Migraines and Vomiting for 15 Years. Neuromuscular Dentistry and SPG Blocks May Resolve Symptoms.

Anne: I've been getting migraine headaches for the past 15 or so years. I always have terrible nausea and vomiting. I have tried many many different things with no luck. I had a migraine yesterday where I vomited non-stop for 12+ hours. The migraines are typically on the right side behind my eye but this time I also noticed pain in my upper jaw.

Dr Shapira response:

Dear Anne,

A diagnostic neuromuscular orthotic can often give dramtic results in lowering the frequency and severity of migraine attacks (and associated nausea) and is especially helpful with tension-type headaches and referred muscle headaches. The muscular headaches are frequently the trigger for the migraines. The nausea is a secondary autonomic effect. The trigeminal nerve (or dentists nerve) is involved in almost all migraines and other types of headache. It is also associate with autonomic symptoms. An SPG block can sometimes offer amazing relief. There is an out of print book "Miracles on Park Avenue" that discusses some of the benefits of SPG blocks.

An Spenopalatine Ganglion Block can be done at the first sign of a headache and prevent a full attack. I usually teach my patients this easy technique.

I do see long distance patients, but I like a complete history and phone interview before scheduling. I usually will have patients come in Sunday and I see them Monday AM and PM, Tuesday AM and PM and Wednesday morning for their first set of appointments. Call my office if you would like me to see you at 847-623-5530.

A neuromuscular work-up will usually show the problems and allow for correction but their may be other factors besides the jaws, jaw muscles, jaw joints, posture and trigeminal nerves. Allergies or chemical triggers can still serve as headache triggers.

Headaches and Sleep Disorders: New article in Cephalgia. Learn how Neuromuscular Dentistry and Sleep Dentistry can help relieve these problems.

A new article in Cephalgia discusses the comorbidities of sleep and headache. It is well established that the two most commmon causes of "Morning Headache" are TMJ disorders and Sleep Apnea. There is an excellent paper fron the National Heart Lung and Blood Institute on the relation of these two disorders. The paper "CCARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" can be found at
www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

The article in Cephalgia stated
Adults with severe headache are at significantly higher risk of also suffering from sleep problems, when compared with the general population, regardless of specific headache type. Optimal treatment of headache must include investigation for sleep disorders and vice versa."

The two primary sleep disorders associated with headache in my experience are sleep apnea and maintenance insomnia. Maintenance insomnia is usually the result of sleep apnea/ UARS (upper airway resistance syndrome) or restless legs (periodic leg movements in sleep PLMS)

Patients pesenting with severe stree frequently have sleep onset insomnia. Chronic pain frequently leads to stress(cortisol) disorders.

Treatment of Sleep Apnea is considered the Gold Standard for Sleep Apnea but most patients do not tolerate treat and abandon it completely (up to 60%) or more commonly use it only a few hours a night which is leaves significant residual disease and risks of cardiovascular disease, excessive daytime sleepiness, tiredness, headaches and migraines.

An excellent alternative treatment for sleep apnea is an oral appliance (http://www.ihatecpap.com) It is extremely effective for Upper Airway Resistances Syndrome, Snoring Arousals, and mild to moderate sleep apnea. It has been shown to be effective in severe sleep apnea but is usually not effectively in the morbidly obese. Morbidily obese patients with headaches and migraines are probably CPAP candidates but oral appliance therapy can be used if they do not tolerate CPAP.

Treatment of Sleep Disordered Breathing can be remrkably effective in treating many types of headaches, especially morning headaches. Oral Appliances are preferred by the majority patients over CPAP when they are offered a choice. A side effect of oral appliance therapy is bite changes. Exercises taught to patients can prevent most changes but many patients chose not to do the exercises. The reason is that when the jaw is advanced for 8 hours it "heals" in this new position frequently eliminating headaches and migraines. While dentists treating sleep apnea with oral appliances usually try to prevent bite changes dentists treating patients for TMJ disorders (TMD) chronic tension headaches and migraines actually welcome bite changes.

Daytime headaches are very effectively treated with a different type of oral appliance called a neuromuscular orthotic. If the headaches are eliminated a second phase of treatment can make these changes permanent. Understanding that TMD and Sleep Apnea are different faces of the same structural/developmental disorder.

Another pertinent and timely study J Headache Pain. 2011 Aug 17. "Clinical features of headache patients with fibromyalgia comorbidity." looks at chronic heqdaches and fibromyalgia comorbidities with tension headache, chronic daily headacahe and migraine. These are comorbidities to TMJ disorders (TMD) and problems of the Trigeminal Nervous system that is over one half of the total input to the brain.

Sleep disorders as well as tension-type headaches, chronic daily headaches and fibromyalgia can all be substantially improved in most patients with various types of oral orthopedic appliances that not only alter posture and airway but can change the autonomic overload from noxious stimuli into the trigeminal system. One appliance is specifically approved for migraine prevention.




Cephalalgia. 2011 Apr;31(6):648-53. Epub 2011 Jan 10.
Headaches and sleep problems among adults in the United States: findings from the National Comorbidity Survey-Replication study.
Lateef T, Swanson S, Cui L, Nelson K, Nakamura E, Merikangas K.
Source

National Institute of Mental Health, USA. TLateef@cnmc.org
Abstract
BACKGROUND:

Several studies have demonstrated an association between headache and disturbed sleep. None have examined this association across the headache spectrum. Our goal was to determine whether migraine and migraine with aura differ from nonmigraine headache in terms of associated insomnia complaints or severity of sleep problems.
METHODS:

A probability sample of US adults was used. A structured interview administered by trained interviewers was used. Diagnostic criteria for migraine and migraine with aura were based on the International Headache Society classification. The presence or absence of four forms of sleep disturbance associated with an insomnia diagnosis was ascertained.
RESULTS:

There was a significant association between frequent severe headache, including migraine with and without aura, and disordered sleep. Adults with headache reported more frequently difficulty initiating sleep (odds ratio [confidence interval] = 2.0 [1.6-2.5]), difficulty staying asleep (2.5 [2.1-3]), early morning awakening (2.0 [1.7-2.5]) and daytime fatigue (2.6 [2.2-3.2]) and also were more than twice as likely to report three or more of these symptoms(2.5 [2-3.1]) compared to the individuals without headache.
DISCUSSION:

Adults with severe headache are at significantly higher risk of also suffering from sleep problems, when compared with the general population, regardless of specific headache type. Optimal treatment of headache must include investigation for sleep disorders and vice versa.

PubMed abstracts below:

Comment in * Cephalalgia. 2011 Apr;31(6):643-4.

J Headache Pain. 2011 Aug 17. [Epub ahead of print]
Clinical features of headache patients with fibromyalgia comorbidity.
de Tommaso M, Federici A, Serpino C, Vecchio E, Franco G, Sardaro M, Delussi M, Livrea P.
Source

Neurophysiopathology of Pain Unit, Neurological and Psychiatric Sciences Department, Medical Faculty, Policlinico General Hospital, Aldo Moro University, Neurological Building, Piazza Giulio Cesare 11, 70124, Bari, Italy, m.detommaso@neurol.uniba.it.
Abstract

Our previous study assessed the prevalence of fibromyalgia (FM) syndrome in migraine and tension-type headache. We aimed to update our previous results, considering a larger cohort of primary headache patients who came for the first time at our tertiary headache ambulatory. A consecutive sample of 1,123 patients was screened. Frequency of FM in the main groups and types of primary headaches; discriminating factor for FM comorbidity derived from headache frequency and duration, age, anxiety, depression, headache disability, allodynia, pericranial tenderness, fatigue, quality of life and sleep, and probability of FM membership in groups; and types of primary headaches were assessed. FM was present in 174 among a total of 889 included patients. It prevailed in the tension-type headache main group (35%, p < 0.0001) and chronic tension-type headache subtype (44.3%, p < 0.0001). Headache frequency, anxiety, pericranial tenderness, poor sleep quality, and physical disability were the best discriminating variables for FM comorbidity, with 81.2% sensitivity. Patients presenting with chronic migraine and chronic tension-type headache had a higher probability of sharing the FM profile (Bonferroni test, p < 0.01). A phenotypic profile where headache frequency concurs with anxiety, sleep disturbance, and pericranial tenderness should be individuated to detect the development of diffuse pain in headache patients.

PMID:
21847547
[PubMed - as supplied by publisher]

MIGRAINE TREATMENT WITHOUT DRUGS. MIGRAINES ARE USUALLY RELATED TO THE TRIGEMINAL NERVES, THE BEST TREATMENT IS TO CORRECT NEURAL INPUT.

There are many different kinds of Migraines and headaches. They all share the same basic features, a common pattern that is frequently seen with migraine is an initial dull ache that develops into a constant, throbbing and pulsating pain that can be experienced in the temples, front or back of one side (or both sides)of the head. The pain is usually accompanied by nausea and vomiting, and sensitivity to light and noise.

A common factor in almost all headaches and migraines is the involvement of the Trigeminal Nerve. Treating migraines and other headaches without drugs can frequently be easily accomplished by changing the neural input into the trigeminal nervous system. TMJ disorders (TMD) are often called "The Great Imposter" I strongly recommend that anyone who suffers from Migraines, Tension-Type Headaches, Chronic Daily Headaches or other chronic head and neck pain read
"SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" in Sleep and Health Journal at:
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

Two of the most common types of migraine are "migraine with aura" or "Classic Migraine" and "migraine without aura" or "common migraine".

Frequently patients with severe headaches are diagnosed as having "migraine" when they actually have a severe tension headache, muscular headache or cervicogenic headache which can present as a migraine. Many patients and physicians can are fooled into thinking every severe headache is a migraine. Severe headaches are frequently neuromuscular in orgin and easy to alleviate or eliminate. This can lead to the wrong treatments being utilized that while helpful they are not ideal and can increase headache frequency and/or drug overuse.

Rebound headaches and drug overuse headaches are among the most difficult to treat because in addition to the original problems we now are also dealing with a medication caused disorder.

The Common Migraine or Migraine without Aura
because the headache is associated with changes in the size of the arteries inside the skull and in the head and neck. The blood flow to the anterior two thirds of the meninges of the brain is controlled by the trigeminal nerve and this type of headache can frequently be eliminated without drugs with a neuromuscular orthotic that stops the nociceptive input to the brain from the fifth cranial nerve or trigeminal nerve. Neuromuscular Dentistry is most effective when it is ussed to intervene before the pre-headache phase when blood vessels constrict; at the time vascular dilation occurs the migraine begins. The The inflamed as well as swollen blood vessels are believed to be the cause of migraine pain and are caused by neurally mediated inflammationand by increasing the pressure on the swollen walls of the blood vessels. Neuromuscular Dentistry is more effective at preventing or eliminating migraines then a stopping them in the middle of an acute attack.

Migraine sufferers may experience only occasional episodes while others have repetitive migraines two to four times per month. Other patients can get continuous migraines that very in intensity. Most migraine headaches last at least four hours, although very severe ones can last up to a week. I recently treated the wife of a physician who had a continuous headache for over 50 years that was eliminated after only two visits. This is unusual but not unheard of when utilizing neuromuscular dental orthotics. Headaches may begin at any time of the day or night; but when they has a TMJ (TMD) disorder and/or sleep apnea. Migraines rarely awaken a person from sleep but morning headaches frequently can convert into full blown migraines. These morning migraines are especially easy to treat with a neurmucular diagnostic orthotic.

Classic Migraine or Migraine with Aura are about a third of the migraine population. These are also trigeminally innervated migraines and when treated by a neuromuscular orthotic may give a different response. I have seen patients who still experience the aura but the pain never follows. Depending on the triggers that percipitate the migraines the orthotic will often decrease the severity and frequency of these headaches but not completely eliminate them

Migraine sufferers frequently experience visual problems during the headache. Migraine that begins with an aura is usually a manifestation of neurological symptoms. These symptoms are most frequently associated with the trigeminal nerve and the aura begins from five to thirty minutes before the actual onset of the headache. Neuromuscular dentists will frequently use Sphenopalatine ganglion blocks to head off this type of migraine before it hits. Once these migrines are in full swing standard migraine medications are the best way to limit and control pain.

I usually will teach patients how to self administer SPG blocks (sphenopalatine ganglion blocks) with local anaesthetic intranasally applied with a Q-tip. Patients may see wavy or jagged lines,wierdly moving blobs reminescent of Lava lamps, squiggles, worms, polka dots or strobe like flashing lights. Any time patients have flashing lights in their eyes they must consider the possibility of a detatched retina. Other symptoms include tunnel vision or blind spots in one or both eyes or vision going black and white and dimming that is similar to being lost in the fog.

Auras can also be non-visual in nature and can involve sounds , dizziness or strange bodily aches or the feeling like something is crawling thru you. It is not uncommon for smells and tastes to be part of an aura and some patients report that the Aura sonunds , tastes and odors can percipitate attacks when they are encountered in real life.

Feelings of numbness or a "pins-and-needles" sensation as well as difficulty in recalling or speaking the correct word can be experienced with migraine but can also be neurological symptoms of a stroke and must be considered serious at all times. Other less common types of migraine include Hemiplegic Migraine, Ophthalmoplegic Migraine, Retinal Migraine, Basilar Artery Migraine and Abdominal Migraine

Many of these other types of migraines can be very difficult to diagnose but it is important to remember they are are mediated by the Trigeminal nervous system and may respond well to treatment with a neuromuscular diagnostic orthotic which can eliminate or drastically decrease both frequency and severity.

NEW ARTICLE IN JOURNAL PAIN LINKS TEMPLE HEADACHES TO TMJ DISORDERS

TENSION-TYPE Headaches in the temples are positively correlated to TMD dysfunction. This correlation extends to all of the various TMJ symptoms.

It has long been known that headaches are almost a universal symptom of TMJ disorders. Treatment of TMJ disorders usually leads to significant reduction in headache pain. Neuromuscular Dentistry should always be considered diagnostic work-up of chronic headache patients. The majority of patients experience elimination or very significant pain relief within a brief time period after being treated with a diagnostic neuromuscular orthotic. PPatients frequently consider the results "miraculous"

Learn more about Neuromuscular Dentistry:
Sleep and Health Journal
http://www.sleepandhealth.com/neuromuscular-dentistry

What is not as well known is that TMD is only one of a large family of craniomandibular disorders and problems related to the trigeminal nervous system. The Trigeminal Nerve and its central nervous system connections are involved in almost all headaches. The use of Neuromuscular Dentistry is extremely effective in treating TMJ disorders and associated headaches.

Neuromuscular Dentistry is also extremely effective in treating Chronic Daily Headaches, Tension-Type Headaches, Classic Migraine, Atypical Migraine , Migraine Staticus, Sinus and facial pain, occiptal headache and other chronic pains of the head and neck.

Physicians who do not have the same thorough understanding of the Trigeminal Nerve frequently underplay the importance of the Trigeminal Nerve in almost all headaches. This leads them to approach treatment of headaches with powerful drugs that often have dangerous side effects.

Neuromuscular Dentistry works by reducing noxious input to the central nervous system thru the Trigeminal Nerve.

Pain. 2010 Dec 31. [Epub ahead of print]
Influence of headache frequency on clinical signs and symptoms of TMD in subjects with temple headache and TMD pain.
Anderson GC, John MT, Ohrbach R, Nixdorf DR, Schiffman EL, Truelove ES, List T.

University of Minnesota School of Dentistry, Department of Developmental and Surgical Sciences, Minneapolis, MN, USA.
Abstract
The relationship of the frequency of temple headache to signs and symptoms of temporomandibular joint (TMJ) disorders (TMD) was investigated in a subset of a larger convenience sample of community TMD cases. The study sample included 86 painful TMD, nonheadache subjects; 309 painful TMD subjects with varied frequency of temple headaches; and 149 subjects without painful TMD or headache for descriptive comparison. Painful TMD included Research Diagnostic Criteria for Temporomandibular Disorders diagnoses of myofascial pain, TMJ arthralgia, and TMJ osteoarthritis. Mild to moderate-intensity temple headaches were classified by frequency using criteria based on the International Classification of Headache Disorder, 2nd edition, classification of tension-type headache. Outcomes included TMD signs and symptoms (pain duration, pain intensity, number of painful masticatory sites on palpation, mandibular range of motion), pressure pain thresholds, and temple headache resulting from masticatory provocation tests. Trend analyses across the painful TMD groups showed a substantial trend for aggravation of all of the TMD signs and symptoms associated with increased frequency of the temple headaches. In addition, increased headache frequency showed significant trends associated with reduced PPTs and reported temple headache with masticatory provocation tests. In conclusion, these findings suggest that these headaches may be TMD related, as well as suggesting a possible role for peripheral and central sensitization in TMD patients. Subjects with painful temporomandibular disorders (TMD) showed significant trends for increased signs and symptoms of TMD associated with increased frequency of concurrent temple headaches.

Copyright © 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
PMID: 21196079 [PubMed - as supplied by publisher]

TENSION-TYPE HEADACHES AND MIGRAINES OFTEN HAVE COMMON CO-MORBIDITIES OF TEMPOROMANDIBULAR DISORDERS, MYOFASCIAL PAIN AND FORWARD HEAD POSITION

A new article "Pure tension-type headache versus tension-type headache in the migraineur." in Curr Pain Headache Rep. 201:465-9.0 Dec;14(6) (PubMed abstract below) looks at primary headache disorders. What is most interesting is that they state that differential diagnosis is made difficult to the frequent presence of co-morbidities including temporomandibular disorders and myofascial pain.

I wish the authors could realize that what they classify as co-morbidities are actually underlying triggers and causes of both migraines and tension-type headaches. When they assume that these headaches are primary they miss the opportunity to actually treat and prevent them from occuring. The authors go on to state "chronification, particularly of migraine, leads to a decrease in the associated symptoms of migraine, such as nausea, photophobia, and phonophobia, so that these headaches more closely resemble tension-type headache" and missing the fact that central sensitiztion and chronicity is due to not treating the primary trigeminal nerve problem that is secondary to repetitive motion injuries from underlying dysfunction that leads to myofascial pain disorders.

There is a musclar component as well as a neurogenic/vascular component to all headaches. The real issue is the elimination of the conditions that trigger tension-type headaches, migraines and TMJ (TMD) disorders. Neuromuscular dentistry is extremely effective in preventing and eliminating tension-type headaches and migraines because it eliminates the repetitive strain injuries by idealizing the physiologic status of the entire trigeminal nervous system that is responsible in whole or in part for almost all migraines and tension-type headaches as well as other head, neck and facial pain.


Curr Pain Headache Rep. 201:465-9.0 Dec;14(6)
Pure tension-type headache versus tension-type headache in the migraineur.
Blumenfeld A, Schim J, Brower J.
The Headache Center of Southern California, 320 Santa Fe Drive, Encinitas, CA 92024, USA. blumenfeld@neurocenter.com
Abstract
Primary headache disorders include tension-type headache and migraine. These headache types can be differentiated based on strict clinical definitions that depend on the patient's signs and symptoms. However, some of the clinical features can overlap, and in addition, the same comorbid conditions can occur in both headache types. Distinction between these headache types on occasion can be difficult due to comorbid conditions such as temporomandibular joint disorders and myofascial pain with forward head posturing, which may be present in both headache disorders, and thus result in similar features in both conditions. Furthermore, chronification, particularly of migraine, leads to a decrease in the associated symptoms of migraine, such as nausea, photophobia, and phonophobia, so that these headaches more closely resemble tension-type headache. Finally, in some patients, both tension-type headache and migraine may occur at different times.
PMID: 20878271 [PubMed - in process]