain but their TM Joints are normal. These are neuromuscular problems and may have many contributing factors. Trigeminal Neuralgia is rarely the cause of pain and when it is there is usually very specific triggers. The pain usually comes and goes going from normal to intense pain after stimulating trigger.
KI have seen patients with similar symptoms that are later tracked back to cracked toooth syndrome that was not evident early on. Vacumn sinusits can also give similar symptoms.
That said, the most common cause of pain is myofascial pain acute muscle spasm, myositis or other pain of muscular orgin.
A simple test that all general dentists and/or endodontists should know is how to do trigger point deactivation with a vapocoolant and stretch that can often give instanyt pain relief. Use of a diagnostic block to the muscle can also correct these problems when used to make a differential diagnosis.
The patient did not describe whether the pain was affected by jaw movement, if there was limited opening, or many other vital facts to know if there was joint involvement.
The correct approach is to make an accurate diagnosis. This involves a thorough evaluation of the jaw musclesand (TMJ) joints but also the head and neck musculature.
The best route is to seek out a neuromuscular dentist who is trained to evaluate and correct these problems.
I frequently see patients in Chicago who have not found help locally.
Diagnosis is the key to successful treatment. Treatment should be reversible until significant pain relief is accomplished and both the patient and the doctor are comfortable with primary and secondary diagnosis.
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