A new article in the Journal of Musculoskeletal Pain by Michael Sorrell, MD of Tufts University showed excellent results in treating Migraine utilizing trigger point injections and physical therapy with supervised home stretching. The examination for myofascial trigger points is a step rarely done in normal neurological work-ups of migraine patients. The majority of patients in the study had previously been diagnosed with migraine (common, classic migraine without aura) and had undergone previous unsuccessful drug treatment. These patients were unaware that their pain could be referred from muscles until the examination of the tender muscles revealed the referred pain that duplicated their migraine pain.
The examination did not include all of the the masticatory muscles but did include masseter and temporalis muscles, the sternocleidomastoid muscle,the trapezius muscle, the corrugater supercilius, the semispinalis, splenius cevicus and capitus muscles, as well as the suboccipitalis and levator scapulae muscles. If muscle palpation examination reproduced the headache the patients were included in the trial. If the study included more complete evaluation of trigeminally innervated muscles had been done additional patients may have qualified for treatment.
This study only included patients with chronic migraine and migraine without aura whose pain could be reproduced from muscle examination. A subgroup of 11 patients with Migraine with aura (5 of 11 patients migraine symptoms reproduced on examination) was also included in the study. Those patients did remarkably well with 68% mean improvement in those receiving physical therapy and home stretching compared to 5% improvement in the group not utilizing physical medicine. Over 88% of the study group reported over 50% improvment.
This is an important article primarily because it is from a neurology group treating migraines. It is well established that tension-type headaches and chronic daily headaches respond to physical medicine and treatment of myofascial trigger point. Migraines are usually very responsive to physical medicine as well but this is usually not reported in neurology articles. The field of Neuromuscular Dentistry actively focuses on the elimination trigger through use of TENS, TP injections, Spray and Stretch and other techniques as well. More importantly use of neuromuscular trigger points prevents the formation of new trigger points. The majority of Migraine headaches are mediated thru the Trigeminal Nerve. Trigger points in the masticatory muscles send nociceptive (pain) impulses into the trigeminovascular system that then results in changes to blood flow to the brain thru the anterior 2/3 of the meninges that are under Trigeminal nervous control. The Trigeminal nerve also mediates sinus pain, some ear pain, facial pain, tooth and jaw joint pain. The trigeminal nerve is also known as the “Dentists Nerve” and it accounts for approximately half of all input to the brain.
The examination in the above article ignored many of the masticatory muscles known to creat migraine like symptoms. A complete examination of masticatory muscles ideally is done by a neuromuscular trained dentist (http://www.ihateheadaches.org) who understands the physiology of this complex system. I recommend that all patients with chronic headaches and migraines see a neuromuscular dentist as part of a comprehensive work-up. The majority of patients with migraines have signs and symptoms of temporomandibular disorders including myofascial trigger points. TMD is frequently the missed diagnosis (see “Suffer No More” Dealing with the Great Imposter http://sleepandhealth.com/story/suffer-no-more-dealing-great-impostor) that prevents patients from full recovery. A more extensive discussion of Neuromuscular Dentistry can be found at http://sleepandhealth.com/neuromuscular-dentistry.
There is also an important concept of myofascial triggers serving as a trigger for migraines. Removal of these triggers can eliminate future migraines. These trigger are via the trigeminal nerve as well. A concept of all headaches being composed of both vascular and muscle components has previously been presented. In this diagnostic scheme severity of the headache does not constitute migraine diagnosis. A severe headache can be primarily muscular or vascular as can a mild or moderate headache. The vascular can trigger the muscle mediated headache or the myofascial pain can trigger vascular or neurogenic pain.
I have frequently seen migraine patients achieve complete relief thru a combination of a neuromuscular diagnostic orthotic alone or in conjunction with physical medicine modalities. I have seen other patient who have greatly reduced frequency of migraine but when a migraine does occur medication is still necessary due to severity. This is common with hormonal headaches and migraines. I have female patients with severe daily migraines that are eliminated by the diagnostic orthotic but the patient will still have a tension type headache or mild migraine at ovulation or prior to Menses.
These are patients who I believe we have relieved the myofascial components of their pain but the hormonal triggers remain. The headaches that are then present are less severe. Other patients may only get the aura when presented with triggers but no pain. I do believe that evaluation and elimination of myofascial triggers is important for all migraine patients but in some patients the myofacial trigger points are a secondary result of the migraine pain rather that a primary cause of migraine. It is still important to eliminate these secondary trigger points so the do not increase and become a primary problem.
I strongly endore Dr Sorrell approach to these difficult problems and I believe he will experience greater success and patient satisfaction with treatment with this approach.
I would suggest that utilization of a prescription vapocoolant spray would increase the effectiveness of the home stretching exercises. Patients in Chicago,, Lake County Illinois and Kenosha County interested in learning more about Neuromuscular Dental treatment will find the following website helpful http://www.delanydentalcare.com/neuromuscular.html.