Subject: Re:  migraine prevention -- Tepper's "co-pharmacy" approach

-> : Migraine is NOT caused by constriction followed by dilatation of {*filter*}
-> : vessels. The trigeminovascular hypothesis of Moskowitz postulates that
-> : activation of the pathways from the trigeminal nucleus to the
-> : perimeningeal vessels results in a neurogenic inflammation associated
-> : with plasma protein extravasation and changes of inflammation in the
-> : {*filter*} vessels.  Seratonin seems to be at the heart of this system.

I'm just a dentist and don't understand this biochemistry and
physiology.  It is interesting.

-> : Chronic daily headaches are called "transformed migraine". They are
-> : thought to be due to a constant state of withdrawing from some form of
-> : medication.  The symptoms include headaches that seem to respond to

Science continues to probe into the causes of so-called "migraine".

I have seen a number of people who have had headaches, diagnosed as
migraine, for years.  Experiments with one medication and another.  
Titrating, then withdrawing.  Many who have been relieved of their
years-long headaches report the unfortunate side effects of potent
neurochemical modifiers their doctors have written for them to take
when they present in the examination room with a complaint of severe
headaches.

During examination of my patients, I physically touch the muscles of
their head and neck to detect tender spots (Janet Travell's 'trigger
points').  I question patients whose trigger points are palpable on
one or both sides about the possibility that they suffer headaches.  
This screening technique has resulted in a good number of changes in
diagnosis--from migraine to myalgia.

Some interesting muscles to pay particular attention to when a patient
gives a migraine history are:  sternocleidomastoids, masseter,
temporalis, medial and lateral pterygoids, and suboccipitals.  By 'pay
attention to', I mean PALPATE.  Touch the patient.  Feel the muscles.

I am aware that there are cases of headache which are not within my
scope of examination to identify as muscular related tension headache.  
However, enough cases are coming to my attention that I advise you and
your colleagues to touch the muscles of the head and neck--palpate.  
Learn the skills of identifying muscle trigger points.  

A good number of patients we see have been (apparently) needlessly
placed on medicines which also have effects on sympathetic innervation
of muscles and are effective in low doses in helping myalgia, but the
diagnosis--the identification of etiology is not found.  Such patients
are often found to have bruxism, clenching, orthodontic class II bites,
periodontal disease/loose teeth, ill-fitting dentures, a bad marriage,
tough times with money, and so on...  They may end up with further
problems from inadequate physical examination and inadequate interview
to get to know the person's life.

Migraine medication prescription protocols need to include dental
screening and myofascial examinations to rule out dental origins.  
That's just my opinion.  I could be wrong, but I don't think so.

Dr. Suzman, this is what a dentist sees.  I have not studied fully
enough to know the hypothetical chemical imbalances which may
also be at the core of some peoples' migraines.  I do, however, believe
that the above etiologies I have listed are more commonly overlooked
than identified by physicians.  This is why I want physicians to have a
broader grasp of dental etiologies and dental screening techniques.

To this end I have developed a presentation on head and neck pain of
dental etiology.  It had its first showing at the Missouri Osteopathic
Summer Scientific Session.  Proctor and Gamble sponsored my
presentation.  My goal is to stimulate physicians' awareness of dental
etiologies for head and neck pain and bring dentists into the loop in
consultations and referral--to a fuller degree than you may currently
be involving dentists or screening your patients' oro{*filter*} structures.

 A useful book in this regard from the MD field has been Janet
Travell's "Myofascial Pain and Dysfunction" Volume I.  Abundant dental
literature sources exist to describe dental pain referral which can be
confused with migraine.  Also, dental screening techniques for
headaches are found in dental literature.

How do you screen your patients to rule-out dental etiologies?  What
percentage of patients you see have periodontal disease, for example?

Thanks for your time.  

 * 1st 2.00m #2774 * If all you have is a hammer, everything looks like a nail.

First, just to set the record straight, I am not a physician, but I am a
migraineur! Dr. Tepper is the only physician mentioned in the previous posts.

As to your comments, I think the migraine/tension headache dichotomy is
steadily being eroded. Many migraineurs have trigger points and myalgia as
part of their symptoms. Many of the same {*filter*} are effective in both
conditions. Dr. Neil Raskin, in his monograph _Headache_, views them as
occupying ends of a spectrum. Physicians in the alt.support.fibromyalgia group
seem to view migraine and fibromyalgia as "cousin" diseases.

I haven't read much about dental aetiologies for headaches, but it certainly
makes sense to check for the conditions you referred to. Part of the problem
may be that TMJ problems have, I believe, been oversold as a cause for
headaches. This may have left the neurologists suspicious of "physical" causes
for headache.

I have cross-posted this response to alt.support.headaches.migraine

Peter Suzman

Something to add to your list of things to check for: aspartame (NutraSweet)
triggers migraines (among other things) in many people.

of references and collects case studies on adverse reactions to aspartame.

--Alex

1. What is the *physiological* abnormality that constitutes a "trigger point"
(I have read Travell)? And, I have utilized her methods with some success in
the past.

2. Excessive muscle tension (contraction) *cannot* be determined by
palpation. The only commonly used *objective measures* are needle or surface
electromyography. I have trained many Dentists in the latter. A
well-developed and/or fibrotic muscle may feel "tight" to the touch, *or*
subjectively to the patient. Have you ever tried correlating your palpations
with one of these measures?

Jack Sandweiss

Research Associate
California Medical Clinic for Headache
Encino, CA