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Headaches

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The American Headache Society (in which Dr. Shirazi is a member of) has classified headaches into three main groups (updated in 2007). Those groups are:

  1. Primary Headaches (the vast majority of headaches: Tension Type, Migraine Type, and Cluster Type headaches)

  2. Secondary Headaches (less than 10% of headaches, caused by either: bleeding in the brain, a tumor (a tissue overgrowth in the brain), meningitis and/or encephalitis (inflammation of the tissues that surround the brain, increasing cranial pressure).  These headaches will not be discussed further here.

    and

  3. Facial Pain, Cranial Neuralgias and other headaches.

At the TMJ & Sleep Therapy Centre of Conejo Valley, a comprehensive evaluation is performed to evaluate for the specific cause or causes of the headache, and we have a large network of physicians, chiropractors, therapists and other healthcare providers that we work with and refer to in order to get the maximum benefit for our patients  Dr. Shirazi is a licensed Dentist, Acupuncturist and Sleep Technologist, using all of the resources available to get maximum benefit for his patients.  Our Testimonial Page offers many people hope and encouragement.


Figure 0 - Primary Headaches, Three Types
Tension Type Headaches:

Are the most common of all headaches, found in all age groups and are nearly equal in prevalence among men and women, they typically are expressed with pain in the front of the head and base 
of skull, as seen in figure 1.
   





  FIGURE 1 - TENSION TYPE HEADACHES


Tension type headaches typically have pain that radiates in a band like fashion on both sides, from forehead to base of skull. Pain often starts or radiates to the neck and upper back (trapezius) muscles. (Figure 2)







     FIGURE 2 - TENSION TYPE HEADACHES REFERRAL PATTERN

   

This is commonly seen in our practice with patients with Jaw issues (clenching teeth at night, clicking/popping, and jaw pain).  Often times, patients are either unaware of their jaw pain or clenching of their teeth at night, and only notice the headache itself.  Jaw issues can also be a cause of Forward Head Posture (FHP).  FHP has been strongly associated with Tension type headaches and Jaw issues.

Normal head posture is where the center of the ear is centered with the spine and shoulders (figure 3)

 


FIGURE 3 - NORMAL HEAD POSTURE

Forward Head Posture (figure 4) occurs when there is a Jaw issue, an airway issue, or other orthopedic imbalance(s), or even a combination thereof.  This FHP puts extreme pressure on the neck itself; for every inch of FHP, the neck must carry an extra 10 lbs. (the average weight of a human head).









FIGURE 4 - FORWARD HEAD POSTURE

   
This weight on the neck can cause pain and/or numbness up to the head and down the arms to the finger tips (figure 5)










FIGURE 5 - TINGLING, NUMBNESS OR PAIN DOWN ARMS

 

Again, the cause for all this could be related to an underlying Jaw issue or Sleep Breathing Disorder. A Jaw disorder can determine the neck and therefore head position, and vice versa.

At the upper neck level there is an important nervous structure called the Subnucleus Caudalis (figure 6A and 6B), which is essentially an extension of the Trigeminal Nucleus, the source of all Migraines.  It has been documented that chronic tension type headaches can eventually lead to Migraine headaches. Chronic neck pain and/or tension can cause antagonistic signaling of the Subnucleus Caudalis.


FIGURE 6A - SUBNUCLEUS CAUDALIS

FIGURE 6B - SUBNUCLEUS CAUDALIS

Migraines

The term migraine is originally derived from the Greek word hemicrania, which means "half of the head." And, for 70 percent of the time, the migraine is one-sided or occurring on one side of the head (figure 7). Migraine is considered a vascular headache because it is associated with changes in the size of the arteries in and outside of the brain. These vascular changes are ultimately caused by the Trigeminal Nerve/Ganglion.  An inflammation, or recurring antagonistic signals to the Trigeminal Nerve/Ganglion in your head triggers a chain reaction: the changes in serotonin in the blood vessels and the brain lead to shifts of blood flow, bypassing the capillaries and going through shunts to the veins. The distention of these vessels contributes to the pain of migraine. The nerves around the blood vessels release chemicals, which cause inflammation eliciting pain signals into the brain/head. The Trigeminal Nerve/Ganglion receives its information from the Jaw, mouth, face, teeth (figure8), and all over the body (through the subnucleus caudalis).  If nociceptive (pain) signals can be significantly reduced or eliminated to the Trigeminal Ganglion the result seen is a reduction or elimination of Migraines.  What's most important however, is obtaining an accurate diagnosis, of which their may be a need for a multidisciplinary care. .


FIGURE 7 - MIGRAINE HEADACHES

FIGURE 8 - BLOOD VESSELS RELATED TO TRIGEMINAL NERVES

Migraine headaches typically last from 4-72 hours and vary in frequency from daily, to fewer than 1 per year. Migraine affects about 15% + of the population. Three times as many women as men have migraines.

Types of Migraines:
Common Migraines are the most common form as described above, accounting for 70% - 80% of all migraines.  Common Migraines do not have aura's associated with them.

Classic Migraines , accounting for the rest, are associated with aura. Auras are visual disturbances (outlines of lights or jagged light images) that precede a migraine; these warning symptoms may occur anywhere from a few minutes to 24 hours before the migraine. The visual changes are common in one or both eyes. They may occur in any combination of the following:

* Seeing zigzag lines
* Seeing flashing lights
* Other visual hallucinations
* Temporary blind spots
* Sensitivity to bright light
* Blurred vision
* Eye pain

Other symptoms that may precede or accompany the migraine include:

* Loss of appetite
* Nausea
* Vomiting
* Chills
* Increased urination
* Increased sweating
* Swelling of the face
* Irritability
* Fatigue

The use of acupuncture to treat tension type and migraine type headaches is well documented.  Here is an excerpt from an article by Charles Vega MD, et. al.:

January 26, 2009 - Acupuncture is at least as effective as prophylactic drugs for migraine and may also benefit some patients with frequent tension-type headache, 2 large reviews conclude.

"The data suggest that in about half of patients, acupuncture decreases the frequency of migraine or frequent tension-type headache by about 50%, which is quite similar to other effective treatments for these disorders," lead reviewer Klaus Linde, MD, from the Center for Complementary Medicine Research at Munich Technical University, in Germany, told Medscape Psychiatry.

"Compared with drug treatments, acupuncture has fewer side effects, although some patients are adverse to needle insertion," he added.

For Physicians looking for CME credit, here is the full article: http://www.medscape.com/viewarticle/587318

 

Cluster Headaches:

Cluster Headaches are characterized by severe, unilateral pain that is around the eye or along the side of the head (figure 9), seen 5-8 times more commonly in men that women.  Cluster Headache attacks last from 5 to 180 minutes and occur once every other day to up to 8 times daily.  Attacks are associated with tearing on the same side of the head that the pain is located. Patients may also experience nasal congestion, runny nose, forehead and facial sweating, dropping eyelids or eyelid swelling.

Most people get their first cluster headache at age 25 years, although they may experience their first attacks in their teens to early 50's, where they typically will begin to automatically reduce.

There are 2 types of cluster headache:

  1. Episodic: This type is more common. There may be 2 or 3 headaches a day for about 2 months and not another headache for a year. The pattern then will repeat itself.
  2. Chronic: The chronic type behaves similarly but it occurs chronically.

   Cluster headaches have strongly been correlated with obstructive sleep apnea. Typically CH occur between 9pm and 9am, and are worse during REM sleep, where sleep apnea is at its worst.  Furtermore, the most commonly accepted treatment for onset of CH is inhalation of medical Oxygen. It is abortive for over 70% of cluster headaches.



FIGURE 9 - CLUSTER HEADACHES

Facial Pain, Cranial Neuralgias and other headaches:

Facial Pain, commonly called atypical facial pain, was first introduced by Frazier and Russell in 1924. It has since been renamed Persistent Idiopathic Facial Pain (PIFP). PIFP refers to pain along the territory of the trigeminal nerve (figure 10A and 10B) that does not fit the classic presentation of other cranial neuralgias (Pascual, 2001). The duration of pain is usually long, lasting most of the day (if not continuous). Pain is usually confined at onset to a limited area on one side of the face, has a deep ache, and is poorly localized. PIFP affects both sexes roughly equally, but more women than men have seeked medical care.


FIG. 10A - BRANCHES OF TRIGEMINAL GANGLION THAT UPTAKE NEURALGIAS

FIG. 10B. - BRANCHES OF TRIGEMINAL GANGLION THAT UPTAKE NEURALGIAS

Cranial Neuralgias

The primary symptom of a cranial neuralgia is recurrent pain in the same area of the head, face or scalp. The severity of pain can vary greatly. The pain may fade, but is likely to return and it often occurs along the length of the affected cranial nerve. Depending on the type of neuralgia involved, the pain may be described in many ways, including sharp, excruciating, burning or shock-like with only the lightest touch to that part of the face or scalp needed to trigger it. In addition, some patients may also experience itching, numbness and muscle weakness.

The most common of all the neuralgias are the Trigeminal Neuralgias (or tic doloureux) (figure 10B), in subcategories called Facial Neuralgias, and Burning Mouth Syndrome.  The symptoms can be along the first, second or third branch of the trigeminal nerve (figure 10B).  Other neuralgias include, but are not limited to: Occipital Neuralgia (figure 11), Glossopharyngeal Neuralgia, Supraorbital Neuralgia (figure 12), Nasociliary Neuralgia, Superior Laryngeal Neuralgia and other neuralgias associated with Cranial Nerves (of which there are a total of 12 pairs).


FIGURE 11 - OCCIPITAL NEURALGIA

FIGURE 12 - SUPRA ORBITAL NEURALGIA
   

FIGURE 13 - SINUS HEADACHES

Causes of Neuralgias:

The causes Neuralgias are many, starting most commonly with compression, irritation or a distortion of cranial nerves or upper cervical roots by a structural distortion; other possible causes are herpes infection, diabetic neuropathy, Tolosa-Hunt Syndrome (a painful ophthalmoplegia caused by nonspecific inflammation of the cavernous sinus or superior orbital fissure), or they may have a Central Origin, meaning from the Central Nervous System, which implies it can be 'referred' or 'sensitized' pain from the TMJ.

 

Other Headaches:

One of the possible causes of other headaches is a Sleep Disordered Breathing issue such as Obstructive Sleep Apnea causing a hypoxia, or decreased level of oxygen. The low level of oxygen eventually changes the vasculature inside the brain leading to headaches.

Sinus Headaches (figure 13) can be caused by inflammation in the mucosal linings of the frontal, maxillary, or ethmoid sinuses or the nasal cavity itself.  The inflammation is typically due to a viral, bacterial, or fungal infection or allergies. Healthy sinuses allow mucus to drain and air to circulate throughout the nasal passages. When sinuses become inflamed, these areas get blocked and mucus cannot drain. When sinuses become blocked, they provide a place for bacteria, viruses, and fungus to live and grow rapidly. Although a cold is most often the culprit, a sinusitis can be caused by anything that prevents the sinuses from draining.  However, Sinus headaches have been found on people without any sinus or nasal congestion whatsoever.  This is typically due to a referral of pain from an unknown source, typically seen in our office from referred jaw pain. Pain can often be caused from an area thats not where the pain is felt, called referred pain.  As seen in figure 14, there can be facial, eye and top of the head pain referred from the SCM (sterno-cleido mastoid muscle).  Or even jaw and side of head pain referred from the Trapezius muscle (Figure 15). As mentioned at the beginning of this page, an accurate diagnosis is the key in getting resolution.



FIGURE 14 - REFERRED PAIN FROM SCM

FIGURE 15 - REFERRED PAIN FROM TRAPEZIUS
Thanks to Google images for some of the above figures and images