Dr. Shapira's Chicago Headache Blog

I HAVE BEEN TRETING PATIENTS WITH CHRONIC HEAD AND NECK PAIN, FACIAL PAIN, MIGRAINES TENSION-TYPE HEADACHES FOR 30 YEARS. I SEE PATIENTS PRIMARILY IN MY GURNEE OFFICE AND OVER THE YEARS PATIENTS HAVE FOUND THAT IT WAS WORTH THE DRIVE FOR RELIEF OF PAIN. I HAVE RECENTLY CREATED CICAGOLAND DENTAL SLEEP MEDICINE ASSOCIATES AND I AM ABLE TO SEE PATIENTS IN SCHAUMBURG IN THE OFFICES OF DR ALAN ACIERNO AN EXCELLENT GENERAL DENTIST.

PATIENTS WITH HEADACHES AND SLEEP DISORDERS CAN MAKE APPOINTMENTS TO SEE ME IN SCHAUMBURG BY CONTACTING ME AT DELANY DENTAL CARE LTD IN GURNEE. CALL TOLL FREE AT 1-800-TM-JOINT OR 1-8-NO-PAP-MASK OR VISIT MY WEBSITE @ http://www.delanydentalcare.com/neuromuscular.html

Labels: atypical migraine, barrington, chronic daily headaches, ELGIN, MCHENRY, NEUROMUSCULAR DENTISTRYY, Schaumburg

When chronic or acute ear pain occurs an evaluation by an otolaryngologist or ENT is a good way to begin treatment. The exception to this rule is when movements of the lower jaw cause the ear pain or the motion of the lower jaw is limited. This is a sign of a TMJ disorder. If it happens suddenly it may be the sign of an acute close-lock of the TM Joint and a dentist with experience in treating temporomandibular disorders is a must. Neuromuscular Dentistry is extremely effective in treating chronic haeadaches, migraines, Tension Headaches and TMD but when an acute close lock occurs time is of the essence to prevent permanent damage.

Many neuromuscular dentists know how to manage the chronic pain aspect of TMD but are less sure of handling an acute disk dislocation.

The wrong treatment is to not attempt to reduce the dislocation, taking anti-inflamatories or pain meds without attempting to reduce the dislocation. The longer the disk is out the more likely there will be permanent damage or internal derangement of the TMJ.

A trip to the emergency room is usually non-productive or may even create additional damage if they try to force the jaw open.

A simple method to reduce a close-lock it to stimulate a strong gag reflex which will sometimes reduce the dislocation. It is then necessary to stabilize the joint with an orthotic.

Labels: atypical migraine, ear pain, facial pain TMJ, migraine neuromuscular dentistry, neuromuscular dentistry, otalgia, temporomandibular joint, TM Joint, TMD Migraine

An article by Jeanetta C. Rains1 and J. Steven Poceta gives an opinion paper on the relation of sleep to headache. They feel that headache is linked to a wide variety of sleep disorders that may impact treatment results and headache management.

They believe that after standard diagnosis of headache a sleep history should be collected according to headache problems. Initally they state that you should rule out sleep apnea in patients with headaches on awakening. I agree and have frequently said that the two main causes of morning headaches are TMJ disorders, Sleep Apnea and Bruxing. The NHLBI of the NIH published a report "Cardiovascular and Sleep Related Consequences of Temoporomandibular Disorders" Morning headaches can also be caused by jaw clenching but newer evidence relates clenching to awakenings by sleep disordered breathing.

They believe that cluster headaches, chronic migraine and chronic tension-type headache should have sleep apnea ruled out as a cause. I believe that looking at the neuromuscular system to evaluate patients for TMJ disorders, muscle disorders and trigeminal nervous disorders related to the bite is also essential. Neuromuscular Dentistry is a method that has been shown to be "overwhelmingly successful according to Dr Barry Cooper and as published in Cranio Journal.

If there are signs and symptoms of sleep apnea they Rx polysomnography and treatment with CPAP. While CPAP is effective I feel patients with headaches and sleep apnea would be much better served by combining treatments by utilizing an intra-oral apnea appliance that will also help decrease headaches of trigeminal orgin, or almost all types of headaches. Studies with oral appliances for headache treatment show a minimal 50% improvement in the majority of patients. They do not advocate suspending regular headache treatment when treating apnea but many of the patients treated with oral appliances report complete relief of headaches. CPAP can also be effective but 60% of patients reject it and it causes negative side effects in a significant number of patients who use it leading to discontinuation of CPAP and/or poor compliance.

The authors stated that use of oral appliance, surgery and weight loss are untested displaying a suprising amout of ignorance about the current parameters of care for treating sleep apnea that considers oral appliances to be a first line of treatment for mild to moderate sleep apnea and an alternative for severe apnea when CPAP is not tolerated. The percentage of patients that do not tolerate CPAP is the same for mild, moderate and severe sleep apnea patients.

The authors reported "patients with migraine and tension-type headache, insomnia is the most common sleep complaint, reported by one half to two thirds of clinic patients." They did not specify it is was sleep onset insomnia or maintenance of sleep insomnia.

The authors also stated "All headache patients, particularly those with episodic migraine and tension-type headaches, may benefit from inclusion of sleep variables in trigger management."

I believe it in incumbent on physicians and dentists treating headaches be acutely aware of the effect of sleep disorders on headache.

They should also be aware that psychiatric disorders and depression frequently occur in chronic pain patients as a direct result of the chronic pain.

Treatment of sleep disorders and headache with a combination of a neuromuscular daytime orthotic and a n intraoral sleep apnea appliance or use of a 24 hour orthotic is "overwhelming successful" as published in Cranio Journal.

Labels: atypical migraine, chronic daily headaches, cluster headache treatment, cluster headaches, neuromuscualr dentistry, oral appliances, SLEEP APNEA, sleep disorders, tension-type headaches

Drug herapy always carries some risks. The following abstract details how a patient was treated for migraines with ergotamine. The patient was suffering from tiredness and weight loss and fever after a single dose of ergotamine. A second dose led to tongue necrosis (necrosis means death of the tissue) The authors felt that the necrosis of the tongue could have been the result of undiagnosed temporal arteritis a condition that can also cause blindness. A clinical sign of temporal arteritis is an elevated sed rate.

Ergotamine is a well known drug in migraine treatment and this is an unusual case. With neuromuscular dentistry we are always on the look out for red herrings. The patient who has a serious disorder that is causing symptoms or a serious disordersthat is not causing the symptoms but is covered up by the pain disorder.

My favorite patients to treat are patients who have had MRI's, CAT scans, Brain Scans, numerous blood tests ruling out organic diseases. These patients are "safe" because all the severe problems have been eliminated as possible causes of the problem.

Neuromuscular Dentistry cannot treat temporal arteritis which is usually treated with steroid but often dissapears after a biopsy.

PUBMED Abstract
Ugeskr Laeger. 2009 Jan 12;171(3):125-6.
[Necrosis of the tongue triggered by ergotamine in unrecognized temporal arteritis]
[Article in Danish]

Olesen JB.

Regionshospitalet Horsens, Medicinsk Afdeling. Jesper.blegvad@ki.au.dk
Tongue necrosis is a rare complication in arteritis temporalis. Our case is a 74-year-old patient who presented with weight loss, tiredness and fever during a 2-3-month period after ingestion of 2 mg ergotamine to treat her migraine. Tongue necrosis then occurred after ingestion of another 2 mg of ergotamine. Our patient had no preexisting diagnosis of arteritis temporalis. We reviewed possible clinical manifestations of temporal arteritis and cases of tongue necrosis in the world literature. It is possible that ergotamine can cause necrosis due to vasoconstriction of blood vessels which have an unstable blood flow.

PMID: 19174020 [PubMed - indexed for MEDLINE]

Labels: atypical migraine, neuromuscular dentistry, Temporal arteritis, TMJ/TMD

Osteopathic manipulation and Chiropractic manipulation both treat headaches by changing input into the trigeminal nerve much like neuromuscular dentistry does. The article states: " Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache." The pathology in the neck is addressed to reduce pain (nociceptive) input into the trigeminal nucleus caudalis. The easiest and most direct method of reducing nociceptive input into the trigeminal nerve is a diagnostic orthotic followed by definitive long term treatment. The beauty of neuromuscular dentistry is that correcting the stomatognathic/ trigeminal system leads to auto correction of many neck problems.

The reason that NUCCA and A/O (atlas orthogonal) chiropractic is so effective when used in conjunction with a neuromuscular orthotic is that the chiropractic and/or osteopathic adjustments hold when the underlying masticatory pathology is adressed.



J Am Osteopath Assoc. 2007 Nov;107(10 Suppl 6):ES10-6.
Diagnosing and managing migraine headache.
Mueller LL.

University Headache Center, University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, 42 E Laurel Rd, University Doctors Pavilion, Ste 1700, Stratford, NJ 08084-1354, USA. SOMPhysicians@umdnj.edu
Comment in:

J Am Osteopath Assoc. 2008 Apr;108(4):191; author reply 191, 214.
Headache is one of the chief complaints among patients visiting primary care physicians. Diagnosis begins with exclusion of secondary causes for headache. More than 90% of patients will have a primary-type headache, so diagnosis can often be completed without further testing. Although tension-type headaches are the most common kind of headache, patients with this type of headache rarely seek treatment unless occurrence is daily. Migraine, which affects more than 30 million people in the United States, is the most common headache diagnosis for which patients seek treatment. Migraine is a chronic, often inherited condition involving brain hypersensitivity and a lowered threshold for trigeminal-vascular activation. Intermittent debilitating attacks are characterized by autonomic, gastrointestinal, and neurologic symptoms. Migraine results in a marked decrease in a patient's quality of life, as measured by physical, mental, and social health-related instruments. Accurate assessment of a patient's disability will guide physicians in prescribing appropriate modes of therapy. However, migraine remains underdiagnosed, and patients with migraine remain undertreated. A comprehensive treatment approach to migraine may include nonpharmacologic measures, as well as abortive and prophylactic medications. Informing patients about realistic treatment expectations, possible delayed efficacy of medications, and avoidance of caffeine and overuse of medications is critical for successful outcomes. Management of migraine is a dynamic process, because headaches evolve over time and medication tachyphylaxis may occur, necessitating changes in therapy. Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache.

PMID: 17986672 [PubMed - indexed for MEDLINE]

Labels: A/O, atlas orthogonal, atypical migraine, cluster headache treatment, Migraines, neuromuscualr dentistry, NUCCA, nucleus caudalis, spenopalatine block TMJ, TMD, trigeminal nerve

Transformed Migraine (common Migraine) usually has a history of beginning as episodic migraine attacks which increse in frequency. This occurs over aperiod of months to years and the Transformed Migraine (TM) occur frequently, often daily and are a combination of vascular and Tension-type Headaches. The TM can very from mild to moderate severity with epsodes of increased severity. These headaches usually begin in teen years or early 20's. Transformed Migraine attacks are frequently accompanied by nauseau, phonophobia (sensitivity to noise), photophobia (sensitivity to light) which lessen over time. A large porportion of patients are women with 90% of whom have a history of migraine without aura.

Patients with Transformed Migraines frequently report a vascular quality, that exhibits a throbbing nature. In some cases, it can be difficult to distinguish between tension-type headaches and TM. These headaches are also identical to headaches frequently seen in patients with TMD or temporomandibular dysfunction. The history of headaches beginning in teen years and usually women fit the profile of TMD sufferers. There is a theory that all headaches are a combination of neurovascular and muscular headache pain. In this view of headaches the muscular or tension-type headache can trigger the vascular (or neurogenic) headache and the Vascular (or neurogenic ) headache can serve trigger the muscular headache. This theory always fits headaches arising from the trigeminal nervous system because it controls meningeal blood flow and masticatory muscles.

These headaches usually respon beautifully to treatment with a neuromuscular orthotic which can frequently eliminate the majority of pain. Some patients, especially those with long standing pain have developed myofascial trigger points that are not completely relieved by TENS and an orthotic. Those patients frequently can be helped by manual trigger point therapy, trigger point injections and/or nerve blocks to break up myofascial trigger points.

Unfortunately clinical studies have shown that almost 80% of these patients overuse symptomatic medications. This medication over-use can frequently increase migraine occurrence. The development of Medication Overuse Headache (MOH), also known as Rebound Headache is often seen with daily use of analgesics, either prescription or over-the-counter. Other risk factors for TM or CM include high life stress (as seen in TMJ or TMD patients), snoring and /or sleep apnea a TMJ disorder according to the NHLBI (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf), head injury and history of orofacial trauma including wisdom teeth extraction and/or orthodontics (especially involving 4 bicuspid extraction).

Depression and anxiety are features shared by patients with Migraine, TMJ disorders, Tension-type headaches and Chronic Daily Headaches. Healthy lifestyle habits including sleeping, eating and exercising are important for all of these disorders. The typical neurologist will prescribe a variety of preventive therapies including Antidepressant and Anticonvulsant medications for transformed Migraine with a goal of reverting the headaches back from daily to episodic attacks. The Neuromuscular Dentist approach is to eliminate the myofascial pain by use of TENS and a neuromuscular orthotic and eventually eliminate the nociceptive input to the brain to eliminate the original migraineor vascular headache. The original migraine is usually a result of unhealthy neuromuscular input from the trigeminal nerve or airway collapse at night due to uderlying jaw pathology that leads to snoring, sleep apnea and upper airway resistance syndrome (sleep distrubance known to cause/promote fibromyalgia)

The use of triggr point infections is a way to hasten recovery when utilizing neuromuscular dentistry. An article in The Journal of Neurology, Neurosurgery and Psychiatry examined the effect of greater occipital nerve blocks and trigger point injections on Transformed Migraine (pubmed abstract below). The article compared these proceedures with and without use of triamcinolone which the authors concluded was unnecessary for the therapeutic effect. The therapeutic effect was impressive, there was immediate reduction in pain (3.2 points) and neck pain was reduced(1.5 points) and resulted in 2.7/3.8 headache free days. Th results were equal with or without the steroid. The use of anaesthetic injections to turn off migraine pain is effective for a short period of time but when combined with neuromuscular dentistry and the use of TENS and an orthotic to prevent recurrence of the problem can be part of a long term correction of this difficult problem.

Another article in Cranio (pubmed abstract below) "Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches." compared treatment of myofascial trigger points with three different methods.They found that " Statistically, all the groups showed favorable results for the evaluated requisites" "Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory." The treatment of myofascial trigger points successly treated the headaches. Breaking up the trigger points with the injection or the needle is effecteive without botulinum toxin or steroid use. Use of manual medicine, myotherapy and /or massage will also brek-up trigger points. Regardless of the method of eliminating the trigger points long term relief will depend on eliminating the noxious input to the trigeminal nervous system for long term relief. The use of the diagnostic neuromuscular dentistry orthotic is essential for most patients wanting to avoid a lifetime of drug use to treat the condition.

Yet another study in Headache (pubmed abstract below) "Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study." found very significant relief of headache pain of ETTH, Episodic Tension-Type Headaches by treatment of Cervical Myofacial Trigger Points. The study showed that trigger point injection with saline gave good results for up to 12 weeks where the Botox results did last for longer periods. Again this is a case calling for combination therapy of a Neuromuscular dentistry diagnostic orthotic and trigger point injections. Utilizing the combination should cause long term elimination of myofascial trigger points. Many patients will nor require the trigger point injections but they are helpful for difficult cases and to decrease treatment time with the diagnostic orthotic.

A diagnostic orthotic is used in Neuromuscular Dentistry (http://www.sleepandhealth.com/neuromuscular-dentistry) to eliminate pain and symptoms prior tolong term correction. This 2 phase treatment protocol allows patient neuromuscular stabilization and pain relief before making any irreverible occlusal changes.

One additional PubMed article is included below "The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine." which evaluated the effect of Greater Occipital Nerve Block on Migraine and
allodynia. Allodynia is when a stimulus that is not normally perceived as painful causes pain. The study had 19 patients and 17 or almost 90% had headache relief. All 19 patients had relief of allodynia. Neuromuscular Dentists should learn to use trigger point injections and Greater Occipital Nerve Blocks as part of comprehensive phase 1 treatment with neuromuscular orthotics to increase pain relief. Long term relief without the chronic use of drugs is ideally and frequently attainable with Neuromuscular Dentistry.

The Las Vegas Institute now teaches stimulation of the Accesory Nerve (cranial nerve XI) along with the Trigeminal Nerve (cranial nerve V) when utilizing TENS to relax muscles i


J Neurol Neurosurg Psychiatry. 2008 Apr;79(4):415-7. Epub 2007 Aug 6.
Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomised comparative study.
Ashkenazi A, Matro R, Shaw JW, Abbas MA, Silberstein SD.

Department of Neurology, Thomas Jefferson University, 111 South 11th Street, Suite 8130, Philadelphia, PA 19107, USA. avi.ashkenazi@jefferson.edu
OBJECTIVE: To determine whether adding triamcinolone to local anaesthetics increased the efficacy of greater occipital nerve block (GONB) and trigger-point injections (TPIs) for transformed migraine (TM). METHODS: Patients with TM were randomised to receive GONB and TPIs using lidocaine 2% and bupivacaine 0.5% + either saline or triamcinolone 40 mg. We assessed the severity of headache and associated symptoms before and 20 minutes after injection. Patients documented headache and severity of associated symptoms for 4 weeks after injections. Changes in symptom severity were compared between the two groups. RESULTS: Thirty-seven patients were included. Twenty minutes after injection, mean headache severity decreased by 3.2 points in group A (p<0.01) and by 3.1 points in group B (p<0.01). Mean neck pain severity decreased by 1.5 points in group A (p<0.01) and by 1.7 points in group B (p<0.01). Mean duration of being headache-free was 2.7+/-3.8 days in group A and 1.0+/-1.1 days in group B (p = 0.67). None of the outcome measures differed significantly between the two groups. Both treatments were well tolerated. CONCLUSIONS: Adding triamcinolone to local anaesthetics when performing GONB and TPIs was not associated with improved outcome in this sample of patients with TM.

PMID: 17682008 [PubMed - indexed for MEDLINE]

Cranio. 2009 Jan;27(1):46-53.
Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches.
Venancio Rde A, Alencar FG Jr, Zamperini C.

Marquette University School of Dentistry TMD and Orofacial Pain, P.O. Box 1881 Milwaukee, WI 53201-1881, USA.
Trigger point injections with different solutions have been studied mainly with regard to the management of myofascial pain (MFP) patient management. However, few studies have analyzed their effect in a chronic headache population with associated MFP. The purpose of this study was to assess if trigger point injections using botulinum toxin, lidocaine, and dry-needling injections for the management of local pain and associated headache management. Forty-five (45) myofascial pain patients with headaches that could be reproduced by activating at least one trigger point, were randomly assigned into one of the three groups: G1, dry-needling, G2, 0.25% lidocaine, at 0.25% and G3 botulinum toxin and were assessed during a 12 week period. Levels of pain intensity, frequency and duration, local postinjection sensitivity, obtainment time and duration of relief, and the use of rescue medication were evaluated. Statistically, all the groups showed favorable results for the evaluated requisites (p < or = 0.05), except for the use of rescue medication and local post injection sensitivity (G3 showed better results). Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory.

PMID: 19241799 [PubMed - indexed for MEDLINE]

Headache. 2009 May;49(5):732-43. Epub 2008 Oct 24.
Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study.
Harden RN, Cottrill J, Gagnon CM, Smitherman TA, Weinland SR, Tann B, Joseph P, Lee TS, Houle TT.

Center for Pain Studies, Rehabilitation Institute of Chicago, 446 E. Ontario, Chicago, IL 60611, USA.
OBJECTIVE: To evaluate the efficacy of botulinum toxin A (BT-A) as a prophylactic treatment for chronic tension-type headache (CTTH) with myofascial trigger points (MTPs) producing referred head pain. BACKGROUND: Although BT-A has received mixed support for the treatment of TTH, deliberate injection directly into the cervical MTPs very often found in this population has not been formally evaluated. METHODS: Patients with CTTH and specific MTPs producing referred head pain were assigned randomly to receive intramuscular injections of BT-A or isotonic saline (placebo) in a double-blind design. Daily headache diaries, pill counts, trigger point pressure algometry, range of motion assessment, and responses to standardized pain and psychological questionnaires were used as outcome measures; patients returned for follow-up assessment at 2 weeks, 1 month, 2 months, and 3 months post injection. After 3 months, all patients were offered participation in an open-label extension of the study. Effect sizes were calculated to index treatment effects among the intent-to-treat population; individual time series models were computed for average pain intensity. RESULTS: The 23 participants reported experiencing headache on a near-daily basis (average of 27 days/month). Compared with placebo, patients in the BT-A group reported greater reductions in headache frequency during the first part of the study (P = .013), but these effects dissipated by week 12. Reductions in headache intensity over time did not differ significantly between groups (P = .80; maximum d = 0.13), although a larger proportion of BT-A patients showed evidence of statistically significant improvements in headache intensity in the time series analyses (62.5% for BT-A vs 30% for placebo). There were no differences between the groups on any of the secondary outcome measures. CONCLUSIONS: The evidence for BT-A in headache is mixed, and even more so in CTTH. However, the putative technique of injecting BT-A directly into the ubiquitous MTPs in CTTH is partially supported in this pilot study. Definitive trials with larger samples are needed to test this hypothesis further.

PMID: 19178577 [PubMed - indexed for MEDLINE]

Headache. 2005 Apr;45(4):350-4.
The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine.
Ashkenazi A, Young WB.

Department of Neurology, Jefferson Headache Center, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
OBJECTIVE: To evaluate the effect of GONB, with or without trigger point injection (TPI), on dynamic mechanical (brush) allodynia (BA) and on head pain in migraine. Background.-Patients with migraine often have cutaneous allodynia that is related to sensitization of central pain neurons. Greater occipital nerve block (GONB) is an effective treatment for migraine headache; however, its effect on cutaneous allodynia in migraine is unknown. METHODS: We studied patients with migraine and BA who were treated with GONB with or without TPI. Demographic data, migraine history, and headache features were documented. Allodynia was evaluated using a structured questionnaire and by applying a 4 x 4-inch gauze pad to skin areas in the trigeminal and cervical dermatomes. Degree of allodynia (the allodynia score) was measured on a 100-mm visual analog scale (VAS) before treatment and 10 and 20 minutes thereafter. Headache levels were assessed using an 11-point verbal scale. Allodynia scores, as well as headache levels, before and after treatment were compared. RESULTS: Nineteen patients were studied. Mean age was 43.6+/-11.8 years. Twenty minutes after treatment, headache was reduced in 17 patients (89.5%) and did not change in 2 (10.5%). The average headache level was 6.53 before treatment and 3.47, 20 minutes after it. The average allodynia score decreased after 20 minutes in all patients. Average allodynia score per site was reduced by 18.69 mm and 13.74 mm in the trigeminal and cervical areas, respectively. There was a positive correlation between allodynia index, obtained through the questionnaire, and allodynia score, obtained by examination. CONCLUSION: GONB, with or without TPI, reduced both head pain and brush allodynia in this migraine patient group.

PMID: 15836572 [PubMed - indexed for MEDLINE]

Labels: atypical migraine, botox, CDH, ETTH, trigger point injections

There is an very cool trick that can be used to provide instant relief for some migraines and tesion-type headaches. Because most headaches are trigeminal in orgin stimulation of the GAG reflex will often alleviate both headaches from muscle spasm and/or myofascial pain. The gag reflex is a protective reflex that prevents aspiration of vomit into the lungs by rapid wide opening of the mouth.

The GAG reflex causes the elevators of the mandible (mouth closing muscles) to instantly relax completely and the suprahyoid and infrahyoid muscles that are depressors of the mandible (mouth opening muscles) instantly contract. This causes a mouth opening like a snake as oposed to a normal hinge opening. If a patient has a tension-type headache,ETTH, chronic daily headache or muscle contraction headache from the jaw muscles they will frequently have complete or very significant headache relief. This same technique can also be used to reduce an acute close lock (joint locking that prevents opening) of the mandible.

Migraine headaches can also be turned off or sometimes prevented if this proceedure is done before a full migraine occurs. The mechanism is both reduction of muscle pain which is a significant portion of most migraines but also a change in the circulation to the anterior 2/3 rds of the meninges of the brain. The trigeminal nerve controls that blood flow and a forceful gag will often correct the vascular cause of the migraine thru trigeminal nerve changes. This can also be used by patients who do not have access to their headache medication.

It is very important to keep the teeth from touching after stimulating the gag reflex to prevent a return of the headache.

Many physicians and patients consider nauseau and vomiting associated with headaches to be diagnostic of migraines but this is not always the case. TMJ and muscle caused headaches frequently are associated with nauseau.

Patients who have migraines that are relieved after vomiting should consider the trigeminal nerve and its related muscles as a cause of their headaches. Neuromuscular Dentistry can frequently supply long-lasting relief for these patients. The gag reflex is a remedial maneuver that can relieve a severe headache but long-term improvement in the quality of life can be achieved for many patients by utilizing a diagnostic neuromuscular orthotic. If substantial relief is achieved the patient can the consider a long term correction based on the position of the jaw when wearing the orthotic.

Labels: atypical migraine, Gag reflex, neuromuscular dentistry, TMD, vomiting

I recently treated a patient who a a continuous headache for over 50 years. I originally saw hew husband and my Schaumburg Chicagoland Dental Sleep Medicine Associates office to treat his sleep apnea with an oral appliance. We successfully treated his sleep apnea and in the process eliminated his snoring which she commented greatly improved her life. We then discussed her headaches and did spray and stretch with ethyl chloride and relieved her 50 year headache and gave her an Aqualizer appliance as a temporary "crutch" Her headache stayed away until the Aqualizer broke.

I nest saw "M" at my Gurnee office and did a diagnostic appointment and a diagnostic orthotic. Her next visit she reported being totally headache free. LIFE CHANGING! Over the last few months we have reconstructed her mouth to the position determined by the diagnostic orthotic and she remains headache free despite extremely high family stress due to medical issues.

Her grandchildren would ask her everyday "Do you still not have a headache."

Labels: atypical migraine, cluster headaches, Gurnee, neuromuscular dentistry, Schaumburg

A recent abstract discussed a facial pain and failure of numerous treatments. It was then dcided the patient had atypical migraine. The abstract is reprinted with my comments following.
Acta Neurol Belg. 2009 Sep;109(3):235-7.
Migraine presenting as chronic facial pain.
Debruyne F, Herroelen L.

Headache Clinic, Department of Neurology, University Hospital UZ Gasthuisberg, Leuven, Belgium. freddebruyne@yahoo.com
We report the case of a 44-year-old woman with chronic facial pain. She was treated with several analgesics, prophylactic medications and infiltrations, but all treatment modalities were ineffective. Finally, the diagnosis of medication-overuse headache complicating migraine without aura was made and an appropriate treatment was initiated. Migraine is a very common primary headache and rarely presents as isolated facial pain. Stimulation of the dura with activation of the trigeminovascular system can result in pain in any of the three divisions of the trigeminal nerve. This is the anatomic basis of migraine pain presenting as referred pain to the second division of the trigeminal nerve. The atypical presentation of migraine pain can easily lead to inappropriate treatment regimens.

This patient had chronic facial pain and was treated with numerous drugs and then diagnosed as medication overuse headache and complicating migraine without aura. They used drug therapy but no mention is made of use of an orthotic. This myoptic type of treatment is common. Throw a drug at the problem , then another and another.

The conclusion that atypical pain can lead to inappropriate treatments regimens speaks for itself. When pain is from the maxillary branch of the trigeminal nerve it would seem appropriate to evaluate the masticatory system first.

Labels: atypical migraine, facial pain, medication overuse headache, trigeminolvascular system