Dr. Shapira's Chicago Headache Blog

I came across this interesting abstract (below) on the spenopalatine ganglion and how it can cause remote effects. According to the article published in Arch Phys Med Rehabil. 1979 Aug;60(8):353-9 it can be responsible for wide ranging disorders. "Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others." I must disagree that the symptoms are "psychosomatic", I would venture that doctors facing idiopathic conditions sometimes label what they do not understand as psychosomatic. I have not read the original article only the abstract at this time and I am not sure how the authors are using the term psychosomatic.

All of the symptoms are mediated by the autonomic nervous system. The authors point out the connections to the Trigeminal Nerve, facial nerve and to the internal carotid artery plexus of the sympathetic nervous system. these connections could explain how the SPG is ntimately involved in TMD (TMJ) disorders and facial pain, migraines, tension headaches and other problems.

Neuromuscular dentistry will have effects on the trigeminal and facial nerves that travel thru the SPG but use of intranasal spenopalatine blocks will be a valuable tool in treating these autonomic aspects of chronic pain. Neuromuscular Dentists and all physicians and dentists treating chronic pain should be well versed in utilization of intranasal SPG blocks.

The rage reaction may also be affected by the SPG which may explain chemical changes seen in the brains of chronic pain patients. The connections to the pituitary gland could have effects on a wide variety of hormonal conditions.

I have seen remarkable results in some patients while utilizing SPG intranasal blocks while in other patients they seem ineffective. This may actually constitute a diagnostic evaluation for how large an autonomic effect is in a given patient.

Neuromuscular dentistry can evaluate the changes that take place in the masticatory muscles by utilizing EMG measurements of the masticatory muscles before and after SPG blocks. However we will only be able to measure the effects on voluntary muscles but not on visceral muscles or autonomic function. The field of neuromuscular dentistry has tremendous effects on the trigeminal nerve input to the brain. The Trigemnal nerve (fifth cranial nerve) is responsible for over 50% of the total input to the brain. the autonomic components are still not well understood by clinicians treating migraines, tension headaches, TMD, myofascial pain and other disorders. RSD (Reflex sympathetic Dystrophy) or CRPS (complex regional pain syndrome) are autonomic manifestations are some some of the most troubling in clinical treatment of pain.

The authors presents arguments supporting the following hypotheses:" 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered."

I am sometimes amazed at the effectiveness that we achieve utilizing a neuromuscular orthotic while we still do not have a good grasp on the underlying neurology. I believe why we are so successful in eliminating, preventing and treating chronic migraines and headaches is that the correction of the proprioceptive input accomplished by neuromuscular dental orthotics or occlusal corrections is such an emormous reduction in noxious neural input that we accidentally produce vast beneficial effects throughout the trigeminovascular system, the autonomic nervous system, the hormonal systems influenced by the pituitary gland and in the part of the brain (retained) that is involved in rage reflexes found in lower animals.

Arch Phys Med Rehabil. 1979 Aug;60(8):353-9.
Sphenopalatine (nasal) ganglion: remote effects including "psychosomatic" symptoms, rage reaction, pain, and spasm.
Ruskin AP.

Many articles implicate the nasal ganglion in the production of remote symptoms and discuss treatment. Symptoms are primarily spastic, involving both visceral and voluntary muscles including muscle spasm in the neck, shoulder, and low back; asthma, hypertension, intestinal spasm; diarrhea, angina pectoris, uterine spasm; intractable hiccup, and many others. All these symptoms appear to have 2 common denominators. They are mediated by the autonomic nervous system and at least in some instances can be "psychosomatic." The sphenopalatine ganglion (SPG) is a major autonomic ganglion located superficially in the pterygopalatine fossa, with major afferent distribution to the entire nasopharynx and important connections with the trigeminal nerve, facial nerve, internal carotid artery plexus of the sympathetic nervous system and, as shown in the rat, direct connection with the anterior pituitary gland. This paper presents arguments supporting the following hypotheses: 1. The SPG probably has a crucial role in lower animals in declenching the reflex responses known collectively as the rage reaction. 2. The SPG is a major point of entry to the autonomic system exposed to pathologic influences and readily accessible for therapeutic influences and readily accessible for therapeutic intervention. 3. A wide variety of symptoms are produced or maintained by alteration in autonomic system tonus and some of these may be affected by intervention on the SPG. 4. The possible relationship of some symptoms and "psychosomatic" conditions to the autonomic nervous system and the rage reaction must be considered.20

PMID: 464779 [PubMed - indexed for MEDLINE]

Labels: autonomic response, chronic daily headaches, CRPS, RSD, sphenopalatine ganglion, sphenopalatine ganglion block, trigeminal nerve

I just attended the 2010 American EquilibrationSociety meetng in Chicago titled "TREATING THE TMD PATIENT: Putting the Puzzle pieces together". Great news for patients with migraines, tension headaches and Temporomandibular disorders.

The meeting opened with an excellent letter by Henry Gremillion, who was recently named Dean of the Louisiana School of Dentistry. He spoke on "MYOGENOUS OROFACIAL PAIN" or pain coming from the muscles. It is well known that the majority of pain has orgins in the muscles, including tension-type headaches and chronic daily headaches as well as most pain associated with TMD disorders.

Dr Gremillion quoted a scary study where a single injection of nerver growth factor, a compound found in sore muscles and around trigger points could activate nociception (pain) for up to 7 weeks not just in the area of injection but in distant muscular and joint areas. Because nerve growth factor is also released in painful areas it explains why treatment can take weeks to show effectiveness. These biochemical changes are associated with neuralplasticity and central sensitization.

There is also a cmlative effect where up to 50 first order neurons can feed into a single second order neuron leading to referred pain and explaining some of the complexity of dealing with headaches coming from muscles but mediated thru the trigeminal nerve and trigeminovascular system resulting in biochemical changes in the brain. While many physicians and some dentists seek to treat this pain with enormous amounts of medications it is possible to change the neural input and and positively effect the CNS (central nervous system) Chemical inbalnces in the brain can be triggered by peripheral nervous system input. A point that was emphasized by the second speaker Dr Jay Shah of the NIHwhose lecture "NEW FRONTIERS IN THE PATHOSPHYSIOLGY OF MUSCULOSKELETAL PAIN : ENTER THE MATRIX" was truly extraordinary in explaining the biochemical changes that occurs in and around trigger points.

Even more exciting is the use of ultrasound imaging and especially vibrational sonoelastography to measure the stiffness around myofascial trigger points and to show the effects on blood flow in the immediate vicinity of trigger points. He also showed that the same biological and chemical changes occur around both latent and active trigger points. These peripheral changes create central nrvous sytem biochemical changes via afferent nerves. He discussed how pain can be due to noxious stimulus or loss of "DESCENDING INHIBITION OF PAIN" AND HOW INHIBITORY NERVE APOPTOSIS CAN CREATE PERMANENT PAIN STATES. TIME IS OF THE ESSENCE IN ADDRESSING NEUROMUSCULAR PAIN! Dr Shaw is a senior staff physiatrist in the rehabilitation medicine dept. After hearing him speak about the treatment of pain and basic research into underlying causes I believe at least some of our tax dollars are truly being used wisely.

His croup does micrassay of the chemicals around myofascial trigger points and they are now using miniscule accupunture needles which have two chanels prepared with lasers to collect chemical assays painlessly with minimal disruption to the tissues. The work he describes should make all patients with myofascial pain and /or fibromyalgia hopeful for better lives with pain controlled. These studies put the rest the idea that TMJ disorders are psychosocial or physical. There is no longer any doubt about the medical nature of these muscle disorders.

Patients with chronic headaches and migraines will surely benefit as this type of research flourishes. This research is also proving the validity of many basic precepts of neuromuscular dentistry. Correction of periheral problems that sey off muscle nociceptors and endogenous biochemicals cause amplification and perpetuation of peripheral and central sensitization that lead to persistent pain.

DR GREMILLION ALSO DISCUSSED VARIOUS ETIOLOGICAL HYPOTHESIS OF CHRONIC MUSCLE PAIN THAT ALL CORRELATED WITH NEUROMUSCULAR DENTISTRY TREATMENT. The central hypothesis dealth with first order to second order neuron ratios, the repetitve strain hypothesis is exactly what neuromuscular dentistry treats with microtrauma leading to macro problems. The peripheral sensitization hypothesis explains how microtrauma can cause central sensitization and the central biasing Mechanism hypothesis explains the equilibrium shifts as facilitation and inhibition ratios shift. He also discussed Sympathetic Dysregulation that can lead to Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndromes (CRPS)

Labels: CENTRAL SENSITIZATION, CGRP neuromuscular dentistry, chronic daily headaches, CRPS, facial pain, fibromyalgia, myofacial pain, neuromuscular dentistry tmd, RSD, TMD, TMJ