Childhood and Adolescent Headaches: Physicians often miss the easy diagnosis. Developmental issues need to be addressed at an early age.

Dr. Shapira Blog, Diagnosis of TMJ, Epigenetic orthodontics 0 Comments

The failure of the medical community to address the neuromuscular and myofascial  pain aspects of pediatric headaches and migraines in conjunction with trained dentists is problematic to children’s health.  Early referral to dentists trained in treating airway, sleep disordered breathing , myofascial pain and dysfunction and TMD disorders   can be life changing.

Referral information:  https://thinkbetterlife.com/referrals/

Children with severe or chronic daily headaches are a serious concern to parents, educators and to the medical profession. Lack of proper diagnosis can negatively affect children for the rest of their lives.

An acute first-time headache must always be taken very seriously as serious medical conditions must ruled out. This may involve CAT Scans, MRI’s as well as trips to the ER, ENT or pediatric neurologists. It is important to rule out serious organic disease. It is also important to avoid excessive diagnostic procedures that carry risks.

Fortunately most childhood and adolescent headaches are benign in terms of serious medical concerns but devastating to the quality of life at this important period of children’s lives.

Pediatricians frequently treat the headaches as primary headaches because they do not have training or understanding of the Trigemeninal nervous system and the interactions of Myofascial Pain and Dysfunction, airway, especially the Nasopharyngeal airway and tongue position.

Pediatric snoring may be a key diagnostic flag of nasopharyngeal respiratory issues that include sleep apnea and morning headaches. Sleep apnea in children may be responsible not just for headaches but also for behavioral disorders like ADD, ADHD and ODD or Attention Deficit Disorder, Attentional Deficit Hyperactivity Disorder, and Oppositional Defiant Disorder.

These children often display adenoid facies (allergy faces) including issues with mouth breathing, deviate swallows, dark circles under their eyes as well as other signs and symptoms.

All children with chronic headaches should be evaluated for neuromuscular structural issues that could be the underlying cause of their headaches.

A study described in NasoRespiratory Disorders published by University of Michigan and edited by McNamarra compared children with Allergy faces and genius level IQ’s to children with “pretty faces” and average IQ’s In this disturbing study teachers described the genius level children with allergy symptoms as slow learners, troublesome and other negative adjectives while the “pretty faced” children were described as smart, helpful and intelligent. Children respon to these adult attitudes of them.

My personal experience with my son who had symptoms of sleep apnea including poor disturbed sleep, night-time sweating and hyperactivity which were brought to the attention of his pediatricians from the time he was 3 years old and were dismissed. At five years old he was evaluated prior to starting kidergarden and we were informed he had ADD, ADHD and could not start kindergarden and would need to be on Ritalin for life.

This plan was rejected by my wife and I and we took Billy to Rush Medical School and Rosalind Cartwright Phd and went through a sleep study. He had an Apnea Index of 60 or woke every minute. He had tonsils and adenoids removed and his mouth was widened orthopedically / orthodontically as well as correcting a tongue and lip tie. This same child who could not start kindergarden and “needed” Ritalin graduated college double major/ double minor Magna Cum Laude, he never took Ritalin, his drug of choice was oxygen from being able to breathe normally, he needed to breathe and have high quality sleep.

He also went from a 50% to a 90% on the growth curve and went from being short and chubby to stretched out slim body type. His behavior was remarkable improved. He never complained of headaches but was often angry, his anger also disappeared. It has been over 30 years ago that my son had these issues. I have lectured about this for many years but change is very slow and this is seen primarily as a sleep issue. There needs to be an awareness of the global nature of these developmental issues. A new article “Lifestyle and oral facial disorders associated with sleep bruxism in children” in Cranio May 2017 concluded “Nightmares and snoring are associated with nocturnal bruxism in children. Bruxism in children elicits consequences such as headache, orofacial pain, and pain related to awakening.” (see abstract below)

I treat adult patients for chronic headache, sleep disorders, facial pain and migraines related to jaw position, disrupted nasopharyngeal airway and MPD and TMJ disorders. These patients did not just happen but developed into adults with these issues from childhood.

Robert Corrucini has shown in his landmark book “How Anthropology Informs the Orthodontic Diagnosis of Malocclusion’s Causes” that the development of the human face and jaws has been subjected to negative epigenetic changes over the last 400 years. This is due to pollution, allergies, decrease in breast feeding and introducton of soft mushy diets that prevent proper development of jaws, jaw muscles, jaw joints and effects breathing and posture.

Dr Gozal at University of Chicago has shown that these problems should be ideally corrected before the age of 8 years old. Most dentists do not assess or address airway issues related to jaw and tongue position in patients at this crucial period of their lives.

Chronic headaches in children can lead to long-term consequences that last a lifetime. Another article in J Headache Pain. 2016 concluded that
“The associations between psychosocial aspects and TMD-pain related aspects in children and adolescents. concluded “TMD-pain in children and adolescents does not seem to affect the social activities. However, TMD-pain seem to have a strong association to emotional, behavior and somatic functioning, with higher frequencies of anxiety, depression, somatic problems, aggressive behavior and thought problems, than children and adolescents without TMD-pain. With respect to the biopsychosocial model the present study indicates that there are significant associations to psychosocial, somatic and behavioral comorbidities and TMD-pain in children and adolescents….” (Oabstract below)

THIS ARTICLE IN BMC Oral Health. 2015 “Prevalence and association of self-reported anxiety, pain, and oral parafunctional habits with temporomandibular disorders in Japanese children and adolescents: a cross-sectional survey.” CONCLUDED THAT ”
In this young Japanese population, TMD symptoms were associated with other orofacial pain conditions, particularly neck pain, although they were only weakly associated with trait anxiety. Diurnal clenching was strongly associated with TMD symptoms. Health professionals should carefully consider these factors when developing appropriate management strategies for TMD in children and adolescents.” (abstract below)

This 10 year old article “Evaluation of the signs and symptoms of temporomandibular disorders in children with headaches” concluded that “There is a higher frequency of TMD in pediatric patients with headaches; thus, it is important to look for TMD signs and symptoms in this population.” (abstract below)

I have lectured on the common developmental aspects of Sleep Apnea and TMJ disorders both in the US and in Buenos Aires, Argentina on how these development changes occur. These are preventable disorders they are discussed in the literature but usually ignored in clinical practice.

This next article looks at headaches related to chewing gum in adolescents. Pediatr Neurol. 2014 Jan “The influence of excessive chewing gum use on headache frequency and severity among adolescents.” concluded that E’xcessive daily gum-chewing may be associated with chronic headache and should get more attention in the medical literature. Physician and patient awareness of this association could have a meaningful impact on the quality of life of children and adolescents with chronic headache who chew gum excessively.” This is something well known in adults who chew gum that headaches are more frequent, so of course it is true in adolescents. (abstract below)

Suffer no more discusses headaches in adults but these childhood issues predispose adults to chronic pain issues.

https://www.sleepandhealth.com/suffer-no-more-dealing-great-impostor/

These patient videos are of adults but many started their headache issues as children. While they can be treated at any time, the earlier the better.

https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

PUBMED ABSTRACTS BELOW:
Cranio. 2017 May;35(3):168-174. doi: 10.1080/08869634.2016.1196865. Epub 2016 Jun 22.
Lifestyle and oral facial disorders associated with sleep bruxism in children.
Alencar NA1, Fernandes AB1, Souza MM1, Luiz RR2, Fonseca-Gonçalves A1, Maia LC1.
Author information
Abstract
OBJECTIVE:
The aim of the study was to investigate the routine, sleep history, and orofacial disorders associated with children aged 3-7 years with nocturnal bruxism.
METHODS:
Children (n = 66) were divided into groups of parent reported nocturnal bruxism (n = 34) and those without the disorder (n = 32). Data about the child’s routine during the day, during sleep and awakening, headache frequency, temporomandibular joint (TMJ), and hearing impairments were obtained through interviews with parents/caregivers. Electromyography examination was used to assess the activity of facial muscles. Multiple logistic regression (MLR), chi-square test, and t-test analyses were performed.
RESULTS:
MLR revealed association of nightmares (p = 0.002; OR = 18.09) and snoring (p = 0.013; OR = 0.14) with bruxism. Variables related to awakening revealed an association with bruxism (p < 0.05). Parents of the main group (children with nocturnal bruxism) reported more complaints of orofacial pain, facial appearance, and headache occurrence (p < 0.05). Auditory and muscle disorders were not significant variables (p > 0.05).
CONCLUSION:
Nightmares and snoring are associated with nocturnal bruxism in children. Bruxism in children elicits consequences such as headache, orofacial pain, and pain related to awakening.
KEYWORDS:
Bruxism; Children; Electromyography; Oral facial pain; Routine; Sleep

J Headache Pain. 2016;17:30. doi: 10.1186/s10194-016-0622-0. Epub 2016 Apr 5.
The associations between psychosocial aspects and TMD-pain related aspects in children and adolescents.
Al-Khotani A1,2, Naimi-Akbar A3, Gjelset M4, Albadawi E5, Bello L6, Hedenberg-Magnusson B4,7,8, Christidis N4,7.
Author information
Abstract
BACKGROUND:
Temporomandibular disorders (TMD) in children and adolescents is prevalent with pain as a common component, and has a comorbidity with psychosocial problems such as stress, depression, anxiety as well as somatic complaints. Therefore, the aim of the study was to investigate if psychosocial problems in children and adolescents are associated with TMD with pain (TMD-pain) and TMD without pain (TMD-painfree) when compared to children and adolescents without TMD.
METHODS:
This cross-sectional study consisted of 456 randomly selected children and adolescents, enrolled from 10 boy’s- and 10 girl’s- schools in Jeddah, between 10 and 18 years of age. On the examination day, prior to the clinical examination according to Research Diagnostic Criteria for TMD Axis I and II, the participants first answered two validated questions about TMD pain, and after that the Arabic version of the Youth Self Report scale. According to their clinical examination and diagnosis the participants were divided into three groups; non-TMD group, TMD-pain group, and TMD-painfree group.
RESULTS:
The TMD-pain group presents a higher frequency of the internalizing problems anxiety, depression and somatic complaints than non-TMD group (p <  0.05). Regarding externalizing problems the only significant association found was for aggressive behavior in the TMD-pain group (p < 0.05). The TMD-pain group also shows a higher frequency of social problems than the non-TMD group. However, no such difference was found when compared to the TMD-painfree group. There was also a significant association with a higher frequency of thought problems in the TMD-pain group (p < 0.05). The children’s and adolescents’ physical activities were within border line clinical range for all three groups, whereas the social competence was within the normal range. There were no significant associations between any of the groups in this respect.
CONCLUSIONS:
TMD-pain in children and adolescents does not seem to affect the social activities. However, TMD-pain seem to have a strong association to emotional, behavior and somatic functioning, with higher frequencies of anxiety, depression, somatic problems, aggressive behavior and thought problems, than children and adolescents without TMD-pain. With respect to the biopsychosocial model the present study indicates that there are significant associations to psychosocial, somatic and behavioral comorbidities and TMD-pain in children and adolescents in the Middle East region.
KEYWORDS:
Adolescents; Children; Pain; Psychosocial; Temporomandibular disorders

BMC Oral Health. 2015 Jan 21;15:8. doi: 10.1186/1472-6831-15-8.
Prevalence and association of self-reported anxiety, pain, and oral parafunctional habits with temporomandibular disorders in Japanese children and adolescents: a cross-sectional survey.
Karibe H1, Shimazu K, Okamoto A, Kawakami T, Kato Y, Warita-Naoi S.
Author information
Abstract
BACKGROUND:
Associations between temporomandibular disorder (TMD) and psychological variables, pain conditions, and daily activities have been reported more commonly in middle-aged individuals than in children. However, to determine factor-specific preventive programs for TMD, it is important to evaluate the associations between multiple factors and TMD symptoms during childhood. The aim of this study was to assess the relationship between TMD symptoms and other orofacial pain conditions, daily activities, and trait anxiety in a population-based cross-sectional survey of Japanese children and adolescents.
METHODS:
A total of 1,415 subjects (11-15 years old) self-reported their TMD symptoms, headache, neck pain, and toothache, and completed questionnaire scales that assessed 15 daily activities. Trait anxiety was assessed using the State Trait Anxiety Inventory for Children-Trait (STAIC-T) scale. Subjects were dichotomized into a TMD group or control group, based on whether they reported at least 1 TMD symptom: the TMD group (≥1 TMD symptom, n = 182) and the control group (no TMD symptoms, n = 1,233). Data were analyzed using the chi-square test and multivariate logistic regression analysis.
RESULTS:
The prevalence rates for headache and neck pain were significantly higher in the TMD group than in the control group (44.0% vs. 24.7% and 54.4% vs. 30.0%, respectively; both P < 0.001). The odds ratios for TMD symptoms in subjects with neck pain and frequent diurnal clenching were 2.08 (P < 0.001) and 3.69 (P = 0.011), respectively. Moreover, high STAIC-T scores were weakly associated with TMD symptoms. CONCLUSIONS: In this young Japanese population, TMD symptoms were associated with other orofacial pain conditions, particularly neck pain, although they were only weakly associated with trait anxiety. Diurnal clenching was strongly associated with TMD symptoms. Health professionals should carefully consider these factors when developing appropriate management strategies for TMD in children and adolescents. PMID: 25604542 PMCID: PMC4324877 DOI: 10.1186/1472-6831-15-8 Send to Arq Neuropsiquiatr. 2007 Jun;65(2A):251-5. Evaluation of the signs and symptoms of temporomandibular disorders in children with headaches. Bertoli FM1, Antoniuk SA, Bruck I, Xavier GR, Rodrigues DC, Losso EM. Author information Abstract PURPOSE: The purpose of this study was to evaluate the presence of signs and symptoms of temporomandibular disorders (TMD) in children with headaches in a neuropediatric ambulatory. METHOD: Fifty patients between 4 and 18 years of age were examined: 31 had headaches (24 migraine, 4 tension type and 3 unspecific headache) and 19 formed the control group. The data collection was comprised of a structured questionnaire answered by the children’s parents, and a subjective evaluation about the childrens emotional state. A specific questionnaire for TMD was applied, followed by a clinical dental examination of the children. As signs of TMD, mouth opening limitation, mandibular trajectory deviation in opening mouth, and joint noise were considered. As symptoms, pain on palpation of masseter and temporal muscles and on the poromandibular joint. RESULTS: A significant increase in signs and symptoms of TMD was found in patients with headaches when compared to the control group. There was also a significant difference in signs and symptoms of TMD according to age (increased with age) and emotional state (tense>calm).
CONCLUSION:
There is a higher frequency of TMD in pediatric patients with headaches; thus, it is important to look for TMD signs and symptoms in this population.

Pediatr Neurol. 2014 Jan;50(1):69-72. doi: 10.1016/j.pediatrneurol.2013.08.015. Epub 2013 Nov 1.
The influence of excessive chewing gum use on headache frequency and severity among adolescents.
Watemberg N1, Matar M2, Har-Gil M3, Mahajnah M4.
Author information
Abstract
BACKGROUND:
Excessive gum-chewing is underreported as a headache precipitant in children and adolescents. We evaluated the influence of daily excessive gum-chewing in older children and teenagers with chronic headache, emphasizing the impact of habit discontinuation and its reintroduction.
METHODS:
Patients with chronic headache and excessive gum-chewing were consecutively recruited and asked to fill questionnaire pertaining headache characteristics, potential triggers, family history of headaches, and gum-chewing habits. These individuals were classified into four groups depending on the number of daily hours of gum-chewing. All children discontinued chewing for 1 month, reintroduced the habit, and were reinterviewed after 2 to 4 weeks.
RESULTS:
Thirty patients (25 girls) were recruited. Median age was 16 years. Most had migraine-like headaches. Following gum-chewing discontinuation, 26 reported significant improvement, including headache resolution in 19. All 20 patients reinstituting the habit reported symptom relapse within days. Duration of headache before discontinuation and the number of daily hours of chewing had no influence on the response to habit discontinuation.
CONCLUSION:
Excessive daily gum-chewing may be associated with chronic headache and should get more attention in the medical literature. Physician and patient awareness of this association could have a meaningful impact on the quality of life of children and adolescents with chronic headache who chew gum excessively.
Copyright © 2014 Elsevier Inc. All rights reserved.
KEYWORDS:
adolescents; chewing gum; children; headache; temporomandibular joint; trigger

 

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