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 nervous system, facial pain, improving quality TMD, migraine treatment SPG, pituitary, Spenopalatine ganglion block headaches, TMJ

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

The diagnosis of facial pain is frequently not called headache pain and often receives a wrong diagnosis. Possible causes of facial pain are TMJ disordrs, trigeinal neuralgia, parotid gland disorders, masticatory muscle pain or pain referred from the cervical an shoulder reasons. Facial pain may resolve easily with neuromuscular dental treatment but it is important to rule out pain of organic nature.

Facial pain and sinus pain are frequently different terms patients use to describe pain referred from muscles which are the easiet pain a neuromuscular dentist treats.

When there is neuralgia pain it is usually sharp, sudden and lancinating and very emotionally charge. I have had patients with trigeminal neuralgia that will protect their trigger area no matter what. It is important to identify triggers that set off this type of excruciating pain. I have seen many patients over the years with neuralgia like pains. Some resonded well to neuromuscular dental treatment immediately while others responded to trigger point injections.

Frequently the area must be calmed down by drug therapy or counter irritants like capascin cream before attempting to place a patient on a TENS unit.

Labels: facial pain, facial pain specialist, facial pain TMJ, Facial pain trigeminal neuralgia, neuromuscular dentistry, trigeminal neuralgia TMJ, trigeminl neuralgia

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

An article from Johns Hopkins School of Medicine evaluated TMD patients relative to sleep disorders and pain sensitivity. The study found two or more sleep disorders in 43% of patients. Insomnia and sleep bruxism were the two most commonly found sleep disorders. Both Primary Insomnias (PI) and Respiratory Disturbance Index (RDI) were associated with increased pain sensitivity.

The authors concluded Primary Insomnia and Sleep Apnea were at such high rates that any TMD patients complaining of sleep distubances should be rferred for polysomnography (sleep test). They also felt that Primary Insomnia was highly associate with hyperalgesia and may be linked to the onset of central sensitivity and be the underlying etiology in idiopathic pain disorders. The authors also stated "The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes."

The NHLBI has previously published a report "Cardiovascular and Sleep Related Consequences of Temporomandibular Disorders" Which details the numerous problems related to TMD problems. The majority of problems are related to sleep apnea (http://www.ihatecpap.com/sleep_apnea_dangers.html) and to disturbances in the trigeminal nervous system and the trigeminal vascular effects.

It is becoming more apparent that TMJ joint pain and headaches related to TMD are only the tip of the iceberg. Correction of the neuromuscular function of the stomatognathic system could lead to widespread improvements in health and function in sites often not associated with TMD problems. An excellent article on neuromuscular dentistry can be found in Sleep and Health Journal at http://www.sleepandhealth.com/neuromuscular-dentistry.

PubMed abstract below:
Sleep. 2009 Jun 1;32(6):779-90.
Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder.
Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, Klick B, Haythornthwaite JA.

Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, USA. msmith62@jhmi.edu
STUDY OBJECTIVES: We characterized sleep disorder rates in temporomandibular joint disorder (TMD) and evaluated possible associations between sleep disorders and laboratory measures of pain sensitivity. DESIGN: Research diagnostic examinations were conducted, followed by two consecutive overnight polysomnographic studies with morning and evening assessments of pain threshold. SETTING: Orofacial pain clinic and inpatient sleep research facility. PARTICIPANTS: Fifty-three patients meeting research diagnostic criteria for myofascial TMD. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We determined sleep disorder diagnostic rates and conducted algometric measures of pressure pain threshold on the masseter and forearm. Heat pain threshold was measured on the forearm; 75% met self-report criteria for sleep bruxism, but only 17% met PSG criteria for active sleep bruxism. Two or more sleep disorders were diagnosed in 43% of patients. Insomnia disorder (36%) and sleep apnea (28.4%) demonstrated the highest frequencies. Primary insomnia (PI) (26%) comprised the largest subcategory of insomnia. Even after controlling for multiple potential confounds, PI was associated with reduced mechanical and thermal pain thresholds at all sites (P < 0.05). Conversely, the respiratory disturbance index was associated with increased mechanical pain thresholds on the forearm (P < 0.05). CONCLUSIONS: High rates of PI and sleep apnea highlight the need to refer TMD patients complaining of sleep disturbance for polysomnographic evaluation. The association of PI and hyperalgesia at a nonorofacial site suggests that PI may be linked with central sensitivity and could play an etiologic role in idiopathic pain disorders. The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes.

PMID: 19544755 [PubMed - indexed for MEDLINE]

Labels: facial pain, Idiopathic pain, neuromuscular dentistry, sleep disorders, TMD, TMJ, TMJ Specialist

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

thank you very much for replying.

my family dentist told me i was grinding at night. i had no pain or obvious problems, so i told him to forget it, but he kept insisting. he made me a night guard which looked like a retainer i wore in 7th grade after i had braces. he instructed me to wear it at night, and if i was stressed to wear it during the day.

i wore it from march of 08 and my pain started in august of 08. as a result, i have an anterior open bite. i was told my molars supra erupted because the night guard kept them apart. i was also the the night guard is what *caused* this entire cycle because it loaded my joints and opened my bite.

the orthotic does not control my facial pain. i have tingling in my cheeks, aching, and forehead and scalp aching. my jaw feels tired and has total loss of proprioception.

it does not make sense to me that TMJ can cause the above facial symptoms. do you have other patients with symptoms like mine?

how does one regain the space lost between the condyle and fossa?

Reply
I have seen hundreds of patients with similar symptoms. TMJ disorders are often caused the Great Imposter because so many iverse problems can result. Check out this link for a story I wrote for Sleep and Health.
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor
Did the pain come on sudely or very gradually?
Normally you will not have a lot of supereruption from wearing an appliance only at night? If there is an acute dislocation of the disk it can create problems like you are having.
Do you have a problem opening your mouth wide as that is often seen with acute dislocation.?

Labels: anterior open bite, facial pain, nightguard, TMD, TMJ

comments : i wore an anterior nightguard which changed my bite. i now have an open bite. only one molar touches down. a few months into wearing this night guard, i had a sudden onset of excruciating tooth pain which started on one side of my teeth and spread to the other side within one week. the nerves in my face were also affected as my cheeks ache and also my forehead and scalp. my neuro says i do not have TN but my nerves are irritated. the only thing which helped was a lower mandibular splint. it took my teeth pain away within a few weeks however my bite is still open when i do not wear it. what do i do next? how do i take the pain away for good? can a bite change cause al this face pain? i never get headaches, only facial and tooth pain. my TMJ joints are only 4mm, and were pushed up and back into the upper part of my skull. the discs are both displaced. i have no space left in between either joint and the upper part of my skull. i am on an anti convulsant, and an anti
depressant for pain control, it is helping somewhat. please advise. Kristin

Labels: facial pain, neuromuscular dentistry, TMD, TMJ, tooth pain