Can Neuromuscular Dentistry Treatment Prevent and Eliminate Migraines, Cluster Headaches and Chronic Daily Headaches

There is big money in the treatment of migraines.  Can Neuromuscular Dentistry prevent migraines better than drug therapy?

Learn more at www.IHateHeadaches.org   www.ThinkBetterLife.com

 According to the Tevapharm.com website Teva and Hepartes entered in an agreement to discover and develop novel, small-molecule CGRP Antagonists for treatment of migraine.  Hepartes may receive potential payments of $400 million.  This is excellent news because much of the current drug regimens have safety and effectiveness issues.

Is there a better alternative to CGRP Antagonists for migraine?  It is important to understand the underlying physiology of headache and migraine when considering this question.

Calcitonin gene-related peptide is a vaso-active neuropeptide released by branches of the Trigemino-vascular system of the Trigeminal Nerve.  CGRP and other neurotransmitters released at nerve synapses have been implicated in migraine headaches. 

Drug therapy for migraines are big business worldwide.  The question is there a better method of preventing and eliminating migraines available.

It is unlikely that funding to evaluate neuromuscular dentistry as migraine prevention will ever materialize.  This is in spite of the fact that it is well established that almost 100% of all headaches and migraines (including Trigeminal Autonomic cephalgias) are Trigeminally controlled.

The Trigeminal Nerve is often called the Dentist's nerve because it innervates the teeth (ie. dental pulp), the Periodontal Ligaments, the Jaw Muscles, the Jaw Joints, the anterior two thirds of the tongue, the tensor of the ear drum, the tensor of soft palate (opens and closes eustacian tubes).

The Trigemino-Cervical Complex descends cervically and connects to the sympathetic chain and is responsible for neck and occipital headaches.

The TrigeminoVascular System controls blood flow to the anterior two thirds of the meninges of the brai.  It is in this location that CGRP are released causing vaso dilation asociated with migraines.

The question is not can these drugs work but rather is it possible to prevent the release of the vasoactive neuropeptides by changing input to the trigeminal nervous system?

After accounting for amplification in the Reticular Activating System the Trigeminal Nervous System accounts for more that half of all input to the brain.

If we think of the brain as our central computer we can discuss the computer concept

GARBAGE IN- GARBAGE OUT  as a cause of all migraines and headaches.

Noxious input to the Trigeminal Nervous System causes release of neurotransmitters and vaso-active neuropeptides to the meninges of the brain  that are trigeminally innervated.

Can changing input correct migraine physiology.  The Sphenopalatine Ganglion (SPG) is the Largest Parasympathetic Ganglion of the head.  The SPG Block is extremely effective is stopping and preventing migraines and since it is generally done with lidocaine it is very safe.

Trigeminal fibers pass thru the Ganglion but do not have cell bodies there.  There are currently numerous implantable devices being studied that can change neural input to the Sphenopalatine Ganglion and treat Migraines, Cluster Headaches, Anxiety, Depression and many other disorders.  The block turns of the sympathetic overload of the fight or flight response.  In the parasympathetic mode we feel relaxation, safety, satiety, sexual,  loving, etc

This is proof of fact that changing neural input can treat, prevent and eliminate migraines and other headaches.

Neuromuscular Dentistry also has been shown to be very effective in treating patients with chronic headaches and migraines.  Unfortunately thousands of individual case studies do not carry the same evidence based medicine weight of double blind drug studies.  By its nature it is not possible to do double blind studies with neuromuscular Dentistry.......

There is a situation that clearly showed  the effectiveness of a Neuromuscular TMJ treatment program at Chicago HMO in the 1980's until 1993.

In the 1980's until 1993 I worked closely with Dr Mitchell Trubitt the Medical Director of Chicago HMO.  What started as a fight for insurance coverage for a single patient moved on to a test with six patients to see if Neuromuscular Dentistry could lead to cost savings for insurance compaines.  The initial test was six patients who were treated with neuromuscular orthotics for their TMJ and Headache problems.   All six patients had two surgical opinions stating TMJoint surgery was needed.  All six patients were treated without surgery.  The patients all reported being very happy with results that included relief of headaches and migraines.

The results were that we demonstrated estimated massive savings $250,000 on  just those six patients.  Because of the positive results of that test Chicago HMO began to cove 100% of the cost of Phase one Neuromuscular TMJ treatment .  These savings reflected hospitalization and surgery costs, surgical fees, anaesthesia and physical therapy.  Chicago HMO did not cover phase two treatment so all patients were fitted with appliances made on vitallium frameworks to prevent breakage.  Patients desiring orthodontics or crowns were not reimbursed by medical insurance.

Chicago HMO did not decide to cover  TMJ, disorders, in fact contract language specifically stated non-surgical treatment of TMJ problems were not covered.  In spite of that language Dr Trubitt authorized coverage due to cost savings.  Chicago HMO doctors who referred patients for non-surgical treatment actually were charged less for out of network referrals.  TMJ was given the same cost for referring physicians as Cancer and Heart Disease.

Patients not only experienced improvements in TMJ disorders but also reduction and elimination of headaches and migraines.  TMJ has been called "The Great Imposter" because so many diverse ymptoms are associated with it.  At the time Chicago HMO had no means of tracking drug savings nor did they consider costs of other related disorders.

When insurance coverage and out of pocket costs were taken out of the picture with a guarantee payment we were no longer in a pay per procedure mode but a global fee.  Trigger point injections, SPG Blocks and other procedures were used without additional costs leading to rapid patient improvement.

While there were no patient complaints during the program there were several complaints from oral surgeons objecting to a general dentist seeing patients for non-surgical treatment on patients they deemed surgery necessary.

In 1993 United Health Care bought out Chicago HMO (parent HMO America) and the program ended abruptly even though it had demonstrated significant savings over several years.

I met with the new medical director along with Dr Trubitt in an attempt to keep this very successful treatment and cost containment program going but was told that since United Health Care didn't pay for surgery they would save money treating TMJ non-surgically.

Four years after this experience The Shimshak article was  published that showed that patients carrying a TMJD diagnosis had a 200% increase in total medical expenses.  Shimshak stated "The majority of these differences were attributed to conditions that were not usually considered related to TMJ disorders. These utilization and cost differences extended, in varying degrees, over a wide range of diagnostic and healthcare provider categories."  (Pubmed abstract below)

One year later a follow-up study showed that the increased costs were actually 300% over patients not carrying TMJ diagnosis.  Shimshak stated "For some of the major diagnostic categories, such as nervous, respiratory, circulatory, and digestive, the inpatient and outpatient claims differences in utilization and costs were as large as 3 to 1. For only one diagnostic category, pregnancy and childbirth, were utilization and costs greater for non-TMJ subjects than TMJ patients. The psychiatric claims for TMJ patients exhibited differences that were at least twice as large as those for the non-TMJ subjects." (pubmed abstract below)

Cranio. 1997 Apr;15(2):150-8.

Medical claims profiles of subjects with temporomandibular joint disorders.

Shimshak DG1, Kent RL, DeFuria M.

Author information

Abstract

The primary goal of this study was to evaluate the claims profiles of subjects with TMJ disorders relative to a control group without the disorders and to provide a characterization of the type of healthcare services received and the associated costs of healthcare for patients with TMJ disorders. The administrative data base of a major medical insurer was used to compare the claims history of 1,819 patients diagnosed with TMJ disorders to matched controls. The analysis was based only on medical claims. The study found that total medical claim payments for the patients with TMJ disorders were double that of the subjects without TMJ disorders, and similarly, the utilization of institutional and professional care services was found to be approximately twice as high, though not uniformly distributed across all Major Diagnostic Categories, physician specialties or types of service. The level and nature of the differences in the quantity and costs of healthcare between subjects with and without TMJ disorders were unexpectedly large. The majority of these differences were attributed to conditions that were not usually considered related to TMJ disorders. These utilization and cost differences extended, in varying degrees, over a wide range of diagnostic and healthcare provider categories.

Cranio. 1998 Jul;16(3):185-93.

Health care utilization by patients with temporomandibular joint disorders.

Shimshak DG1, DeFuria MC.

Author information

Abstract

The claims data base of a large New England managed care organization was used to compare the health care utilization patterns of patients with TMJ disorders to non-TMJ subjects. Inpatient, outpatient and psychiatric claims data were examined over a wide range of diagnostic categories. Age and sex adjusted results showed that, overall, patients with TMJ disorders were greater utilizers of health care services and had higher associated costs than non-TMJ subjects. For some of the major diagnostic categories, such as nervous, respiratory, circulatory, and digestive, the inpatient and outpatient claims differences in utilization and costs were as large as 3 to 1. For only one diagnostic category, pregnancy and childbirth, were utilization and costs greater for non-TMJ subjects than TMJ patients. The psychiatric claims for TMJ patients exhibited differences that were at least twice as large as those for the non-TMJ subjects.

Learn more at www.IHateHeadaches.org   www.ThinkBetterLife.com

Migraine: New Article in Cephalgia: Targeting pericranial nerve branches to treat migraine: Current approaches and perspectives.

This new article in Cephalgia (PubMed Abstract below) discusses evidence that interventions targeting peripheral Nerves are useful.

This is not new information to anyone who has experienced relief and elimination of Migraines from occipital Nerve Blocks or SphenoPalatine Ganglion Nerve Blocks.  Both of these nerve blocks can be safely and efficiently used to decrease, treat and eliminate migraines.

The Sphenopalatine ganglion block is easy for patients to self administer at home to prevent migraines.

Neuromuscular Dentistry has shown thousands and thousands of patients that correction of craniomandibular problems can decrease and eliminate migraines by changing the input into the Trigeminal Nervous System.  All headaches and migraines are mediated in part of fully by the Trigeminal Nerve and the TrigeminoVascular System.

There is a massive amount of input into the Trigeminal Nervous system from proprioception that passes thru the mesencephalic nucleus.  The mesencephalic nucleus is very specialbecause it does not contain chemical synapses.  The neurons are electrically coupled unlike other central nevous system (CNS) ganglia.  The mesencephalic nucleus is the only CNS Ganglia to contain cell bodies of a primary afferent nerve.  The Trigeminal Ganglion is the primary sensory nucleus of the Trigeminal Nerve.

Trigeminal Neuralgia is sometimes treated by destroying parts of the Trigeminal Ganglion with thermocoagulation or injection of glycerol.

Another well known procedure for preventing and treating migraines is osteopathic and chiropractic treatment.  Especially effective are upper cervical chiropractic techniques used by NUCCA and Atlas-Orthoganol Chiropracters.

A very dfferent type of perpheral stimulation of the Trigeminal Nerve can decrease migraine.  Humans smell Menthol with their Trigeminal Nerve. The use of topical menthol is an effective topical pain treatment but smelling of menthol and activation of the Trigeminal Nerve may account for much of this action.    Activation of the antitussive effects of menthol  "occur secondary to the activation of TRPM8+/TRPV1− nasal trigeminal afferent neurons."  (http://jap.physiology.org/content/115/2/268).
These effects were the reason cigarrette companies added menthol .

The trigeminal system is unique in its ability to smell and taste Menthol in a different manner than olfactory nerve (smell) , chord tympani of facial nerve (taste), posterior third of tongue tastefrom Glossopharyngeal nerve.
Smells and taste are frequently associate with migraines as percipitating factors, Auras and can be used in a preentive manner.

Cephalalgia. 2015 Mar 3. pii: 0333102415573511. [Epub ahead of print]

Targeting pericranial nerve branches to treat migraine: Current approaches and perspectives.

Ambrosini A1, D'Alessio C2, Magis D3, Schoenen J3.

Author information

Abstract

BACKGROUND: 

Migraine is a highly prevalent neurological disorders and a major individual and societal burden. Migraine is not curable at the present time, but it is amenable to acute symptomatic and preventive pharmacotherapies.

SUMMARY: 

Since the latter are frequently unsatisfactory, other treatment strategies have been used or are being explored. In particular, interventions targeting pericranial nerves are now part of the migraine armamentarium. We will critically review some of them, such as invasive and noninvasive neurostimulation, therapeutic blocks and surgical decompressions.

CONCLUSIONS: 

Although current knowledge on migraine pathophysiology suggests a central nervous system dysfunction, there is some evidence that interventions targeting peripheral nerves are able to modulate neuronal circuits involved in pain control and that they could be useful in some selected patients. Larger, well-designed and comparative trials are needed to appraise the respective advantages, disadvantages and indications of most interventions discussed here.

© International Headache Society 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Neuroscience. 2011 Aug 25;189:377-83. doi: 10.1016/j.neuroscience.2011.04.065. Epub 2011 May 7.

Perception of specific trigeminal chemosensory agonists.

Frasnelli J1, Albrecht J, Bryant B, Lundström JN.

Author information

Abstract

The intranasal trigeminal system is a third chemical sense in addition to olfaction and gustation. As opposed to smell and taste, we still lack knowledge on the relationship between receptor binding and perception for the trigeminal system. We therefore investigated the sensitivity of the intranasal trigeminal system towards agonists of the trigeminal receptors TRPM8 and TRPA1 by assessing subjects' ability to identify which nostril has been stimulated in a monorhinal stimulation design. We summed the number of correct identifications resulting in a lateralization score. Stimuli were menthol (activating TRPM8 receptors), eucalyptol (TRPM8), mustard oil (TRPA1) and two mixtures thereof (menthol/eucalyptol and menthol/mustard oil). In addition, we examined the relationship between intensity and lateralization scores and investigated whether intensity evaluation and lateralization scores of the mixtures show additive effects. All stimuli were correctly lateralized significantly above chance. Across subjects the lateralization scores for single compounds activating the same receptor showed a stronger correlation than stimuli activating different receptors. Although single compounds were isointense, the mixture of menthol and eucalyptol (activating only TRPM8) was perceived as weaker and was lateralized less accurately than the mixture of menthol and mustard oil (activating both TRPM8 and TRPA1) suggesting suppression effects in the former mixture. In conclusion, sensitivity of different subpopulations of trigeminal sensory neurons seems to be related, but only to a certain degree. The large coherence in sensitivity between various intranasal trigeminal stimuli suggests that measuring sensitivity to one single trigeminal chemical stimulus may be sufficient to generally assess the trigeminal system's chemosensitivity. Further, for stimuli activating the same receptor a mixture suppression effect appears to occur similar to that observed in the other chemosensory systems.

Copyright © 2011 IBRO. Published by Elsevier Ltd. All rights reserved.

Highland Park Dentist is New Chair of The American Alliance of TMD Organizations. New Highland Park Office Focuses on TMJ Disorders, Sleep Apnea, Snoring, Chronic Daily Headaches and Migraines

The Alliance of TMD Organizations' mission is to support and protect the rights and freedom of patients and their doctors. A grave new threat is now looming that may have very negative effects on patients and doctors.

The American Alliance of TMD held its annual meeting on February 26-27 at the Chicago Marriott. Long Time Highland Park resident Ira L Shapira became the new Chair of the TMD Alliance.

The Alliance (http://www.tmdalliance.org/index.html) is dedicated to protecting the rights of TMD patients to receive the care they need. According to Dr Shapira there is a grave new threat has arisen that may effect both the patients rights and ability to have their care reimbursed by insurance. The threat is from a new board claiming the right to grant specialty outside the auspices of the American Dental Association which is and always has represented the dental profession and public safety.

The American Dental Association is the voice of organized dentistry and Specialty recognition in the U.S. The American Dental Association has recognized several dental specialties including: American Board of Dental Public Health, American Board of Endodontics, American Board of Oral and Maxillofacial Pathology, American Board of Oral and Maxillofacial Radiology, American Board of Oral and Maxillofacial Surgery, American Board of Orthodontics, American Board of Pediatric Dentistry, and American Board of Periodontology.

A new group, the American Board of Dental Specialties (ABDS) is acting outside of organized dentistry to create and grant specialty status to groups that have either not met the ADA standards for specialty or had their application rejected by the Ameican Dental Association.

The following Dental Specialty Boards have been granted recognition by the ABDS:

American Board of Oral Implantology. Implant Dentistry; this so called specialty is already well represented by both The American Board of Oral and Maxillofacial Surgery & The American Board of Periodontology.

American Board of Orofacial Pain. This group has been repeatedly denied specialty by the American Dental Association for multiple reasons. There have been other groups who have also been denied specialty in the TMD field by the American Dental Association. All Diplomats of the ABOP will become instant (just add water) specialists. Many of these doctors have previously been involved in questionable groups that unfairly (and possibly fraudulently) deny patients legitimate insurance claims. Specialty Status, however dubious will embolden them to unfairly attempt to restrict medical benefits to patients. This group actually discounts the effect of dentistry and occlusion on oral facial pain. The promote utilizing drugs and psychotherapy to treat TMJ disorders.

Two additional boards seeking specialty are:
American Dental Board of Anesthesiology
American Board of Oral Medicine.

The TMD Alliance and it's individual members have multiple other concerns over any specialty designation in TMD or Oral Facial Pain.

Dr Shapira could not comment further on specifics of the problems associated with this group but the Alliance of TMD Organizations has long been opposed to specialty. Dr Shapira believes this specialty will hurt patients, TMD practitioners as well as the entire dental profession.

The so called specialties being created will need to be approved by each and every state dental board across the country. Dr Shapira urges the ADA and all of its constituents to do all it can to protect the American Public from this dangerous development. State Dental Boards across the country need to reject these questionable new specialties to protect the public until they have been properly vetted. The ADA should consider taking a strong stance in this issue before it is too late.

When the American Dental Association creates a new specialty it Grandfathers in doctors working within the specialty as specialists. The DANGER WITH SELF-DECLARED SPECIALTIES IS ONLY MEMBERS OF A SELECT GROUP ARE ADMITTED AND THEN THAT GROUP IS IN CHARGE OF WHO CAN LATER BECOME A SPECIALIST. The ABOP has been restrictive in the past in who could become members.

THIS IS A REAL DANGER TO THE AMERICAN PUBLIC AND SHOULD BE DISCUSSED IN AN OPEN FORUM.

The Alliance of TMD Organizations includes the following organizations:

American Academy of Craniofacial Pain
(Previously American Academy of Head, Neck and Facial Pain

American Equilibration Society
(The first organization dedicated to TMJ disorders)

International Association of Physiologic Aesthetics
(previously International Association of Comprehensive Esthetics)

International College of Cranio-Mandibular Orthopedics
(The original Neuromuscular dental group)

International Association for Orthodontics

Sacro Occipital Technique Organization-USA
(The only Chiropractic group in the Alliance)

Tennessee CRANIO

The following organizations have lapsed membership in the Alliance but Dr Shapira hopes to bring them back to full membership status:

American Academy of Pain Management
American College of Prosthodontics

Treatment of TMJ and Sleep Disorders has been a consuming passion for Dr Shapira for 35 years who is a Fellow of the International College of CranioMandibular Orthopedics as well as Secretary and the representative from ICCMO to the TMD Alliance along with Dr Barry Cooper, who is Past President of ICCMO, A Life Member of the AES and one of the founding members of the Alliance and past chair. Dr Cooper has an impressive history in the TMD field.
http://www.tmjtmd.com/curriculum-vitae2.html

As a Diplomat of the American Academy of Pain Management and a long time member of both the American Equilibration Society and the Academy of CranioFacial Pain, and a previous member of the IACA Dr Shapira is well versed in all of the pholosophies of each group. As a member Dr Shapira urges the ADA, the Illinois State Dental Society and the Chicago Dental Society to see these pseudo-specialties as a threat to the profession and the public.

Dr Shapira is a founding member of The American Academy of Dental Sleep Medicine (formerly the Sleep Disorder Dental Society), a Diplomate of the American Board of Dental Sleep Medicine and a founding and charter member of DOSA, The Dental Organization for Sleep Apnea. The AADSM should, in Dr Shapira's opinion, join the TMD Alliance this year.

Dr Shapira is the Dental Editor of Sleep and Health Journal.

Dr Shapira did research on the similarities in jaw position in sleep apnea and TMJ patients in the 1980's as a visiting assistant professor at Rush Medical School where he worked with Rosalind Cartwright PhD who is primarily responsible for the entire field of Dental Sleep Medicine. He also studied with Dr Barney Jankelson who created the initial concepts that neuromuscular dentistry still uses today and created a company Myotronics that is the leading manufacturer of instrumentation used by Neuromuscular Dentistry.
His research showed that TMJ and Sleep Apnea patients had very similar jaw postures.

Dr Shapira has maintained a general dental practice with a special emphasis on sleep and pain in Gurnee, Il and has recently started Chicagoland Dental Sleep Medicine Associates in Highland Park. More information on Sleep, TMJ and Headache Treatment can be found on his websites.

http://www.thinkbetterlife.com (Highland Park office)

http://www.delanydentalcare.com (Gurnee Office)

http://www.ihateheadaches.org

http://www.chicagoland.ihatecpap.com.

http://www.Sleepandhealth.com

Dr Ira L Shapira is an author and section editor of Sleep and Health Journal, President of I HATE CPAP LLC, President Dato-TECH, President of Sleep Well Illinois,
 Dr Shapira also holds several patents on methods and devices for the prophylactic minimally invasive early removal of wisdom teeth and collection of bone marrow and stem cells. He is currently working with Dr Tom Diekwisch at the University of Illinois and Baylor University to prove these stem cells can change peoples lives for the better. Dr Shapira is a licensed general dentist in Illinois and Wisconsin.
sin.

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.

CLUSTER HEADACHES AND SLEEP APNEA: CAUSE AND EFFECT AND/OR CURE?

Cluster Headache patients please pay close attention. Sleep apnea has a major statistical connection to your pain. Sleep apnea is a TMJ disorder according to the NIH report (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf) CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS. Oral appliances can treat sleep apnea (http://www.ihatecpap.com) and migraines, chronic daily headaches, and tension-type headaches. Cluster headaches are much more frequent with sleep apnea; diagnosis and treatment is advised.

THIS IS A SLIGHTLY OLDER STUDY (pubmed abstract below) looking at the prevelance of sleep apnea in cluster headache. 80% (25 of 31patients) of patients with cluster headache did have sleep apnea with an average index (RDI) of 19.

The authors concluded that: "The data closely approximate those of Chervin et al, where 80% had RDI > 5. The relationship sleep apnea has in the perpetuation or precipitation of cluster headache is still to be determined."

While they did not say there was a cause and effect this was because this was not a prospective study where patients are watched to see if they develop cluster headaches. ( see below)

"There are some reports that treatment stops the cluster but there is no prospective study. The high incidence (80.64%) seen in this population suggests the cluster patient should receive a sleep evaluation and perhaps intervention with continuous positive airway pressure (CPAP) or an appropriate dental device.


Headache. 2004 Jun;44(6):607-10.
Obstructive sleep apnea and cluster headache.
Graff-Radford SB, Newman A.

The Pain Center, Cedars Sinai Medical Center and UCLA School of Dentistry, Los Angeles, CA 90048, USA.
Abstract
A patient with cluster headache often wakes from sleep. The relationship to sleep apnea has been described. This study sought to confirm the relationship cluster may have with sleep apnea. METHODS: Thirty-nine consecutive patients diagnosed with episodic cluster headache according to the International Headache Society (IHS) criteria were sent for polysomnographic studies. All patients were in an active phase when they were in the study. Patients were told of the proposed relationship and were allowed to choose a sleep laboratory close to their home. RESULTS: Thirty-one patients with episodic cluster headache completed an overnight polysomnographic study. Twenty-three were male and eight female. The average age was 51 years (range 33 to 78 years). The average weight was 173 pounds (range 117 to 260 pounds). A total of 80.64% had sleep apnea (25/31). Average respiratory depression index (RDI) was 19.0 (SD 14.6) with 6 patients having no apnea, 10 having mild, 11 having moderate, and 4 having severe apnea (RDI < 5 = none; RDI 5 to 20 mild; RDI 20 to 40 moderate; RDI > 40 severe). Oxygen saturation decreased on average to 88.4% SD 4.5. Sleep efficiency was 76.2% (SD 13.4). CONCLUSIONS: The data closely approximate those of Chervin et al, where 80% had RDI > 5. The relationship sleep apnea has in the perpetuation or precipitation of cluster headache is still to be determined. There are some reports that treatment stops the cluster but there is no prospective study. The high incidence (80.64%) seen in this population suggests the cluster patient should receive a sleep evaluation and perhaps intervention with continuous positive airway pressure (CPAP) or an appropriate dental device.

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]