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.

Cervicogenic Headaches, TMJ, TMD, and the Trigeminocervical System. Treatment should include trigger point injections and greater occipital blocks.

Headaches and TMJ disorders usually have multiple symptoms. According to an article in Nov 2011 Neurologist these include the following symptoms: complaints of dizziness, tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain.

I firmly believe that the autonomic symptoms ot temporomandibular disorders must be addressed. A neuromuscular orthotic can alleviate many of the symptoms but SPG blocks, greater occipital blocks and trigger point injections are frequently required for more effective treatment. All of these treatments are minimally ivasive and safer and more effective than use of tiptans or topomax.

The abstract reported the following results:

Total number of 147 patients were included. Chief complaints in decreasing frequency: dizziness (93%), tinnitus (4%), headache (3%), and ear discomfort (0.7%). Overall symptoms in decreasing frequency: dizziness (97%), headache (88%), neck pain (63%), tinnitus (23%), and ear discomfort (22%). Improvements after GON/TPI: neck range of motion (71%), headache (57%), neck pain (52%), ear discomfort (47%), dizziness (46%), and tinnitus (30%). Dizziness responders had neck position asymmetries (84%), reproducible dizziness by cervical and suboccipital musculature vibration (75%), and preinjection posterior vertex sensory changes (60%).

Neurologist. 2011 Nov;17(6):312-7.

Role of greater occipital nerve blocks and trigger point injections for patients with dizziness and headache.

Baron EP, Cherian N, Tepper SJ.

Source

Department of Neurology, Cleveland Clinic Neurological Institute, Center for Headache and Pain, Cleveland, OH.

Abstract

BACKGROUND:

: The trigeminocervical system is integral in cervicogenic headache. Cervicogenic headache frequently coexists with complaints of dizziness, tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain. Controversy exists as to whether this constellation of symptoms may be cervically mediated.

OBJECTIVES:

: To determine whether a wider spectrum of cervically mediated symptoms exist, and to investigate a potential role of greater occipital nerve blocks (GON) and trigger point injections (TPI) in these patients.

METHODS:

: Retrospective review of GON/TPI performed in a tertiary otoneurology/headache clinic from May 2006 to March 2007 for suspected cervically mediated symptoms. Data included chief complaint, secondary symptoms, response to injection, pre-GON/TPI posterior vertex sensation changes to pinprick, cervical spine examination, and response to vibration of cervical and suboccipital musculature.

RESULTS:

: Total number of 147 patients were included. Chief complaints in decreasing frequency: dizziness (93%), tinnitus (4%), headache (3%), and ear discomfort (0.7%). Overall symptoms in decreasing frequency: dizziness (97%), headache (88%), neck pain (63%), tinnitus (23%), and ear discomfort (22%). Improvements after GON/TPI: neck range of motion (71%), headache (57%), neck pain (52%), ear discomfort (47%), dizziness (46%), and tinnitus (30%). Dizziness responders had neck position asymmetries (84%), reproducible dizziness by cervical and suboccipital musculature vibration (75%), and preinjection posterior vertex sensory changes (60%).

CONCLUSIONS:

: A wider spectrum of cervically mediated symptoms may exist by influence of trigeminocervical and vestibular circuitry through cervical afferent neuromodulation. Certain examination findings may help to predict benefit from GON/TPI.

Intractable Cluster Headache: Sphenopalatine Ganglion Blocks May be Treatment of Choice.

Cluster headaches is a primary neurovascular headache and is associated with autonomic symptoms. A sphenopalatineablation with radiofrequency is suggested in the following abstract. I disagree. If patients get relief from a sphenopalatine block of their cluster hedaches they will probably find intranasal prophylactic SPB blocks are also effective. An old study on SPG ablation at Mayo was discontinued due to adverse outcomes.

Correction of underlying trigeminal aberations through a neuromuscular orthotic and SPG blocks is a safer and more conservative alternative to SPG ablation.

I would only consider ablation as a very last line of treatment.

Curr Pain Headache Rep. 2010 Apr;14(2):160-3.

Role of sphenopalatine ganglion neuroablation in the management of cluster headache.

Narouze SN.

Source

Pain Management Department, Anesthesiology Institute, Cleveland Clinic, OH 44195, USA. narouzs@ccf.org

Abstract

Cluster headache is a primary neurovascular headache. It is a strictly unilateral head pain that is associated with cranial autonomic symptoms and usually follows circadian and circannual patterns. Chronic cluster headache, which accounts for about 10% to 15% of patients with cluster headache, lacks the circadian pattern and is often resistant to pharmacological management. The sphenopalatineganglion (SPG), located in the pterygopalatine fossa, is involved in the pathophysiology of cluster headache and has been a target for blocks and other surgical approaches. Percutaneous radiofrequency ablation of the SPG was shown to have encouraging results in those patients with intractable cluster headaches.

Sphenopalatine Ganglion Implicated in Migraines and Cluster Headaches via Cerebrovascular Autonomic Physiology

The pathophysiology or cause of almost all headaches, migraines, cluster headaches and tension-type headache involve the Trigeminal Nerve which can effectively be treated in mane headache sufferers through neuromuscular dentistry. Another pathway of relieving chronic headache pain is by utilizing a SPG or Sphenopalatine Ganglion Block which affects the autonomic nervous system and is readily accessible to dentists with either palatal injection or nasal swab.

Newer techniques involving neurostimulation hold promise but the simple use of lidocaine on a nasal swab often produces miraculous relief for patients. When combined with a diagnostic neuromuscular orthotic a 50 - 80% success rate easily achieved in most patients. The following PubMed abstract discusses possible new avenues of addressing the sphenopalatine ganglion. I would advise patients to start with nasal or palatal block. Nasal blocks are easily learned by patients for home administration and can be used to prophylactically to abort migraines similar to triptans or topomax with fewer side effects.

Prog Neurol Surg. 2011;24:171-9. Epub 2011 Mar 21.

Sphenopalatine ganglion interventions: technical aspects and application.

Oluigbo CO, Makonnen G, Narouze S, Rezai AR.

Source

Department of Neurological Surgery, Ohio State University Medical Center, Columbus, Ohio 43210, USA.

Abstract

Recent research has highlighted the important role of the sphenopalatine ganglion (SPG) in cerebrovascular autonomic physiology and in the pathophysiology of cluster and migraine headaches as well as conditions of stroke and cerebral vasospasm. The relatively accessible location of the SPG within the pterygopalatine fossa and the development of options for minimally invasive approaches to the SPG make it an attractive target for neuromodulation approaches. The obvious advantage of SPG stimulation compared to ablative procedures on the SPG such as radiofrequency destruction and stereotactic radiosurgery is its reversibility and adjustable features. The on-going design of strategies for transient and continuous SPG stimulation on as needed basis using implantable SPG stimulators is an exciting new development which is expected to expand the clinical versatility of this technique.

Copyright © 2011 S. Karger AG, Basel.

PMID:

21422787

[PubMed - in process]

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.

Chronic Daily Headache: Neurological Sciences Study Showed 17 of 20 Patients Required Neurmuscular Orthotic

A neuromuscular orthotic is used to correct occlusal discrepancies that can cause chronic daily headaches, migraines and tension-type headaches.The current study (abstract below) showed that 85% of patients with chronic daily headache has significant discrepancies between their occlusion and their ideal neuromuscular position.

The majority of dentists treating TMJ disorders and chronic head and neck pain are lost when it comes to establishing the neuromuscular position. The neuromuscular rest position and occlusion can only be determined after uilizing ultra-low frequency TENS to relax muscles and deprogram the occlusion.

I prefer the term Diagnostin Neuromuscular Orthotic because even though Neuromuscular Dentistry is extremely effective it is imprortant to establish success prior to long term restoration. The diagnostic orthotic is used to find this three dimensional relaxed position.

I see chronic headache and TMJ disorder patients on a long distance basis. The first series of appointments are to establish improved posture and a functionally correted Diagnostic Neuromuscular Orthotic.

I will have my out of town patients arrive on Sunday and then see them Monday AM for diagnostic evaluation, radiographs, impressions and examination. I then deliver the Diagnostic Orthotic Monday afternoon. It is adjusted Tuesday AM and PM and on Wednesday morning. This protocol allows me to send patients home after a short series of appointments with a functionally corrected neuromuscular diagnostic orthotic. I frequently will also do trigger point injections, SPG blocks and other physical therapy modalities.

I insist I receive a complete history and conduct a phone interview prior to giving the patient an appointment. This is essntial to be able to rapidly help patients get relief from chronic daily headaches, migraines and head and neck pain.

Neurol Sci. 2011 May;32 Suppl 1:S161-4.

Chronic daily headache: suggestion for the neuromuscular oral therapy.

Didier H, Marchetti C, Borromeo G, Tullo V, D'amico D, Bussone G, Santoro F.

Source

Fondazione IRCCS Cà Granda, Dipartimento di Scienze Chirurgiche Ricostruttive e Diagnostiche Sezione di Odontostomatologia, Università degli Studi di Milano, Via della Commenda 10, 10122 Milan, Italy.

Abstract

Tweny patients (M: 4, F: 16, mean age 37 ± 11 years) with diagnosis of chronic daily headache (CDH), after drug withdrawal, were under electromyography, kinesiography and masticatory muscle deprogramming by TENS to identify the physiological rest position of the mandible. Our purpose was to clarify a possible role of the neuromuscular stomatognathic system. Examinations showed that 17 patients needed a neuromuscular orthosis, an occlusal device, to provisionally correct the detected discrepancies of jaw position. Of those, the 10 patients who showed an occlusal sagittal discrepancy higher than 2 mm and/or a lateral deviation higher than 0.4 mm, associated with more than three parafunctional activities, had a meaningful decrease on frequency/intensity of migraine crisis and/or of days of headache. VAS pain score during crisis decreased from 9.0 ± 0.9 to 4.9 ± 2.7; frequency of crisis were from 20.7 ± 5.2 to 9.5 ± 7.7. Baseline pain were from 5.3 ± 1.2 to 3.0 ± 1.3. Satisfying clinical results can be reached combining behavioural education and neuromuscular orthosis. This can be very helpful in patients who show significant discrepancy of jaw position that only TENS deprogramming can reveal and kinesiography can detect with such accuracy.

PMID:

21533736

[PubMed - indexed for MEDLINE]

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

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

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

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

The reduction in headaches days was significantly greater with accupuncture.

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

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

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

Source

Kuang Tien General Hospital and Chang Gung University, Taiwan.

Abstract

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

PMID:

22019576

[PubMed - as supplied by publisher]

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