Dr. Shapira's Chicago Headache Blog

A new study Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study in Headache. 2010 Feb 12 is very revealing. It was evaluating chronic daily headaches, pschiatric disorders and TMD. In the study "Individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH (chronic daily headache) were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2).

Of the 1631 subjects 57 (3.6%) had CDH. Chronic migraine comprised represented 36.8% and Chronic tension-type headache represented 17.5%. Medication overuse headache was also common representing 22.8% and probable medication overuse headache representing another 17.5% were also common combined totaling 40.3% of Chronic daily headaches

There were TMD comorbidities observed in 58.1% of the patients. This is no surprise as the trigeminal nerve is almost universally involved in chronic headaches. If a thorough neuromuscular detistry evaluation was done it is likely the percentage of patients with TMD signs or symptoms would be much higher. There were also psychiatric disorders were observed in a large percentage of these patients but living with chronic pain can frequently manifest itself in secondary psychiatric problems.

I frequently find that patients who are in chronic pain, not sleeping well and overutilizing medications change ramatically after they begin using a diagnostic orthotic. I sometimes feel I don't meet the patients until their second or third visit after significant pain reduction.

It is normal to be depressed when you are in constant non-remiting pain. I have frequently said that patients in constant pain who do not become depressed are "certifiable".

When considering comorbidities it is important to understand that TMD is a causitive comorbidity that helps create the chronic headaches while the psychiatric comorbidity may be a result of the pain or not related to the pain problem.

If one was to consider medication overuse a comorbidity then the data would skew considerably. Is the medication overuse headache a symptom of the underlying TMD or psychiatric disorder. Patients with TMD are prone to seeing a wide variety of health practitioners before being diagnosed with tmd (TMJ) disorders. TMD is know as "The Great Imposter" for that reason. Please see the Sleep and Health article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

TMD IS SUCH A MAJOR COMORBIDITY IN HEADACHES THAT EVERY PATIENT WITH CHRONIC HEADACHES OR MIGRAINES SHOULD BE EVALUATED FOR TMD PRIOR TO INITIATING MEDICATION. A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC MAY ELIMINATE THE PAIN PROBLEMS THEREBY AVOIDING FUTURE MEDICATION OVERUSE HEADACHES AND ASSOCIATED PSYCHIATRIC PROBLEMS FROM BOTH PAIN AND MEDICATION OVERUSE.





PUBMED ABSTRACT below
Headache. 2010 Feb 12. [Epub ahead of print]
Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study.
da Silva Jr A, Costa EC, Gomes JB, Leite FM, Gomez RS, Vasconcelos LP, Krymchantowski A, Moreira P, Teixeira AL.

From the UFMG - Headache Clinic, Belo Horizonte, Brazil (A. da Silva Jr, E.C. Costa, J.B. Gomes, and F.M. Leite); University Hospital, Federal University of Minas Gerais - Headache Clinic, Neurology Division, Belo Horizonte, Brazil (R.S. Gomez); Federal University of Minas Gerais (UFMG) - Internal Medicine, Belo Horizonte, Brazil (L.P. Vasconcelos and A.L. Teixeira); Universidade Federal Fluminense - Neurology, Rio de Janeiro, Brazil (A. Krymchantowski); Universidade Federal Fluminense - Headache Clinic, University Hospital, Rio de Janeiro, Brazil (P. Moreira); Federal University of Minas Gerais (UFMG) - Laboratory of Immunopharmacology, Belo Horizonte, Brazil (A.L. Teixeira).
Background.- Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking. Objectives.- To estimate the 1-year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil. Methods.- This was a cross-sectional, population-based, 2-phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2). Medication overuse headache was diagnosed, as per the ICHD-2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM-IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively. Results.- A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension-type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them. Conclusions.- The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers. (Headache 2010;**:**-**).

PMID: 20163479 [PubMed - as supplied by publisher

Labels: Chicago, chronic daily headacahe, chronic daily headaches, chronic daily migraine, comorbidities, facial pain TMJ, ILlinois, Kenosha, lake county, TMD

There was an excellent article in Practical Pain Management by Edwin A Ernst III DMD on Temporal Tendinitis. Common pain reference sites (according to the article) for this condition include: Painful TM Joints (Temporomandibular joint or TMJ), Ear Pain and/or stuffiness in the ear, retro-orbital pain sometimes radiating to occiput and /or shoulder, upper and lower aching teeth, pain in or around the eye, pain in the lateral temple area, and occasionally pain in the area of the stylomandibular ligament. These pains are frequently accompanied by prodromal symptoms similar to migraine of Nausea, vomiting, photophobia and visual disturbances.

This can be extremely intense pain and is frequently initiated by trauma such as an auto accident. Many patients with this disorder can have trouble fitting their back teeth together. The pain can be unilateral or bilateral and patients will frequently use analgesics, opiods or visit hospital ER's because of the pain severity. Physicians rarely palpate the coronoid tendon therefore these patients are easily misdiagnosed. Intra-oral palpation is essential in the diagnostic process and most physicians are not trained in palpation of these important structures. Dr Ernst coined the phrase "The Migraine Mimic " in 1983 but many physicians are not familiar with craniofacial pain literature.

The actual problem is a tendenosis of the temporal tendon at the tip of the coronoid process. Increasing the pressure of palpation causes increases in the level of the pain. If a Migraine Mimic headache is evoked use of lidocaine diagnostic injection should lessen or alleviete the pain.

Treatment with local anesthetic and Sarapin and/or Steroid is recommended by Dr Ernst and if this is not curative he recommends radio-frequency thermoneurolysis. I have never found this to be necessary and prefer to try prolotherapy as a first line treatment and if that is not effective then utilize a steroid. If the pain is exquisitely acute than beginning with steroid may be advantageous.

Temporal tendinitis can also be found in chronic muscle disorder from chronic pathology but is usually significantly less intense. Patients can suffer for years with this condition and be treated for migraines with poor results and no long term resolution.

I still recommend correction of the neuromuscular position of the mandible with a diagnostic orthotic even when temporla tendinitis is diagnosed. If total relief is achieved a reevaluation of baseline jaw position is recommended before phase 2 therapy.

Labels: diagnostic block.coronoid tendon, Edwin Ernst DMD, ILlinois, Migraine mimic, palpation coronoid tendon Chicago, prolotherapy, temporal tendinitis, Temporomandibular disorder, The Great Imposter, TMD, TMJ

I just saw a patient today that I treated a few years ago. Shae had had over 25 years of severe TM Joint pain and Headaches. She was referred to me by an Oral Surgeon in Texas. This patient had worn an oral appliance continuously for years with only partial pain relief.

A diagnostic neuromuscular orthotic and trigger point injections had led to complete pain relierf and she opted for a cosmetic dental reconstruction as she was anxius to no longer wear an appliance. It has been several years since the reconstruction and though she mad a couple of appointments she would always cancel before she camein.

I saw her today, still free of jaw pain and headaches because she had chipped two anterior veneers and had stayed away because she was worried about cost. In the last year her husband and her bought a new house and he lost his job. They now had two mortgages to pay and she needed emergency surgery. There are some personal family problems that are upsetting and a few other crisis. There was no return of the chronic jaw pain and/or headaches in spite of the stress. She had broken her oral appliance that treatwed her sleep apnea as well and that was when she chipped the teetth.

It turns out the chips in the porcelain were minimal and just needed smoothing. She will be receiving a new sleep apnea appliance very soon which will also prevent her from chipping her teeth.

After a lifetime of chronic pain her neuromuscular dentistry kept her comfortable even while under some of the worst stress in her life. Luckily her husband is now working again at a better job and they rented the second house so they are no longer stuck with two mortgages.

Labels: headaches, ILlinois, neuromuscular dentistry, TMD, TMJ