Headaches

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The American Headache Society (in which Dr. Shiraz 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, 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 to our patients.  Dr. Shirazi is a licensed Dentists and Acupuncturist using all of the resources available to get maximum benefit for his patients.

Tension Type Headaches:

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

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.

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. .

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” associated with them.

Classic Migraines 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:

     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.

Chronic: The chronic type behaves similarly but it occurs chronically.

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.

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).

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 such as from a Stroke.

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.

Thanks to Google images for some of the above figures and images