Dr. Shapira's Chicago Headache Blog

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

A recent article in the Journal Pain looked at incidence of facial pain in the Netherlands. The authors wanted to " The aim was therefore to estimate the incidence rate (IR) of trigeminal neuralgia (TGN), postherpetic neuralgia (PHN), cluster headache (CH), occipital neuralgia (ON), local neuralgia (LoN), atypical facial pain (AFP), glossopharyngeal neuralgia (GPN) and paroxysmal hemicrania (PH)"

Trigeminal Neuralgia and Cluster Headaches were the most common types and both increased with age. This study found that facial pain was rare but more common than expected prior to the study. The trigeminal nerve is frequently a culprit in many types of pain disorders. Many, but not all patients with trigeminal neuralgia diagnosis will respond positively to neuromuscular treatment.

My take on this is a little different because I frequently see patients who complain of sinus pain, tooth pain eye pain while pointing to painful areas. Thsi study would have ignored thos findings. Over the years I frequently see patients that have been given a diagnosis of a disorder neuromuscular dentistry can't treat yet they get better with an orthotic. This does not mean the orthotic can treat those conditions and often just points out a misdiagnosis. I have had patients diagnosed with MS whose symptoms disappeared with my treatment. That does not mean I treated the MS, it may just mean that the diagnosis was incorrect.

There is no harm in a second or third opinion.

Pain. 2009 Dec 15;147(1-3):122-7. Epub 2009 Sep 26.
Incidence of facial pain in the general population.
Koopman JS, Dieleman JP, Huygen FJ, de Mos M, Martin CG, Sturkenboom MC.

Dept. of Medical Informatics, Erasmus MC, Rotterdam, The Netherlands. skoop29@gmail.com
Facial pain has a considerable impact on quality of life. Accurate incidence estimates in the general population are scant. The aim was therefore to estimate the incidence rate (IR) of trigeminal neuralgia (TGN), postherpetic neuralgia (PHN), cluster headache (CH), occipital neuralgia (ON), local neuralgia (LoN), atypical facial pain (AFP), glossopharyngeal neuralgia (GPN) and paroxysmal hemicrania (PH) in the Netherlands. In the population-based Integrated Primary Care Information (IPCI) medical record database potential facial pain cases were identified from codes and narratives. Two medical doctors reviewed medical records, questionnaires from general practitioners and specialist letters using criteria of the International Association for the Study of Pain. A pain specialist arbitrated if necessary and a random sample of all cases was evaluated by a neurologist. The date of onset was defined as date of first specific symptoms. The IR was calculated per 100,000PY. Three hundred and sixty-two incident cases were ascertained. The overall IR [95% confidence interval] was 38.7 [34.9-42.9]. It was more common among women compared to men. Trigeminal neuralgia and cluster headache were the most common forms among the studied diseases. Paroxysmal hemicrania and glossopharyngeal neuralgia were among the rarer syndromes. The IR increased with age for all diseases except CH and ON, peaking in the 4th and 7th decade, respectively. Postherpetic neuralgia, CH and LoN were more common in men than women. From this we can conclude that facial pain is relatively rare, although more common than estimated previously based on hospital data.

PMID: 19783099 [PubMed - in process]

Labels: cluster headache treatment, cluster headaches, facial pain, glossopharyngeal neuralgia, migriane, neuromuscular dentistry, spenopalatine block TMJ, trigeminal neuralgia

Patients with morning headaches usually have either TMJ disorders or Sleep Apnea. Sleep Apnea can be treated with CPAP or an Oral Appliance. Patients who have TM Joint clicking and are undergoing treatment for headaches or TMD can benefit in several ways from having a night-time apnea appliance and a daytime neuromuscular orthotic.

A problem that is sometimes encountered with oral appliances for sleep apnea are undesired bite changes. These changes can actually be helpful when treating TMJ clicking and popping and headaches. The bite changes that occur are actuallly the healing of the TM Joint. The jaw usually postures forward unloadding the retrodiscal lamina of the TM Joint that is compressed in patients with clicking. The retrodiscal lamina rehydrates and does not let the condyle go into retrusive pathology which serves to stabilize the disk.

The Daytime appliance allows this position to stabilize and heal. In patients who are not undergoing treatment exercises are done to prevent this healing from occuring. The joints will frequently heal if placed in a healthy position. A recent paper showed no damage to the joints with sleep appliances.

The American Academy of Sleep Medicine recommends that dentists fitting patients with oral appliances for sleep apnea be well versed in treating TMJ disorders. There are many good reasons for this recomendation. Dentists who do not uderstand how bite changes affect the joints and the muscles as well as head posture can create difficult problems they do not have the expertise to treat. Please check my I HATE CPAP website (http://www.ihatecpap.com) for more information about the dangers of sleep apnea and on how oral appliances are used in treating sleep apnea.

Labels: AASM, American Academy of Sleep Medicine, bite Changes, cluster headaches, headaches, neck pain, SLEEP APNEA, TMD, TMJ, TMJ clicking, TMJ pain, TMJ popping, TMJD

An Optician can be a vital team member when it comes to treating headache pain. An Optometrist is a specialist in prescribing contanct lenses and glasses which can frequently help headaches coming from eye strain. An Opthamologist is a MD who specializes in diseases of the eyes and will do surgical interventions when necessary. Opthamologists can prescribe medications and prescribe contacts and glasses.

The Optician is offered considered someone who sells glasses but can often be the most important member of the team when treating occiptital (back of head) headaches and neck pain. Patientw will frequently cause neck pain by poor posture when working in various conditions. A sharp Optometrist can angle the lenses on glasses in order to correct postual problems. An example would be tipping the lenses on an angle so the head must be upright to read from a desk thus preventing patients tipping their necks excessively causing cervical muscle spasm and occipital pain. The same holds true when using a computer of other tasks that glasses can effect head position.

In the textbook Myofascial Pain and Dysfunction: A Trigger Point Manual by Travell and Simons there is are excellent examples of how head posture can be affected by activities and how specially fitted glasses can correct these problems. My family I have used Brian Scott of Doyle opticians in Deerfield for many years and I refer patients to him frequently.

The informed optician can frequently make a enormous difference in patients neck pain.

Labels: angle lenses, cluster headaches, head posture, neck pain, occipital pain, opthamologist, optician, optometrist

Thomas comments : I've been having cluster headaches for about twenty years, skipping a year every once in a while. I'm currently taking gabapentin and amitrypaline, seems to be working as of this time (we will see) and I have oxygen (havent tried it yet
) headaches wake me from sleep, last about 30 to 45 min., pacing and or burying my head in the couch cushions while trying to calm my breathing. etc.

Dr Shapira Response: I would suggest that you have a sleep study done because sleep apnea can be a exacerbate or cause cluster headaches as can bruxism and/or jaw clenching thru the trigeminal nerve. The oxygen (100%0 can often supply almost immediate relief.

Labels: cluster headaches, oxygen, SLEEP APNEA, trigeminal nerve

A new article in the Clinical Journal of Pains shows that patients who develop TMD have increases in Headaches & Migraines but also have significant increases in other bodily pains. In addition to increase in headaches patients who were diagnosed as developing TMD had increases in muscle and joint pain, back pain, chest pain, abdominal pain and menstrual pain.

The study was done on 266 female patients aged 18-34 years old who initially were free of TMD symptoms. Over 5% of the population developed new TMD symptoms. There is no question that the majority of headaches are caused by the trigeminal nerve (dental Nerve) what this study sees to imply is that the trigemino system may increase perception of pain throughout the body. This may be do to central sensitization. This is a rationale for utilizing neuromuscular dentistry to treat patients early to prevent a local problem from becoming widespread.

Dr Barry Cooper has shown an "overwhelming" positive effect on headaches and TMJ disorders with Neuromuscular Dentistry. A neuromuscular dentist has the training and equipment necessary to evaluate physiologic parameters and idealize occlusion to reduce or eliminate TMD symptoms and Headaches and prevent a local problem from becoming a whole body problem.


Clin J Pain. 2010 Feb;26(2):116-20.
Development of temporomandibular disorders is associated with greater bodily pain experience.
Lim PF, Smith S, Bhalang K, Slade GD, Maixner W.

Center for Neurosensory Disorders, School of Dentistry, University of North Carolina at Chapel Hill, NC 27599-7455, USA. peifeng_lim@dentistry.unc.edu
OBJECTIVES: The aim of this study is to examine the difference in the report of bodily pain experienced by patients who develop temporomandibular disorders (TMD) and by those who do not develop TMD over a 3-year observation period. METHODS: This is a 3-year prospective study of 266 females aged 18 to 34 years initially free of TMD pain. All patients completed the Symptom Report Questionnaire (SRQ) at baseline and yearly intervals, and at the time they developed TMD (if applicable). The SRQ is a self-report instrument evaluating the extent and location of pain experienced in the earlier 6 months. Statistical analysis was carried out using repeated measures ANOVA. RESULTS: Over the 3-year period, 16 patients developed TMD based on the Research Diagnostic Criteria for TMD. Participants who developed TMD reported more headaches (P=0.0089), muscle soreness or pain (P=0.005), joint soreness or pain (P=0.0012), back pain (P=0.0001), chest pain (P=0.0004), abdominal pain (P=0.0021), and menstrual pain (P=0.0036) than Participants who did not develop TMD at both the baseline and final visits. Participants who developed TMD also reported significantly more headache (P=0.0006), muscle soreness or pain (P=0.0059), and other pains (P=0.0188) when they were diagnosed with TMD compared with the baseline visit. DISCUSSION: The development of TMD was accompanied by increases in headaches, muscle soreness or pain, and other pains that were not observed in the Participants who did not develop TMD. Participants who developed TMD also report higher experience of joint, back, chest, and menstrual pain at baseline.

PMID: 20090437 [PubMed - in process]

Labels: Chicago, cluster headaches, Lake Forest, neuromuscular dentistry, TMD

I HAVE REPRINTED AN ENTRY FROM THE I HATE CPAP BLOG THAT EXPLAINS WHY MANY HEADACHE PROBLEMS PERSIST AND RUN IN FAMILIES. THEIR IS A DEVELOPMENT PATHWAY THAT LEADS TO PHYSICAL AND STRUCTURAL CHANGES THAT LEAD TO HEADACHES AND MIGRAINES. WHILE NEUROMUSCULAR DENTISTRY ALLOWS US TO TREAT PATIENTS AND ALLEVIATE THE MIGRAINES AND OTHER HEADACHES IT IN IMPORTANT THAT WE RECOGNIZE THAT THESE PROBLES ARE OFTEN PREVENTABLE IF WE ACT EARLY TO PROTECT OUR CHILDREN.

FROM I HATE CPAP BLOG
DEVELOPMENTAL CHANGES IN CHILDREN WITH SLEEP APNEA MUST BE ADDRESSED AFTER REMOVAL OF TONSILS AND ADENOIDS
A recent study in the International Journal of Pediatric Otorhinolaryngology looked at arch Maxillary (upper jaw) development in children with snoring and sleep apnea and evaluated changes after adenotonsillar surgery. The physical changes did not correct after surgery and these children were left with residual problems that could plague the for their entire life. The authors concluded " Dento-facial development in snoring children is not changed by adenotonsillar surgery regardless of symptom relief. If snoring persists or relapses orthodontic maxillar widening and/or functional training should be considered. Collaboration between otorhinolaryngologist, orthodontists and speech and language pathologists is strongly recommended."

It is essential that the pediatric and dental communities recognize that children do not grow and eliminate the problems of enlarged tonsils and adenoids but rather they experience distorted growth that must be corrected. Early diagnosis and treatment of airway is essential for proper dento-facial growth. The NHLBI considers sleep apnea to be a TMJ Disorder. Sleep Apnea, Snoring, Migraines, Tension Headaches, Chronic Daily Headaches and TMJ disorders all begin in a common developmental pathway.

Dental Sleep Meicine and Neuromuscular Dentistry are key in improving the quality of live of these patients as adults. Early intervention may greatly reduce the number of patients who develop these problems.

nt J Pediatr Otorhinolaryngol. 2009 Nov 23. [Epub ahead of print]
Development of craniofacial and dental arch morphology in relation to sleep disordered breathing from 4 to 12 years. Effects of adenotonsillar surgery.
Löfstrand-Tideström B, Hultcrantz E.

Department of Surgical Sciences, Division of Otorhinolaryngology, University of Uppsala, SE - 751 85 Uppsala, Sweden.
OBJECTIVES: To study the development of craniofacial and dental arch morphology in children with sleep disordered breathing in relation to adenotonsillar surgery. SUBJECTS AND METHODS: From a community-based cohort of 644 children, 393 answered questionnaires at age 4, 6 and 12 years. Out of this group, 25 children who were snoring regularly at age 4 could be followed up to age 12 together with 24 controls not snoring at age 4, 6 and 12 years. Study casts were obtained from cases and controls and lateral cephalograms from the cases. Analysis regarding facial features and dento-alveolar development was performed. RESULTS: Children snoring regularly at age 4 showed reduced transversal width of the maxilla and more frequently had anterior open bite and lateral cross-bite than the controls. These conditions persisted for most cases at age 6, by which time 18/25 had been operated for snoring. In most of the cases, surgery cured the snoring temporarily, but their width of the maxilla was still smaller by age 12-even when nasal breathing was attained. At age 12, the frequency of lateral cross-bite was much reduced and anterior open bite was resolved, both in cases and controls. The children who snored regularly at age 12 operated or not operated, showed a long face anatomy and were oral breathers (this applied even to those who were operated). The seven cases who were not operated and the five who were still snoring in spite of surgery at age 12, did not have reduced maxillary width as compared to the controls. CONCLUSION: Dento-facial development in snoring children is not changed by adenotonsillar surgery regardless of symptom relief. If snoring persists or relapses orthodontic maxillar widening and/or functional training should be considered. Collaboration between otorhinolaryngologist, orthodontists and speech and language pathologists is strongly recommended.

PMID: 19939470 [PubMed - as supplied by publisher]

Labels: cluster headaches, development, neuromuscular dentistry, TMJ

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

Neuromuscular Dentistry is a powerful resource for treating chronic headaches and TMJ disorders. It works by correcting abnormal balance in how the muscles of the head and neck function. It also has an enormous effect on the trigeminal nervous system. This is extremely important because the trigeminal nerve is responsible for the majority of migraines, Chronic daily headaches, Episodic Tension-Type Headaches as well as sinus headaches and facial pain.

There is often a classification of vascular headaches versus muscular headaches but this is actually not always appropriate. When there is a disturbance to the trigeminal nervous system it can lead to drastic vascular effects that leads to migraines and/or cluster headaches.

The importance of the Trigeminal Nerve is easily understood with a brief lesson in neuroanatomy. 20% of the input to the brain comes from the spinal cord. The other 80% of input to the brain comes from twelve sets of cranial nerves. These nerves include the occular nerve that is responsible for sight and the nerves responsible for eye movement, the olfactory nerve that is responsible for our sense of smell, the acoustic nerve that is responsible for hearing and balance and the Vagus nerve that controls our gut.

The fifth cranial nerve is the Trigeminal Nerve and it makes up almost 70% of the input frpm the 12 cranial nerves or more tham half the total input to the brain. The trigeminal nerve is the dentist's nerve and it can have enormous effects.

This single nerve goes to the jaw muscles, the jaw joints (TMJ), the teeth, the periodontal ligaments that connect the teeth to the jaw bone and to anterior 2/3 of the tongue. The trigeminal nerve also controls the blood flow to the anterior 2/3 of the brain, the tensor of the ear drum, the tensor of the soft palate that controls the eustacian tube, the lining of the sinuses and several connections to te autonomic nervous system. Again this is over half of the total input to the brain.

The control of blood flow to the brain by the trigeminal nerve explains why migraines and cluster headaches can be helped with neuromuscular dentistry.

The innervation to the sinus membranes explains why neuromuscular dentistry can help sinus headaches and chronic congestion often blamed on allergies.

The tensor of the ear drum explains why tinnitus is often relieved by neuromuscular dentistry.

The tensor palatine explains why swallowing disorders and eustacian tube dysfunction (including pressure in the ears, ear pain)

The symptoms related to the trigeminal nerve are outlined in two articles in Sleep and Health Journal:

SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

NEUROMUSCULAR DENTISTRY (originally published in the American Equilibration Society magazine)
http://www.sleepandhealth.com/neuromuscular-dentistry

Dr Shapira treats patients with Headaches, Sleep Apnea and TMJ disorders from across Illinois and Southern Wiscnsin including Gurnee, Libertyville,Vernon Hills, Lake Forest, Highland Park, Deerfield, Antioch, Barrington, Schaumburg, Chicago, Arlington Heights, Lake Bluff and Kenosha.

Labels: cluster headaches, Gurnee, Libertyvile, neuromuscular dentistry

Blues Freak comments : I have cluster headaces for 8 plus yrs. I wore a TMJ piece nite and day for 2 yrs with no relief. Oxygen for almost a yr. even accuputcunter for over a yr. with a small amount for a short time. I don't work any longer I'm 56 on disabilty now. I need help

Dear Blues Freak,

When you say you are using oxygen I assume that is during an acute attack.. Oxygen (100%) can usually stop a cluster in its tracks. I understand that you wore a "TMJ mouthpiece" but all appliances are not the same. Some appliances are designed to effect primarily the jaw joint (TMJ) rather than address the neuromuscular problems that caused the joint problems. I call some appliances POPs which stands for Piece of Plastic. What is important is not the piece of plastic but how that piece of plastic how it functions. Some TMJ appliances ever do more than act a as a POP. TMD is Temporomandibular Dysfunction which includes muscles and joints. It is often necessary to evaluate the joints connecting the head to the first to vertebrae of the spine. The brain stem passes thru this area and these have an enormous effect on jaw relations as well as the entire nervous system. Atlas Orthogonal and NUCCA are two chiropractic groups that work with this area of the body.

I prefer the term orthotic or orthopedic appliance but what is important is what affect it is having on the body. In neuromuscular dentistry treatment starts with relaxing the muscles by pulsing the trigeminal nerves to create muscle relaxation but more importantly we then use the relaxed position to set the orthotic for minimal adaptation. This allowa the trigeninal nerve and the associated vascular effects to stabilize. http://www.sleepandhealth.com/neuromuscular-dentistry contains an explanation of how neuromuscular dentisty functions.

With cluster headaches it is possible initially to provoke a cluster headache so I would advise if oxygen relieves your pain to make sure the office is equipped with oxygen if needed.

Labels: cluster headaches, neuromuscular dentistry, oxygen, TMD, TMJ