New Report in Journal Headache on Chronic and Episodic Migraine.

This new report in Headache. 2011 Nov 22 looks at differences between Chronic Migraine (More than 15 headache days/month) compared to Episodic Migraine (less than 15 headache days/month) The study found that "those with Chronic Migraine were significantly more likely to experience "severe" headache impact (72.9% vs 42.3%) and had higher odds of greater adverse headache impact compared with persons with Episodic Migraine.

The study found that "Significant predictors of adverse headache impact in both groups included younger age, higher MSS (migraine symptom severity) score, higher average long-duration headache pain severity rating, and depression."

"Lower annual household income, anxiety, and higher standardized headache day frequency predicted adverse headache impact in Episodic Migraine but not in Chronic Migraine."

Not surprising, rates of depression were more than double among persons with Chronic Migraine compared to Episodic Migraine and rates of anxiety were nearly triple in the Chronic Migraine group.

When patients are treated with a diagnostic neuromuscular orthotic it is common to see changes in personality and temperament as the pain is reduced or eliminated. I have often found that I don't "meet" the patient till the second, third or fourth visit because they were "lost" in their pain. As the pain dissipates you actually meet the real person, not the one at the effect of constant pain.

This study (PubMed abstract below) describes Chronic Migraine as more than 15 days of headache while episodic is less than 15. In my experience both of these groups actually are in constant pain but they describe lower levels of pain as feeling good. When patients are feeling better they can be more objective about how bad they really felt prior.

It is essential to understand that the depression and anxiety are somatopsychic effects of being in constant pain. Dpression is a "normal" response to constant pain.

Headache. 2011 Nov 22. doi: 10.1111/j.1526-4610.2011.02046.x. [Epub ahead of print]

Headache Impact of Chronic and Episodic Migraine: Results From the American Migraine Prevalence and Prevention Study.

Buse D, Manack A, Serrano D, Reed M, Varon S, Turkel C, Lipton R.

Source

From Montefiore Headache Center, Montefiore Medical Center, Bronx, NY, USA (D. Buse); Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA (D. Buse and R. Lipton); Allergan, Inc., Irvine, CA, USA (A. Manack, S. Varon, and C. Turkel); Clinical Research, Vedanta Research, Chapel Hill, CA, USA (D. Serrano and M. Reed).

Abstract

Background.- The Headache Impact Test-6 (HIT-6) has been demonstrated to be a reliable and valid measure that assesses the impact of headaches on the lives of persons with migraine. Originally used in studies of episodic migraine (EM), HIT-6 is finding increasing applications in chronic migraine (CM) research. Objectives.- (1) To examine the headache-impact on persons with migraine (EM and CM) using HIT-6 in a large population sample; (2) to identify predictors of headache-impact in this sample; (3) to assess the magnitude of effect for significant predictors of headache-impact in this sample. Methods.- The American Migraine Prevalence and Prevention study is a longitudinal, population-based study that collected data from persons with severe headache from 2004 to 2009 through annual, mailed surveys. Respondents to the 2009 survey who met International Classification of Headache Disorders 2 criteria for migraine reported at least 1 headache in the preceding year, and completed the HIT-6 questionnaire were included in the present analysis. Persons with migraine were categorized as EM (average <15 headache days per month) or CM (average ≥15 headache days per month). Predictors of headache-impact examined include: sociodemographics; headache days per month; a composite migraine symptom severity score (MSS); an average pain severity rating during the most recent long-duration headache; depression; and anxiety. HIT-6 scores were analyzed both as continuous sum scores and using the standard, validated categories: no impact; some impact; substantial impact; and severe impact. Group contrasts were based on descriptive statistics along with linear regression models. Multiple imputation techniques were used to manage missing data. Results.- There were 7169 eligible respondents (CM = 373, EM = 6554). HIT-6 scores were normally distributed. After converting sum HIT-6 scores to the standard categories, those with CM were significantly more likely to experience "severe" headache impact (72.9% vs 42.3%) and had higher odds of greater adverse headache impact compared with persons with EM (OR = 3.5, 95% CI = 2.77-4.41, P < .0001). Significant predictors of adverse headache impact in both groups included younger age, higher MSS score, higher average long-duration headache pain severity rating, and depression. Lower annual household income, anxiety, and higher standardized headache day frequency predicted adverse headache impact in EM but not CM. With few exceptions, gender, race, and body mass index did not significantly predict adverse headache impact. Finally, rates of depression were more than double among persons with CM (CM = 25.2%, EM = 10.0%), and rates of anxiety were nearly triple (CM = 23.6%, EM = 8.5%). Conclusions.- This work further establishes HIT-6 as a useful instrument for characterizing CM and understanding the increased disease related burden. Persons with CM had significantly higher odds of greater adverse headache impact, when compared with EM. Predictors of greater headache impact for both groups included higher MSS scores, higher average headache pain severity, and depression. Additional predictors unique to EM included higher average household income, younger age, higher standardized headache day frequency, and anxiety. This finding may be related to differences in sample size and power. Further exploration is warranted.

© 2011 American Headache Society.

Accupuncture vs Topiramate: New Study in October Cephalgi ( Oct 21, 2011)Shows Superior Results With Accupunture

Neuromuscular Dentistry and accupuncture bot work by restoring normal physiologic states to the body compared to drug treatments that can destroy chemical balance. The current study shows accupuncture to be superior to topiramate but of greater importance is the frequency of side effects. (abstract below)

I will state that Neuromuscular Diagnostic orthotics almost always give better results than either therapy. I frequently work with patients on extremely high levels of medication that is gradually reduced by their physician following treatment. One of the most difficult issues in treating headache patients is medication withdrawal.

Topiramate had adverse events or side effects in 66% of patients compared to 6% in accupuncture group. This level of side effects for drug therapy is enormous considering it did not work as well as accupunture.

The reduction in headaches days was significantly greater with accupuncture.

Cephalalgia. 2011 Oct 21. [Epub ahead of print]

Acupuncture versus topiramate in chronic migraine prophylaxis: A randomized clinical trial.

Yang CP, Chang MH, Liu PE, Li TC, Hsieh CL, Hwang KL, Chang HH.

Source

Kuang Tien General Hospital and Chang Gung University, Taiwan.

Abstract

Background: The aim of this study was to investigate the efficacy and tolerability of acupuncture compared with topiramate treatment in chronic migraine (CM) prophylaxis. Methods: A total of 66 consecutive and prospective CM patients were randomly divided into two treatment arms: 1) acupuncture group: acupuncture administered in 24 sessions over 12 weeks (n = 33); and 2) topiramate group: a 4-week titration, initiated at 25 mg/day and increased by 25 mg/day weekly to a maximum of 100 mg/day followed by an 8-week maintenance period (n = 33). Results: A significantly larger decrease in the mean monthly number of moderate/severe headache days (primary end point) from 20.2 ± 1.5 days to 9.8 ± 2.8 days was observed in the acupuncture group compared with 19.8 ± 1.7 days to 12.0 ± 4.1 days in the topiramate group (p < .01) Significant differences favoring acupuncture were also observed for all secondary efficacy variables. These significant differences still existed when we focused on those patients who were overusing acute medication. Adverse events occurred in 6% of acupuncture group and 66% of topiramate group. Conclusion: We suggest that acupuncture could be considered a treatment option for CM patients willing to undergo this prophylactic treatment, even for those patients with medication overuse.

PMID:

22019576

[PubMed - as supplied by publisher]

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EAR PAIN: What to do when the ENT says there is no infection and does not have a treatment to relieve ear pain.

When chronic or acute ear pain occurs an evaluation by an otolaryngologist or ENT is a good way to begin treatment. The exception to this rule is when movements of the lower jaw cause the ear pain or the motion of the lower jaw is limited. This is a sign of a TMJ disorder. If it happens suddenly it may be the sign of an acute close-lock of the TM Joint and a dentist with experience in treating temporomandibular disorders is a must. Neuromuscular Dentistry is extremely effective in treating chronic haeadaches, migraines, Tension Headaches and TMD but when an acute close lock occurs time is of the essence to prevent permanent damage.

Many neuromuscular dentists know how to manage the chronic pain aspect of TMD but are less sure of handling an acute disk dislocation.

The wrong treatment is to not attempt to reduce the dislocation, taking anti-inflamatories or pain meds without attempting to reduce the dislocation. The longer the disk is out the more likely there will be permanent damage or internal derangement of the TMJ.

A trip to the emergency room is usually non-productive or may even create additional damage if they try to force the jaw open.

A simple method to reduce a close-lock it to stimulate a strong gag reflex which will sometimes reduce the dislocation. It is then necessary to stabilize the joint with an orthotic.

Neuromuscular Dentistry, Central Sensitization and Trigeminal Neuralgia: Is Neuromuscular Dentistry an ideal method to prevent central sensitization?

A new article in Medical Hypothesis (see Pub Med abstract below) on Atypical Trigeminal Neuralgia discusses the pathogenisis of Central Sensitization in patients with Trigeminal Neuralgia. A percentage of patients with Trigeminal Neuralgia will have pressure on the trigeminal nerve either from blood vessels or tumors usually in the area of the foramen ovale.

Many patients who have trigeminal neuralgia have no overt cause for the disorder. When there is a tumor or blood vessel creating undue pressure on the nerve a surgiclal approach is usually corrective but the central sensitization may remain. This article postulates that time is of the essence and the longer the pain persists the more likely that brain plasticity will lead to long term central sensitization. Decompression should be done ASAP according to that line of thought.

The majority of patients diagnosed with trigeminal neuralgia do not have tumor or blood vessels encroaching on the trigeminal nerve. It is well known that treatment of TMJ disorders is highly effective in reducing pain and that Neuromuscular Dentistry has been shown to be "overwhelmingly successful" according to Dr Barry Cooper and published in Cranio Journal.

The same rationale that says the key to preventing central sensitiztion is to address the problem as soon as possible also holds true with neuromuscular problems affecting the jaws, bite, jaw muscles and TMJ (TM Joints).

The effects of pressure on the trigeminal nerve are periferrral effects (noxius input) afecting the CNS. Neuromuscular bite problems are also noxious input from the periferal nervous system.

A second article in Medical Hypothesis "Migraine, neuropathic pain and nociceptive pain: towards a unifying concept." brought this to light and pushed the unifying concept of mifgraine and neuropathic pain. The basic concepts are identical. Correction of noxious input is the key to treating the pain and preventing central sensitization. This is exactly the concepts behind Neuromuscular Dentistry.

This is also explained in an excellent article on Myofascial pain and TMD published in J Pain. 2009 Nov;10(11):1170-8 (see PubMed Abstract below)"Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing." that is interesting because it looks at a group of 20-28 year old patients with myofascial pain, TMD and central sensitization. This group of patients definitively show how periferral pain manifestations induce central sensitization. The time to intervene with neuromuscular dentistry is at an earlier stage before central sensitization occurs.

There is also a concern about the quality of sleep as TMD patients have a much higher incidence of sleep apnea which I believe predisposes patients to central nervous system changes. Migraines, Chronic Daily Headaches, Tension-Type headaches and TMD are all directly effected by the trigeminal nerve and the trigeminovascular connection. Neuromuscular Dentistry can effect the central nervous system by changing the quality of neuro input.

Med Hypotheses. 2010 Feb 19. [Epub ahead of print]

Atypical trigeminal neuralgia: A consequence of central sensitization?
Hu WH, Zhang K, Zhang JG.

Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

Trigeminal neuralgia (TN) is characterized by sudden, recurrent, usually unilateral, severe brief stabbing pains in the distribution of trigeminal nerve. Although it is widely accepted that blood vessel or tumor compression contributes to paroxysms of TN, the pathogenesis of persistent background pain in atypical TN patient is unclear. Central sensitization is pain hypersensitivity caused by central neural plasticity. It is responsible for many temporal and symptomatic features of acute and chronic pain. We hypothesize that central sensitization might account for some symptoms of atypical TN. Based on this hypothesis, we postulate that early medical intervention predicts good outcomes in TN and medicines which are effective on central sensitization may be potential agents for the treatment of atypical TN. Copyright © 2010 Elsevier Ltd. All rights reserved.

PMID: 20172658 [PubMed - as supplied by publisher]

Med Hypotheses. 2010 Feb;74(2):225-31. Epub 2009 Sep 17.

Migraine, neuropathic pain and nociceptive pain: towards a unifying concept.
Chakravarty A, Sen A.

Department of Neurology, Vivekananda Institute of Medical Sciences, Calcutta, India. saschakra@yahoo.com

Migraine, neuropathic pain and nociceptive pain are the three commonest pain syndromes affecting human. In the present article, we first present the salient features of the pathophysiology of the three conditions particularly highlighting the core features that are similar in the three conditions. We argue on the validity of the prevailing concept that maintenance of structural integrity of the nervous system differentiates nociceptive pain from neuropathic pain and point out that the fundamental pathophysiology of lasting nociceptive pain (like cancer pain) and neuropathic pain (like nerve injury pain) is essentially same. Migraine pathophysiology is complex and complicated by two opposing views on site of migraine pain generation - peripheral versus central. We hypothesize that this dichotomy has resulted from focusing on two different sites on a single, somewhat complicated, pain mediating circuitry from the peripheral meningeal and vascular structures through several cell stations in the brain stem and thalamus up to the sensory cortical matrix. At the end, we suggest that fundamentally all the three pain syndromes referred to in the article share a common pathophysiological mechanism, namely peripheral pain perception, peripheral sensitization at dorsal root ganglion or its intracranial counterpart (like trigeminal ganglion) and central sensitization at the spinal cord (dorsal horn for somatic pain), brain stem nuclei and thalamus before final pain perception at the sensory cortical matrix.

PMID: 19765908 [PubMed - in process]
that cause central sensitization and pain.

J Pain. 2009 Nov;10(11):1170-8. Epub 2009 Jul 9.
Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing.

.
Fernández-de-las-Peñas C, Galán-del-Río F, Fernández-Carnero J, Pesquera J, Arendt-Nielsen L, Svensson P.

Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. cesar.fernandez@urjc.es

Our aim was to investigate bilateral, widespread pressure-pain hypersensitivity in nerve, muscle, and joint tissues in women with myofascial temporomandibular disorders (TMD) without concomitant comorbid conditions. Twenty women with myofascial TMD (aged 20 to 28 years old), and 20 healthy matched women (aged 20 to 29 years), were recruited. Pressure-pain thresholds (PPT) were bilaterally assessed over supra-orbital (V1), infra-orbital (V2), mental (V3) nerves, median (C5), radial (C6) and ulnar (C7) nerve trunks, the C5-C6 zygapophyseal joint, the lateral pole of the temporo mandibular joint (TMJ), and the tibialis anterior muscle in a blinded design. The results showed that PPTs were significantly decreased bilaterally over the supra-orbital, infra-orbital, and mental nerves, median, ulnar, and radial nerve trunks, the lateral pole of the TMJ, the C5-C6 zygapophyseal joint, and the tibialis anterior muscle in patients with myofascial TMD as compared to healthy controls (all sites: P < .001). There were no significant differences in the magnitude of PPT decreases between the trigeminal and extratrigeminal test sites. PPT over the mental nerve, the TMJ, C5-C6 zygapophyseal joint and tibialis anterior muscle were negatively correlated to both duration of pain symptoms and TMD pain intensity (P < .05). Our findings revealed bilateral, widespread pressure hypersensitivity in women presenting with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD women. PERSPECTIVE: This article reveals the presence of bilateral and widespread pressure-pain hypersensitivity in women with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD. This finding has implications for development of management strategies.

PMID: 19592309 [PubMed - indexed for MEDLINE]