Trigeminal Nerve Pain or TMJ? Neuromuscular Dentistry or SPG Blocks may help solve problems.

Question: My dentist diagonesed that I might have a TMJ problem, previously had MRI scan for trigeminal nerve pain but came negative, what could the problem be?

Dr Shapira Response: The trigeminal nerve supplies approximately 50% of all input to the brain. Because the MRI scan was normal does not mean the pain is not from or mediated by the trigeminal nerve. This can include TM Joint problems, TMD, Myofascial Pain, otalgia (trigeminal). All of these problems are mediated by the trigeminal nerve which is why neuromuscular dentistry is such an effective approach to chronic pain of the head and neck.

Sphenopalatine Ganglion Blocks can address the autonomic connections of the trimeninal nerve. It is usually a simplification to just call something a "TMJ" problem because there are usually multiple concerns based on symptomatology.

I normally spend an hour or more reviewing the history of patients with pain. The patient gave me no information about the SYMPTOMS that caused her to seek treatment. An accurate chronological history is an essential element in understanding how to approach a problem to bring relief. An MRI will show organic problems but are rarely the diagnostic approach to chronic pain. It is helpful in that it rules out tumors, growths, etc.

An examination of the craniomandibular and cervical musculature is incredibly important in anyone with headaches, facial pain, migraines, trgeminal pain, ear or jaw pain. Evaluation of the TM Joints and jaw motion is also very important.

The Neuromuscular Diagnostic work-up includes EMG evaluation of the jaw and/or neck muscles, Computerized scans of jaw movement and function, Sonography is sometimes used as well.

I get headaches more when I am tired or stressed or when it is sinus season

Glendale: I get headaches more when I am tired or stressed or when it is sinus season

Dr Shaira response: These are very common statement for people with neuromuscular problems, TMJ disorders or TMD

The reason is that most headaches are primarily modulated by the trigeminal nerve. The lining of the sinuses is innervated by the trigeminal nerve so the addition of sinus irritation to and existing problem is enough to push you over the edge. Stress in general is related to TMJ disorders, myofascial pain and headache. There are different types of stress our bodies cope with.

Structural stress is all about muscles, joints, bones, habits, trauma, bite, whiplash etc. Posture is about proper or improper alignment of all these body parts. The Quadrant Theory of Guzay shows that jaw position is incredible important in determining head posture. Head posture is extremely important in treating any chronic pain patient.

Emotional or life stress includes stresses related to family, money, jobs, children , parents, friends etc.

Biochemical stress includes diet, vitamins , minerals, organic disease, aleergies hormones an so on.

When our ability to cope is less than the total of our stresses and the system tells us pain, headache, sinus pressure etc.

It is always the total of stresses exceding our ability to cope that pushes pain over the edge. When you state stress or sinus season pushes you over the edge you are correct. Correcting the underlying structural stress will also raise the threshold before you feel pain. Total stress including all types is the culprit. Lowering any of the components will improve your quality of life.

A neuromuscular diagnostic orthotic is designed to remove noxious (painful) input to the brain, allow the muscles and joints to heal and for posture to correct..

Headaches, Ear Pain, Mouth, Jaw and Tooth Pain related to TMJ, Whiplash and Unstable Atlas

Frank: What are the costs of treatment and is it covered by insurance? I have severely ground teeth. I clench a lot but mostly during day. 61 yrs old I do TMJ massage and that slightly helps. The headaches occur 4-10 times month. Headaches are inside my ears, above ears, in mouth and jaw and seem to sometimes be in the teeth and roof of mouth. I had whiplash injury. When I have atlas aligned it helps but does not stay in alignment.

Dr Shapira response: Insurance sometimes covers part of the cost but most insurance companies are worried primarily about shareholders and profits. Several years ago Chicago HMO agreed to pay 100% of the costs even though it was specifically excluded by their policy. Dr Mitchell Trubitt was the medical director after I showed him (trial of 6 patients) that covering TMJ disorders and neuromuscular dentistry saved them money. For many years I saw 15-25 new Chicago HMO patients patients a month and sometimes more. Success was incredible when cost was not an issue. Unfortunately United Health Care bought out Chicago HMO and they did not continue coverage. An article in Crano showed a 300% increase in medical costs in every field of medicine (except obstetrics) in patients with TMJ disorders.

As to your symptoms and treatment, I would suggest you have and examination and a diagnostic neuromuscular orthotic. It will protect your teeth from damage and address the myofascial pain it sounds like you are having.

Are you complete free of pain on your non-headache days or is the pain at more tolerable levels. Many patients "live" on drugs like ibuprofen and count headache days only when it doesn't work. The cost of living in pain is far greater than the cost of treatment. Chronic pain can suck the life out of you and the joy out of life.

The whiplash and Atlas are directly related to the jaw muscles and jaw joint and it is almost impossible to have a stable atlas / axis / craio articulation without correcting jaw position. The mandible acts like a counterbalance to the head and should be considered "the last vertebrae" which must be stabilized in a healthy position.

A diagnostic neuromuscular orthotic is the best way to determine if treatment will be effective. The orthotic is a reversible treatment that can be a life changer.

Frank: I'm in California? Is that a problem?

My headaches (or severe muscle pain in head neck teeth ears etc.) somedays is completely gone. But if I touch certain muscles they always feel like spasms and are very painful. Even 2 muscles on the side of my neck. Will it help to have all teeth capped to get them back to proper height? Will the cartilage that's wornoff ever grow back? Massage helps some I think? Cold laser helps quite a bit but I will have to do it forever. I no longer grind teeth,I just clench my jaw during the day even though my teeth aren't touching. I probably use 6-10 advil a month. But I use certain homeopathics and ice-cold therapy which are intermittent. ??????????????? I dream of a headache free pain free life.... Sometimes my headache so to speak is in my throat and in the teeth themselves and center of the ears. TKU Frank

Dr Shapira response: Frank, I don't think your pain is ever gone if the muscles are still painful to touch. It just means your pain level is below threshold but it takes a lot of energy to control pain and keep it below threshold. I term that energy "vital energy" it is the energy that makes you happy and lets you enjoy life rather than merely tolerate living. Do not start with having your teeth capped. What if it makes the pain worse. Start with a removable diagnostic neuromuscular orthotic that will let you treat the problem and evaluate success before making irreversible changes. Proceed with caps or other permanent correction only after controllling or eliminating pain to where you have a good quality of life. It is unlikely that cartilage that is totally gone will grow back but damaged cartilage can heal if it is given an ideal situation for healing.

Cold laser is safe but usually not long lasting. Trigger point injections tend to give more lasting results with hot trigger points in muscles. Spray and stretch can give amazing results. The pain patterns you describe are myofascial pain but that is just a guess without an exam.

California, is that a problem? I see long distance patients but to be successful I need several days intensive treatment to try to reach a relative homeostasis. My office can accomadate you but the first series of visits would be Monday thru Wednesday or Thursday and would require you arriving Sunday. Your original question about costs and insurance comes into play because the diagnostic stage of treatment including diagnostic orthotic, trigger points, etc may be an out of pocket expense. I would probably want to have my A/O chiropracter evaluate your Atlas after delivery of an appliance Monday afternoon.

Treatment is all about quality of life and relief of pain. There are no guarantees but my goal is to relieve as much pain as possible. I recently treated a woman who spent 50 years with a continuous headache and received total relief. I did do a reconstruction on that patient (wife of a physician) but only AFTER the pain was relieved.

VESTIBULAR MIGRAINE; THE SIGNS AND SYMPTOMS HAVE LARGE OVERLAP TO TMJ (TMD). ARE VESTIBULAR MIGRAINES BEST TREATED BY NEUROMUSCULAL DENTAL ORTHOTIC

A recent article in HEADACHE (June 2011)"Migraine and Vestibular Symptoms-Identifying Clinical Features That Predict "Vestibular Migraine" looks at patients who have an overlap of vestibular symptoms, such as lightheadedness, unsteadiness, vertigo, balance disturbance and headache.

The study showed just under half of the patients had onset of pain and vestibular symptoms together. This is frequently seen in patients withcraniomandibular neuromuscular disorders and usually responds extremely well to a neuromuscular orthotic, use of ULF TENS, Trigger point injections, spray and stretch elimination of TP's and SPG (Sphenopalatine Ganglion) Blocks.

NEUROMUSCULAR DENTISTRY SHOULD PROBABLY BE A FIRST LINE TREATMENT FOR PATIENTS EXPERIENCING VESTIBULAR SYMPTOMS AND HEADACHE OR MIGRAINE AFTER ORGANIC DISEASE IS RULED OUT.

TMJ DISORDERS HAVE LONG BEEN CALLED "THE GREAT IMPOSTER" because they mimic so many other disorders. All patients with vestibular symptoms and head or neck pain shoud read "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" IN SLEEP AND HEALTH JOURNAL.
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor


The article's conclusions are not diagnostic at all. They cover episodic, acute onset and chronic disorders. The authors stated "Vestibular migraine is a heterogeneous condition with varying symptomatology. As with migraine itself, symptomatic expression varies along a spectrum that extends from episodic to chronic. As the histories of many of the patients we evaluated would not meet current International Classification of Headache Disorders criteria, we suggest that new criteria which account for the heterogeneity and natural history of the disorder may be required to adequately diagnose and treat those who suffer from VM"


Headache. 2011 Jun 7. doi: 10.1111/j.1526-4610.2011.01934.x. [Epub ahead of print]
Migraine and Vestibular Symptoms-Identifying Clinical Features That Predict "Vestibular Migraine"
Cohen JM, Bigal ME, Newman LC.
Source

From Roosevelt Hospital, Headache Institute, New York, NY, USA (J.M. Cohen and L.C. Newman); Merck, Sharp & Dohme Corp., Whitehouse Station, NJ, USA (M.E. Bigal).
Abstract

Background.- Migraine and symptoms that may suggest a vestibular disorder (referred to herein broadly as vestibular symptoms-VS) often co-exist. In part due to a lack of standardized diagnostic criteria, this relationship remains unknown to many physicians. Objective.- To determine common clinical features that may be associated with "vestibular migraine" (VM). Methods.- We retrospectively reviewed charts of patients diagnosed with VM at a headache center. In this group we recorded certain demographic and clinical features related to their disorder, including the most common triggers of the VS and the specific characteristics of the symptoms that suggested VM. Results.- Our sample consisted of 147 patients (68% women, mean age = 45 years, 39% with aura). Migraine onset preceded the onset of VS by a mean of 8 years. A total of 62 patients (42%) had gradual onset of VS, while in 48 (33%) symptoms began suddenly. The most commonly reported symptoms that led to the diagnosis of VM were: unsteadiness (134; 91%), balance disturbance (120; 82%), "light-headedness" (113; 77%), and vertigo (84; 57%). VS and headache occurred concomitantly in 48% of patients. A total of 67 (47%) patients had VS that were chronic from onset, 29 (21%) had episodic symptoms, and in 46 (32%) the VS had evolved from episodic to chronic (with an average duration of 7.04 years required for this evolution to occur). Conclusions.- Vestibular migraine is a heterogeneous condition with varying symptomatology. As with migraine itself, symptomatic expression varies along a spectrum that extends from episodic to chronic. As the histories of many of the patients we evaluated would not meet current International Classification of Headache Disorders criteria, we suggest that new criteria which account for the heterogeneity and natural history of the disorder may be required to adequately diagnose and treat those who suffer from VM.

© 2011 American Headache Society.

PMID:
21649658
[PubMed - as supplied by publisher]

Related citations

New research on Migriane Medication focuses on Trigeminal Nerve

A recent article in Cephalgia (see abstract below) focuses on the kynurenine family of compounds which are metabolites of tryptophan in treating migraines. The use of Neuromuscular Dentistry uses neural input to correct chemical imbalances in the Trigeminal Nervous System to treat and eliminate migraines and chronic daily headaches.

The use of drugs to alter neurotransmitters has been shown to be effective but correcting the nociceptive input to the nervous system is a more effective and reliable method of treating trigeminally mediated pain.

Reports of 80-95% effectiveness in treating headaches with a neuromuscular diagnostic orthotic are common and side effects are minimum.

Correcting the problem by altering neural input is the closest to a "cure" for migraines.

Effectiveness has never been the major problem in treating Headaches, Migraines and TMJ disorders with Neuromuscular Dentistry. The problem is that while the treatment is extremely effective it is expensive and insurance companies write contracts that limit coverage. The current cost conscious environment virtually insures that patients will continue to suffer needlessly because lack of coverage puts this extremely effective treatment out of financial viability for any patients.

Patients who suffer from migraines and chronic daily headaches and can affrd neuromuscular dentistry will find it extremely effective.

A downside to neuromuscular dental treatment is that it can be time intensive especially at the start of treatment protocols.

Ending needless pain and suffering is always rewarding to both patients, friends , families and the practitioners.



Cephalalgia. 2011 May 18. [Epub ahead of print]
The L-kynurenine signalling pathway in trigeminal pain processing: A potential therapeutic target in migraine?
Guo S, Vecsei L, Ashina M.
Source

University of Copenhagen, Denmark.
Abstract

Introduction: In recent years the kynurenine family of compounds, metabolites of tryptophan, has become an area of intensive research because of its neuroactive properties. Two metabolites of this family have become of interest in relation to migraine and pain processing. Discussion: Experimental studies have shown that kynurenic acid (KYNA) plays an important role in the transmission of sensory impulses in the trigeminovascular system and that increased levels of KYNA decrease the sensitivity of the cerebral cortex to cortical spreading depression. Furthermore, another metabolite of the kynurenine family, L-kynurenine, exerts vasodilating effects similar to nitric oxide by increasing cyclic guanosine monophosphate. Conclusion: This review summarizes current knowledge of the role of kynurenine signalling in trigeminal and central pain processing, including its therapeutic prospects in migraine treatment.

PMID:
21593189
[PubMed - as supplied by publisher]

Increased Cortical Activity that causes headaches is increased with sleep apnea.

A recent study in Sleep Med on altered Cortical Excitability in sleep apnea concluded that " This TMS-based study suggests that untreated severe OSAS patients have imbalanced cortical excitabilities that enhanced inhibition or decreased brain excitability when awake during the day."

This may be a major cause of chronic headaches or migraines or other biochemical imbalances leading to stress disorders ofr depression. Many patients do not reach the clinical definition of sleep apnea but have UARS (upper respiratory resistance syndrome). This has been implicated in fibromyalgia and central sensitization as well.

I have included a few relevant pubmed articles below.

Sleep apne is the result of a TMJ disorder (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf)

Neuromuscular Dentistry can help reduce incresed corticl activity, Treatment of sleep apnea can do the same.

Patients with sleep apnea have a smaller airway 24/7 that collapses at night. Correction of apnea and daytime jaw position may be ideal for all patients with chronic pain and sleep apnea.



Sleep Med. 2010 Oct;11(9):857-61.

Altered cortical excitability in patients with untreated obstructive sleep apnea syndrome.
Joo EY, Kim HJ, Lim YH, Koo DL, Hong SB.

Sleep Center, Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Comment in:

Sleep Med. 2010 Oct;11(9):820-1.

Abstract
OBJECTIVE: To investigate cortical excitability in patients with obstructive sleep apnea syndrome (OSAS) during wakefulness.

METHODS: The authors recruited 45 untreated severe OSAS (all males, mean age 47.2 years, mean apnea-hypopnea index=44.6h(-1)) patients and 44 age-matched healthy male volunteers (mean apnea-hypopnea index=3.4h(-1)). The TMS parameters measured were resting motor threshold (RMT), motor evoked potential (MEP) amplitude, cortical silent period (CSP), and short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF). These parameters were measured in the morning (9-10 am) more than 2h after arising and the parameters of patients and controls were compared. The Epworth Sleepiness Scale (ESS) and the Stanford Sleepiness Scale (SSS) were also measured before the TMS study.

RESULTS: OSAS patients had a significantly higher RMT and a longer CSP duration (t-test, p<0.001) compared to healthy volunteers. No significant difference was observed between MEP amplitudes at any stimulus intensity or between the SICI (2, 3, 5ms) and ICF (10, 15, 20ms) values of OSAS patients and healthy volunteers (p>0.05).

CONCLUSIONS: This TMS-based study suggests that untreated severe OSAS patients have imbalanced cortical excitabilities that enhanced inhibition or decreased brain excitability when awake during the day.

PMID: 20817550 [PubMed - in process]

Handb Clin Neurol. 2010;97:73-83.

Biological science of headache channels.
Pietrobon D.

Abstract
Several episodic neurological diseases, including familial hemiplegic migraine (FHM) and different types of epilepsy, are caused by mutations in ion channels, and hence classified as channelopathies. The classification of FHM as a channelopathy has introduced a new perspective in headache research and has strengthened the idea of migraine as a disorder of neural excitability. Here we review recent studies of the functional consequences of mutations in the CACNA1A and SCNA1A genes (encoding the pore-forming subunit of Ca(V)2.1 and Na(V)1.1 channels) and the ATPA1A2 gene (encoding the alpha(2) subunit of the Na(+)/K(+) pump), responsible for FHM1, FHM3, and FHM2, respectively. These studies show that: (1) FHM1 mutations produce gain-of-function of the Ca(V)2.1 channel and, as a consequence, increased glutamate release at cortical synapses and facilitation of induction and propagation of cortical spreading depression (CSD); (2) FHM2 mutations produce loss-of-function of the alpha(2) Na(+)/K(+)-ATPase; and (3) the FHM3 mutation accelerates recovery from fast inactivation of Na(V)1.5 channels. These findings are consistent with the hypothesis that FHM mutations share the ability to render the brain more susceptible to CSD, by causing excessive synaptic glutamate release (FHM1) or decreased removal of K(+) and glutamate from the synaptic cleft (FHM2) or excessive extracellular K(+) (FHM3).

PMID: 20816411 [PubMed - in pr

Handb Clin Neurol. 2010;97:47-71.

Pharmacology.
Bolay H, Durham P.

Department of Neurology, Gazi Hospital and Neuropsychiatry Centre, Gazi University, Besevler, Ankara, Turkey.

Abstract
Headache treatment has been based primarily on experiences with non-specific drugs such as analgesics, non-steroidal anti-inflammatory drugs, or drugs that were originally developed to treat other diseases, such as beta-blockers and anticonvulsant medications. A better understanding of the basic pathophysiological mechanisms of migraine and other types of headache has led to the development over the past two decades of more target-specific drugs. Since activation of the trigeminovascular system and neurogenic inflammation are thought to play important roles in migraine pathophysiology, experimental studies modeling those events successfully predicted targets for selective development of pharmacological agents to treat migraine. Basically, there are two fundamental strategies for the treatment of migraine, abortive or preventive, based to a large degree on the frequency of attacks. The triptans, which exhibit potency towards selective serotonin (5-hydroxytryptamine, 5-HT) receptors expressed on trigeminal nerves, remain the most effective drugs for the abortive treatment of migraine. However, numerous preventive medications are currently available that modulate the excitability of the nervous system, particularly the cerebral cortex. In this chapter, the pharmacology of commercially available medications as well as drugs in development that prevent or abort headache attacks will be discussed.

PMID: 20816410 [PubMed - in process]

Cephalalgia. 2010 Sep;30(9):1101-9. Epub 2010 Mar 19.

Cortical hyperexcitability and mechanism of medication-overuse headache.
Supornsilpchai W, le Grand SM, Srikiatkhachorn A.

Department of Physiology, Faculty of Medicine, Chulalongkorn University, Patumwan, Bangkok, Thailand.

Abstract
The present study was conducted to determine the effect of acute (1 h) and chronic (daily dose for 30 days) paracetamol administration on the development of cortical spreading depression (CSD), CSD-evoked cortical hyperaemia and CSD-induced Fos expression in cerebral cortex and trigeminal nucleus caudalis (TNC). Paracetamol (200 mg/kg body weight, intraperitonealy) was administered to Wistar rats. CSD was elicited by topical application of solid KCl. Electrocorticogram and cortical blood flow were recorded. Results revealed that acute paracetamol administration substantially decreased the number of Fos-immunoreactive cells in the parietal cortex and TNC without causing change in CSD frequency. On the other hand, chronic paracetamol administration led to an increase in CSD frequency as well as CSD-evoked Fos expression in parietal cortex and TNC, indicating an increase in cortical excitability and facilitation of trigeminal nociception. Alteration of cortical excitability which leads to an increased susceptibility of CSD development can be a possible mechanism underlying medication-overuse headache.

PMID: 20713560 [PubMed - in process]

My Headaches are throbbing, nausea, stabbing ....Renee

Heeadaches related to the trigeminal nerves and jaw function frequently have all of those qualities. This relates to the vascular, hemodynamic and autonomic functions of the trigeminal nerve. Neuromuscular dentistry can frequently allieve and eliminate these sypmtoms as well as the more common tender, aching, and penetrating headaches. Painful TM Joint symptoms may or may not be present.

Years of Headache Pain, TM Joint Pain and Clicking and Wisdom Tooth Removal

My daughter has suffered several years with severe headaches many of which we have not been able to help her with. She has clicking in her jaw and winces in pain often. Her wisdom teeth were growing in wrong so we had them removed and that has not helped. Her cousin has TMJ but we live in upstate NY above Albany and there are not that many places for us to get help. If you have any suggestions we would appreciate your help.

These types of problems are very common. I would strongly suggest beginning treatment with a diagnostic neuromuscular orthotic. I would initially concentrate on headache relief. The joints will usually do much better once the muscles are healthier and the bite stable. Headaches are usally easily relieved with Neuromuscular Dentistry once the diagnostic orthotic is in place. Reversible treatment with the orthotic is an excellent beginning. If the headaches are relieved (they usually are) you can then decide how to proced.

Removing wisdom teeth will rarely help either TMJ (TMD) disorders or headaches and often makes the problem worse to to stress on the joints during extraction and muscle splinting after the extraction. I usually recommend stabilizing the bite and relieving headaches prior to wisom teeth removal.