Quality of Life Considerations in Migraine and Chronic Daily Headache Treatment

This was originally published as a Blog for www.ThinkBetterLife.com and my Highland Park Illinois office that serves Highland Park, Lake Forest, Dererfield, The entire North Shore, Chicago, Lake County and Cook County. The office is conveniently located on the Metra line North at the Fort Sheridan stop.  The office is dedicated to treatment of Chronic pian, TMJ disorders and sleep disorders including migraines, trigeminal neuralgia, and chronic daily headaches.

Migraines, Chronic Daily Headaches, Tension Headaches and the Trigeminal Autonomic Cephalgias are all extremely invasive and disruptive to overall quality of life.

Medications to treat these disorders are often dangerous and have multiple side effects that range from minor to life threatening.

Medication Overuse Headaches and Rebound Headaches can actually be worse than the original problem the medications are used to treat. Even ubiquitous drugs like Ibuprofen are responsible for thousands of deaths on a yearly basis and a host of GI problems.

The two ways to approach headaches treatment is to prevent the onset or to treat the actual headache when it occurs.

Preventing the onset can be the avoidance of headache triggers and /or drug treatment.

I am not discussing drugs for treating migraines in this paper but rather alternative to stand drug therapies.

An excellent alternative that is more effective than most drugs for most people is the Sphenopalatine Ganglion Block. There are several methods of preforming SPG Blocks some of which require a visit to the doctor and others that can be preformed by the patient in the comfort of their own homes. The Sphenopalatine Ganglion is the largest parasympathetic ganglion in the head. The block turns off sympathetic overload often called the Fight or Flight reflex that can be a major headache/migraine trigger.

The best method is the intranasal approach by the patient to be reviewed later in this article.

There are multiple methods of injection. The injection thru the Greater Palatine foramen is an intraoral injection that is routinely used in dentistry. Oral Surgery procedures often require this block for removing wisdom teeth. Many patients who have maxillary wisdom teeth removed experience a respite from migraines often for an extended time. More often than not the migraine relief is from the block not the removal of the teeth. The block can be done just to turn off a severe headache or as a migraine preventive. It is often accompanied by temporary facial numbness and numbness of the palate.

Injection can also be done extraorally either from above the zygomatic arch or through the masseter muscle. I prefer the approach that avoids the muscle. It is a relatively easy injection and can be done in the office. It is also done by some doctors using video fluoroscopy but that gratly increases the cost. This method of injection is the most effective and fastest onset often relieving the headaches in a minute or two.

This is ideal SPG approach for headaches that would put patients in the ER, migraines or severe headaches of several days duration, and especially headaches related to anxiety, stress and worry.

There are also three devices that can deliver local anaesthetic to the nasal mucosa that overlies the Sphenopalatine Ganglion. The three devices are the TX360 nasal applicator using the MiRX protocol. Its is intended for use for Trigeminal Neuralgia, Migraines, Cluster Headaches and Tension Headaches. It is essentially a high tech double barreled squirt gun that is designed to deliver anesthetic solution over the area covering the Ganglion.

The Sphenocath and the Allevio devices are simpler to use and may deliver the anaesthetic solution in a slightly superior position. The Sphenocath is the original device and the Allevio is a copy made by the Sphenocath ‘s original manufacturer.

My preferrd method when nasal passages are large enough is to utilize hollow cotton tipped applicators that use a capillary action to continually deliver anaesthetic over a longer period of time.

The beauty of this approach is that patients can self apply the block in minutes at an extremely low cost. They can turn off the headache faster than any drugs take effect and Lidocaine or other anesthetic can be used.

Side effects are feeling relaxed, turning off fight or flight response, reduced anxiety, increased parasympathetic actiity such a digestion, feelings of warmth and comfort, increased sexual desire and responsiveness, lower blood pressure and other positive effects.

The most effective method of eliminating triggers is through a diagnostic neuromuscular orthotic that can be created to decrease noxious input to the trigeminal nervous system that causes headache. The diagnostic appliance allows evaluation of the effect in a safe and cost effective approach prior to comencine and dental, orthodontic or orthopedic interventions.

The combination or SPG Blocks and Neuromuscular Dentistry may be the closest we will ever come to curing migraines and other trigeminal type headaches.

Drug treatments are directed at changing neurotransmitter and neuropeptide levels by drug interaction. Neuromuscular Dentistry and SPG Blocks do it by restoring homeostasis and eliminating noxious input to the trigeminal nervous system.

The noxious input causes the ultimate release of neuropeptides by the TrigeminoVascular System like CGRP or Calcitonin gene Related Peptide in the meninges in the anter two thirds of the brain which cause vascular headaches,

It also corrects input to the trigeminal cervical complex that is responsible ofr occipital headaches, while at the same time postural corrections of the head reduce excess cervical muslce activity and makes the spine, especially C1 and C@ or the Atlas and Axis more stable. The mechanics have been well explained in the Quadrant Theorem of Guzay.

CHRONIC DAILY HEADACHES (CDH): MAYO CLINIC CONSIDERS CDH THE MOST DISABLING OF HEADACHES TMJ Treatment May be the Answer

CHRONIC DAILY HEADACHES (CDH):  MAYO CLINIC CONSIDERS CDH THE MOST DISABLING OF HEADACHES

How your headaches are defined may prevent you from having effective treatment.

Living with headaches is a fact of life for many headache survivors.  According to Mayo Clinic  “chronic daily headaches occur 15 days or more a month, for at least three months. True (primary) chronic daily headaches aren't caused by another condition.”  This definition will artificially separate similar headaches into different diagnostic groupings.

Chronic daily headache is not a specific type of headache but rather a disabling pattern of headache occurrence.

Johns Hopkins describes Chronic Daily Headache as “A patient who has headaches as many days as not — at least 15 days a month — is said to have chronic daily headache (CDH). CDH is not a specific type of headache, but rather a descriptive term applied to any number of headache types. The two most common types of primary headache are Migraine and Tension-Type Headache.  Rebound headache or medication overuse headache is a frequent occurrence in patients with CDH.  The treatment actually becomes the disease.

The typical treatment offered by headache specialists and neurologists is a prescription medication.  When the first is not effective the patient is often taken thru a series of single medication trial followed by trials of multiple medications.  This is similar to what happens to patients who utilize OTC medications moving from drug to drug often mixing prescription and non-prescription medications.

Tension-type headaches are the most common type headache but they are often dismissed as being relatively mild and tolerable.  These headaches often progress to Rebound headaches and/or migraine.  Tension-type headaches should be considered to be muscle contraction headaches.  According to Cleveland Clinic “They used to be commonly referred to as muscle contraction headaches or stress headaches, but these old terms have been abandoned.”

90 – 95% of all headaches are actually partially or completely muscle contraction headaches.  There are Vascular/ Neurogenic components to all headaches as well. 

According to the NHLBI of the NIH patients who receive a diagnosis of TMJ have a 60-90% chance of experiencing satisfactory resolution of symptoms but patients diagnosed with other types of headaches will probably be condemmed to live in pain.

 or muscle contraction headaches are considered episodic if they occur less than 15 days/month and chronic if they occur more than 15 days/month.  They may las for 30 minutes to several hours or continue for days at a time.  Because they are a type of headache referred from muscles they tend to have slow onset and are achy in nature.  Patients often describe them as a taut band, pressure headaches, and usually they are bilateral and generalized in location.   What is important to understand is that Tension –Type headaches can be part of a ongoing process that triggers migraines and other more severe headaches.  Tension headaches can be as severe or even more severe than migraine headaches. Tension-Type headaches are considered a Primary headache but referred headaches from the neck muscles  (cervical headaches or cervicalgia) and/or the TMJ  (Tempormandibular Joints) and masticatory muscles are considered secondary headaches..   

These secondary headaches are examples of muscle contraction headache as are headaches related to trigger points and taut bands in Fibromyalgia and Myofascial Pain and Dysfunction. 

According to John Hopkins the following is a list of causes of tension-type headaches.  If you read the list it is almost like saying a normal life is the cause of headaches.  What all of these have in common is that they all provoke muscle contractions secondary to stress.

·        “Inadequate rest

·       Poor posture

·       Emotional or mental stress, including depression

Tension-type headaches can be triggered by some type of environmental or internal stress. This stress may be known (overt) or unknown (covert) to the patient and their family. The most common sources of stress include family, social relationships, friends, work, and school. Examples of stressors include:

·       Having problems at home

·       Having a new child

·       Having no close friends

·       Returning to school or training; preparing for tests or exams

·       Going on a vacation

·       Starting a new job

·       Losing a job

·       Being overweight

·       Deadlines at work

·       Competing in sports or other activities

·       Being a perfectionist

·       Not getting enough sleep

·       Being over-extended; involved in too many activities/organizations”

According to the National Heart Lung and Blood Institute of the National Institute of Health TMD Disorders :

“TMD has been used to characterize a wide range of conditions diversely presented as pain in the face or jaw joint area, masticatory muscle pain, headaches, earaches, dizziness, limited mouth opening due to soft or hard tissue obstruction, TMJ clicking or popping sounds, excessive tooth wear and other complaints.

TMD remains to be classified in the larger context of other muscle and joint disorders or in the category of pain disorders (NIH Technology Assessment Conference, 1996). About half of all cases are attributed to conditions linked to the muscles of mastication”  and “Pain linked to the TMJ and/or muscles of mastication constitutes the essential criterion for case assignment. It often qualifies as “aching”, “throbbing”, “tiring” and exhausting.

These are the same symptoms found in tension headaches and both are associated with similar proportions of female to male patients.  These disorders are also associated with sleep disturbances that tie them to a wide variety of other disorders.

The National Institute of Health and PubMed.gov provide the largest database in the world of headache publications.  These publications universally agree that regardless of the type of headache a patient has almost 100% are caused or mediated by the Trigeminal Nervous system.  The Trigeminal Nerve is often called the Dentist’s Nerve because it innervated the teeth,the periodontal ligament and gums, the jaw muscles, the jaw joints and many associated structures.    The Trigeminal Nerve also controls the blood flow to the anterior two thirds of the meninges of the brain.

Why do TMJ patients do better than other headache patients?  Only dentistry treats headaches by changing input to the brain.  While migraines are often thought to be caused by chemical imbalances within the brain only dentistry attempts to correct these chemical inbalances by eliminating noxious input to the Trigeminal Nervous System.

Neuromuscular Dentistry is probably the single most effective method of controlling noxious (nociceptive) input to the brain.

CENTRAL SENSITIZATION AND TMD: THE CONNECTION TO MYOFASCIAL PAIN, FIBROMYALGIA, HEADACHE, MIGRAINE AND RELATED DISORDERS.

I have frequently discussed the relation between headache, TMD and central sensitization. The trigeminal nerve is a frequent culprit in development of central sensitization which is why neuromuscular dentistry can be such an effective treatment. Decreases in nociceptive input from the trigeminal nerve can allow reversal of a sensitized state.

A new article in Pain "Pain." 2010 Oct 18. "Central sensitization: Implications for the diagnosis and treatment of pain." documents much of what we understand about central sensitization. These heightened central states are caused by noxious or nociceptive input into the brain. The trigeminal nerve carries a tremendous amount of information (nociception) into the CNS.

A recent article "Chronic Orofacial pain" proposes that "we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together." This would be obvious to anyone who evaluates the anatomy and physiology of the brain and especially the stomatognathic system including the jaw muscles, teeth and periodontal ligaments. jaw joints and most importantly the trigeminal nerve. The trigeminal nerve is almost always indicated as a culprit or co-conspirator in chronic and episodic facial pain and headache .

The use of botox on jaw muscles to treat chronic headaches and migraines actually reduces nociceptive input to the trigeminal nerve from and brain from peripheral input. Neuromuscular dentistry also reduces nociceptive input withput the use of toxic nerve agents but utilizing antidromic TENS to relax muscles and establisha healthy physiologic rest position with minimal nociceptive input. Neuromuscular occlusion is simply a physiologic land spot that allows the muscle to return to a health rest position after function.

The computer adage "Garbage in- Garbage out" is what happens when nociceptive input to the brain exceeds our ability to comfortably adapt causing pain and central sensitization. Reduce the "garbage in" with neuromuscula dental techniques and the "garbage out" painful sequellae subside.

Curr Pain Headache Rep. 2010 Feb;14(1):33-40.
Chronic orofacial pain.
Benoliel R, Sharav Y.

Faculty of Dentistry, Department of Oral Medicine, Hebrew University-Hadassah, Jerusalem, Israel. benoliel@cc.huji.ac.il
Abstract
Chronic orofacial pain (COFP) is an umbrella term used to describe painful regional syndromes with a chronic, unremitting pattern. This is a convenience term, similar to chronic daily headaches, but is of clinically questionable significance: syndromes that make up COFP require individually tailored diagnostic approaches and treatment. Herein we describe the three main categories of COFP: musculoskeletal, neurovascular, and neuropathic. For many years, COFP and headache have been looked upon as discrete entities. However, we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together.

PMID: 20425212 [PubMed - indexed for MEDLINE]

Headache and Migraine: Elimination and Prevention Through Neuromuscular Dentistry - Improve The Quality Of Your Life and Live Pain Free!

Reprint of 24/7 press release below:

"Quality of life is destroyed when you live with chronic pain. Migraines, chronic daily headaches and other chronic head and neck pain can frequently be eliminated through the science of Neuromuscular Dentistry and Trigeminal Nervous system relief."

URNEE, IL, June 02, 2010 /24-7PressRelease/ -- A recent patient who suffered a constant headache for over 50 years is now pain free without dependence on medication. Patient M was married to a physician and had access to the finest care available but still lived in continuous pain for over 50 years. Patient M met Dr Ira L Shapira by accident. Her husband had sleep apnea and loud snoring and found Dr Sapira through the website http://www.IHateCPAP.com.

M was at her husband's consultation and Dr Shapira noticed she held her temple during the appointment and asked if she had a headache. She did, and he used a simple technique to turn off a trigger point and to relieve her pain. This was a first for M who had never experienced this in 50 years of living with chronic headache pain. Neuromuscular Dentistry was discussed briefly at that visit and at the second visit her husband received his oral appliance to eliminate his sleep apnea and snoring and M began her Neuromuscular Dentistry treatment.

M recieved a Diagnostic Neuromuscular Orthotic that day and except for one day has been headache free since that time. M does report that when she is sick she may get a headache but it is different than the headaches she lived with for most of her life.

What is Neuromuscular Dentistry and what is a Diagnostic Neuromuscular Orthotic and how does it work?

An article that Dr Shapira was asked to write for the American Equilibration Society is one of the best explanations available online and has been reprinted in Sleep and Health Journal @ http://www.sleepandhealth.com/neuromuscular-dentistry.

A second article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" in Sleep and Health Journal discusses typical patient stories.

In the most simple terms the way Neuromuscular Dentistry works is change input and output from our brains and central nervous system to muscles, joints, and nervous system end organs in the Trigeminal Nervous System. Our brains are similar to computers. GARBAGE IN- GARBAGE OUT explains in computer lingo how bad input leads to bad output. The brain is basically a biological computer and GARBAGE IN- GARBAGE OUT holds true when it comes to our brains.

Input to the brain comes from two sources, input from the spinal column which accounts for 20% of the total input to the brain and input from 12 pairs of cranial nerves that accounts for 80% of brain input. The cranial nerves are responsible for sight, smell, taste, vision, hearing, proprioception and control of the autonomic nervous system.

The trigeminal nerve accounts for approximately 70% of the input to the brain from the 12 cranial nerves or more than half of total brain input. The Trigeminal Nerve is also known as the Dentist's Nerve. It goes to the teeth, jaw joints, jaw muscles, the periodontal ligaments of the teeth, the muscle that tenses the eardrum, the muscle that opens and closes the eustacian tubes, that innervates the lining of the sinuses and nasal mucosa. It also controls the blood flow to the anterior 2/3 of the meninges of the brain. When we smell menthol that is another trigeminal nerve function which may be why Vicks Vapor Rub works for many pains.

The trigeminal nerve also has a enormous autonomic component and is a chief cause of central sensitization. Central Sensitization is a primary aspect of most headaches and migraines, facial pains, fibromyalgia and almost all other chronic pain syndromes.

GARBAGE IN - GARBAGE OUT takes on new meaning when we are talking about the majority of input to the brain. Neuromuscular Dentistry turns bad data our brain receives into good data. Central Sensitization can turn good input into bad output. Examples are Hyperesthesia where there is an over-reaction to pain stimuli and Allodynia where non-painful input is received as Nociceptive of Pain impulses. Fibromyalgia is considered a disease caused by or accompanied by Central Sensitization. The Trigeminal Nerve is also vital for controlling respiration and airway patency. The National Heart Lung and Blood Institute issued a report "Cardiovascular and Sleep Related Consequences Of Temporomandibular Disorders" which is available at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf.

Dr Shapira created http://www.ihateheadaches.org to help patients understand headaches, migraines and how Neuromuscular Dentistry is an essential and vital treatment resource.

Why do patients suffer for years if there is a treatment that can so drastically improve their lives?

Do problems addressed Neuromuscular Dentistry actually affect health and medical costs?

Cranio, The Journal for CranioMandibular Practice published two articles that answer that question. The studies by Shimshak et al showed that patients with TMJ disorders had a 300% increase in medical utilization in all fields of medicine except obstetrics. In other words, aside from not getting pregnant these patients utilize three times the average in medical expenses. Treatment of Temporomandibular disorders and the neuromuscular pathology that cause them can drastically improve patients lives and possibly drastically decrease medical expenses.

The NHLBI report discusses how respiratory disorders related to TMJ disorders can effect many body systems. Dental Sleep Medicine is an extremely effective approach to treating sleep apnea. It is more effective overall than surgery. CPAP is still considered the Gold Standard of treatment for Sleep Apnea but has horrendous issues with patients compliance.

Poor compliance means it works well if used but most patients do not use it. CPAP that is not used is worthless and dangerous because the patient remains untreated. A recent study showed that 60% of patients did not use their CPAP. Other patients refuse to even have a sleep test because they do not want to use CPAP. One study cited at the Trucking and Sleep Apnea conference presented by the American Sleep Apnea Association showed only 5% of truckers using their CPAP. This is a frightening fact considering than patients with untreated sleep apnea have a six-fold increase in motor vehicle accidents. Patients overwhelmingly prefer oral appliances to CPAP when they offered a choice but most patients are never given a choice. That would be understandable if CPAP compliance wasn't an issue. Studies of patients who do use their CPAP show that they average only 4-5 hours a night of use not 7-7 1/2 that is ideal.

Patients with untreated sleep apnea have up to a six-fold increase of risk of heart attacks and strokes which usually occur in the early morning hours. Most CPAP users have already stopped utilizing their CPAP during the early morning hours when the risk is greatest.

Dr Shapira created the website I HATE CPAP! to help the majority of patients who could not tolerate treatment with CPAP. Thousands and thousands of patients visit this website every single month which leads them to appropriate and scientifically supported treatment.

Treatment and prevention sleep apnea with oral appliances is now well accepted but is still fighting for its proper place in medicine. In a few years oral appliances will probably account for a vast majority of treatment of mild to moderate sleep apnea.

Morning headaches have two primary causes, TMJ disorders and Sleep Apnea. The NHLBI says Sleep Apnea is a TMJ disorder. There is an FDA approved appliance for preventing migraines the the NTI-TSS appliance.

The Aqualizer appliance, invented by Dr Martin Lerman is an a simple inexpensive appliance that can produce incredible success but does not offer permanent correction. IAn Aqualizer was used to keep M free of pain between her first and second appointment until her diagnostic neuromuscular orthotic was delivered.

Neuromuscular Dental treatment starts with a Diagnostic Orthotic. When treatment effectiveness is assured patients can proceed with long term phase 2 treatment of a permanent removable orthotic, orthodontic correction or a Neuromuscular Reconstruction. Patient M chose reconstruction which not only eliminated her headaches but also gave her a beautiful new smile. Reconstruction can be accomplished in just a few appointments for patients who do not wish to go through extended treatment with orthodontics or wear a long term orthotic.

The Aqualizer and NTI-TSS are excellent tools but they do not provide definitive treatment.

Dr Shapira studied Neuromuscular Dentistry with Barney Jankelson who founded the science and with his son Robert Jankelson. His 30 years of neuromuscular dentistry and pioneer work in Dental Sleep Medicine makes him uniquely suited to treating patients with chronic head and neck pain.

The Las Vegas Institute is the primary educator in Neuromuscular Dentistry and has appointed Dr Norman Thomas to head educational and research studies into Neuromuscular Dentistry. Dr Thomas is a world leading expert in the field of Neuromuscular Dentistry and how it relates to Physiology and Anatomy of masticatory and postural systems.

Dr Barry Cooper also does a superb job at introducing dentists to the field of Neuromuscular Dentistry. Dr Shapira strongly recommends dentists begin their training with Dr Cooper because he teaches small groups of 1-6 doctors which is the ideal learning environment. Dr Shapira limits his sleep apnea and Dental Sleep Medicine classes to six doctors as well. This allows for one on one interaction and follow-up during the most difficult period of the learning curve.

The international college of craniomandibular orthopedics or iccmo is the leading organization representing neuromuscular dentistry. Dr shapira stronly suggests you find a neuromuscular dentist who is a member of iccmo. Iccmo was founded by dr barney jankelson, the father of neuromuscular dentistry.

Patients in Northern Illinois and southern Wiscosin looking for a Neuromuscular Dentist are a comfortable drive to Dr Shapira's general dentistry office, Delany Dental Care Ltd in Gurnee and to the offices of Chicagoland Dental Sleep Medicine Associates. Dr Shapira currently sees patients in Skokie and Schaumburg and recently announced a new office will open soon in Highland Park, Illinois.

Dr Shapira's team can make arrangements for patients from outside of the Chicago Metropolitan area
to have an intensive course of treatment. Dr Shapira will consider accepting long distance patients on a case by case basis. Patients wishing to see Dr Shapira can contact his office toll-free at 1-800-TM-Joint or 1-8-NO-PAP-MASK or 847-623-5530

Patients can contact Dr Shapira through the following websites:
http://www.ihatecpap.com
http://ww.ihateheadaches.org
http://delanydentalcare.com
http://www.chicagoland.ihatecpap.com/

Dr Shapira will help patients locate a Sleep Apnea Dentist or Neuromuscular Dentist anywhere in the country. Dr Shapira strongly advises patients to seek out treatment of Sleep Apnea only from dentists trained in treating TMJ disorders preferably by Neuromuscular Dentists.

The American Academy of Sleep Medicine (AASM) advised that patients receive oral appliances from dentists trained in Dental Sleep Medicine and treatment of Temporomandibular Disorders (TMD). The American Academy of Dental Sleep Medicine (AADSM) endorsed the position of the AASM.

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