Idiopathic Pain Relief: When Doctors Do Not Know The Cause of Your Pain How Do You Find Relief?

Dr. Shapira Chicago, Libertyville, TMJ 0 Comments

Idiopathic Pain essentially means “The Doctors are Idiots in determining the cause of your pain”.  This can be extremely discouraging as a patients.

Sometimes problems are diagnosed as idiopathic because the doctor is not familiar with the disorder you have.

These types of pain are often treated with a multitude of different medications on a trial and error basis.

There are some very safe and effective treatments for Idiopathic Pain anywhere in the body.  An excellent review of symptoms relievable by SPG Blocks can be found at: https://www.sphenopalatineganglionblocks.com/relief-wide-variety-eye-pains-spg-blocks.

Even problems like Fibromyalgia can  be addressed by SPG Blocks:  https://www.youtube.com/watch?v=A5xUFtuZe_Y

TMJ disorders have been called “The Great Imposter” because they can masquerade as many different types of problems and are usually misdiagnosed multiple times before being identified..  Most physicians other than ENT’s know very little about TMJ Disorders (TMD) .

Chicago TMJ Disorders: TMJ, “The Great Imposter” Amazing Patient Testimonials Videos Describe How Neuromuscular Dental Treatment

 

TMJ, Alias: the Great Imposter, has a Co-Conspirator: Poor Sleep: Orofacial Pain has Multiple Causes which require Differential Diagnosis.

The Sphenopalatine Ganglion Block for Relief of Facial Pain from the Nasal Mucosa.

Dr. Shapira Chicago, Highland Park, TMJ, Uncategorized 0 Comments

This new article in Cranio (abstract below) discusses use of SPG Blocks in treating Facial Pain of Nasal Origin. I teach patients to self administer these block for many types of headache and facial pain.

This specific case was due to a nasal contact headache where the nasal turbinate is touching the septum.

Another approach is to grow the underdeveloped maxilla to open up airway, decrease sinus pain and infections while improving breathing.

This video is a patient who has used SPG Blocks in the past but is now making permanent changes in her nasal airway to improve health including TMJ disorder with the DNA Appliance and Epigenetic orthopedics/ orthodontics.

Cranio. 2018 Jun 8:1-3. doi: 10.1080/08869634.2018.1475859. [Epub ahead of print] Efficacy of sphenopalatine ganglion block in nasal mucosal headache presenting as facial pain.
Lee SH1, Kim Y1, Lim TY1.
Author information
Abstract
Background When intranasal contact points are the cause of headache and facial pain, opinions regarding whether to remove intranasal contact points when they are believed to be the cause of headache and facial pain are divided. Clinical Presentation A 46-year-old woman visited the authors’ pain clinic with complaints of right nasal pain accompanied by frontotemporal headache. She first met an Otorhinolaryngologist and a neurologist. Based on nasal endoscopy and pain pattern, they presumed that her pain was a nasal mucosal headache rather than migraine. A mild septal deviation to the right side with bony spur near the inferior turbinate was observed. The use of medication provided very insufficient relief. However, the sphenopalatine ganglion (SPG) block provided excellent pain relief, and the effect lasted for six months. Conclusion Considering the mechanism of pain in intranasal contact point headache, (SPG) block is a potentially effective therapeutic tool.

KEYWORDS:
Sphenopalatine ganglion block; facial pain; nasal mucosal headache; trigeminal afferent nerves…

Acute Migraine: Sphenopalatine Ganglion Blocks (SPGB) Safe and Effective. Self Administration is a Patient Friendly Approach

Dr. Shapira Blog 0 Comments

A new article published in 208 discusses utilization of Sphenopalatine Ganglion Blocks for treatment of Severe Migraine.  Because it is published byty.the US National Library of Medicine of the National Institute of Health I can reprint it here.

I will make my personal comments in ALL CAPITAL LETTERS.  I ALSO FIND THAT SPG BLOCKS  CAN TREAT MANY OTHER DISORDERS INCLUDING FIBROMYALGIA, NECK, BACK, TMJ DISORDERS, TMD AND SHOULDER PAINS.

SELF-ADMINISTRATION OF SPG BLOCKS SHOULD BE CONSIDERED BY ALL PATIENTS WITH CHRONIC HEAD AND NECK PAIN, CLUSTER HEADACHES, ACUTE MIGRAINES, SINUS PAIN, SINUS HEADACHE AND EYE PAIN.  THIS DOES NOT MEAN THAT NEW PAIN SHOULD NOT BE EVALUATED BY APPROPRIATE PHYSICIANS AND SPECIALISTS.

INTRESTING NEW STUDIES HAVE SHOWN SPG BLOCKS ELIMINATING ESSENTIAL HYPERTENSION IN ONE THIRD OF PATIENTS.

. 2018; 2018: 2516953.
 Published online 2018 May 7.
Sphenopalatine Ganglion Block for the Treatment of Acute Migraine Headache

Abstract

Transnasal sphenopalatine ganglion (THE SPHENOPALATINE GANGLION IS ALSO KNOWN AS THE PTERYGOPALATINE GANGLION, MECKEL’S GANGLIO, THE NASAL GANGLION AND SLUDER’S GANGLION) block is emerging as is an attractive and effective treatment modality for acute migraine headaches, cluster headache, trigeminal neuralgia, and several other conditions.  We assessed the efficacy and safety of this treatment using the Sphenocath® device. 55 patients with acute migraine headaches underwent this procedure, receiving 2 ml of 2% lidocaine in each nostril. (2% LIDOCAINE HAS ANTIINFLAMATORY PROPERTIES AND HAS VERY FAVORABLE SAFETY PROFILE)  Pain numeric rating scale (baseline, 15 minutes, 2 hours, and 24 hours) and patient global impression of change (2 hours and 24 hours after treatment) were recorded. The majority of patients became headache-free at 15 minutes, 2 hours, and 24 hours after procedure (70.9%, 78.2%, and 70.4%, resp.). The rate of headache relief (50% or more reduction in headache intensity) was 27.3% at 15 minutes, 20% at 2 hours, and 22.2% at 24 hours. The mean pain numeric rating scale decreased significantly at 15 minutes, 2 hours, and 24 hours, respectively. Most patients rated the results as very good or good. The procedure was well-tolerated with few adverse events. This treatment is emerging as an effective and safe option for management of acute migraine attacks.  THE EXCELLENT AND RAPID RESPONSE IS EXTREMELY FAVORABLE HOWEVER PATIENTS MUST GO TO THE EMERGENCY DE3PARTMENT OR PHYSICIANS OFFICE TO BE TREATED.  A BETTER APPROACH IS TO TREAT THE PATIENTS TO SELF ADMINISTER THE BLOCKS TO STOP THE MIGRAINE EARLY OR PREVENT IT COMPLETELY IF THE BLOCK IS DONE DURING PRODROME.

THE SPHENOPALATINE GANGLION BLOCK WAS ORIGINALLY DESCRIBED BY SLUDER IN 1908.  DR GREENFELD SLUDER WROTE A TEXTBOOK NASAL NEUROLOGY AND BECAME CHAIR OF OTOLARYNGOLOGY AT WASHINGTON UNIVERSITY MEDICAL SCHOOL IN ST LOUIS.A   A 930 ARTICLE IN THE ANNALS OF INTERNAL MEDICINE BY HIRAM BYRD MD REPORTED ON 10,000 BLOCKS ON 2000 SEPERATE PATIENTS WITH VIRTUALLY NO ADVERSE EFFECTS.  UNFORTUNATELY, THE SPHENOPALATINE GANGLION BLOCK BECAME A VICTIM OF FORGOTTEN MEDICINE WHEN DRUG COMPANIES CREATED A STORM OF PHARMACEUTICALS.  THE SAFETY PROFILE OF THESE DRUGS DO NOT APPROACH THAT OF SPG BLOCKS WITH 2% LIDOCAINE.  A 1986 BOOK ‘MIRACLES ON PARK AVENUE” WAS PROBABLY RESPONSIBLE FOR THE GRADUAL RESURGENCE OF THIS EXCELLENT TECHNIQUE.  THE BOOK DESCRIBED THE NYC PAIN PRACTICE OF DR MILTON REDER AND ENT WHO UTILIZED ONLY SPG BLOCKS TO TREAT A WIDE VARIETY OF PAINFUL CONDITIONS REGARDLESS OF UNDERLYING DIAGNOSIS.

1. Introduction

Migraine is a common primary headache disorder, causing significant disability and personal, societal, and financial burden (SELF ADMINISTRATION OF SPG BLOCKS CAN SIGNIFICANTLY REDUCE COSTS IN TERMS OF EXPENSES, LOST WORK AND SUFFERING) []. It is a highly prevalent condition, affecting 11% of adult population worldwide, including people of all ages, races, geographical areas, and income levels []. Although there are currently many options for acute migraine treatment, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDS), triptans, combinations analgesics, and antiemetics [], these treatment options are often (MORE OFTEN THAN NOT)  suboptimal, with inadequate efficacy and significant side effects []. In addition, several studies [] have shown that migraine patients with poor response to acute treatment are at increased risk for transformation to chronic migraine (CM) (SPG BLOCKS ARE ALSO EFFECTIVE AT TREATING CHRONIC MIGRAINE BUT EARLY INTERVENTION IS STILL THE BEST ROUTE) , with roughly 2.5-3.5-fold greater odds of developing CM []; patients with a moderate or better acute treatment efficacy did not have a significant increased risk. Therefore, there is a continuous need for new treatment modalities to address the therapeutic needs of migraine sufferers, especially those with frequent and disabling attacks [].

Sphenopalatine ganglion (SPG) block has gained interest as an effective treatment modality for migraine and other headache and facial pain syndromes []. SPG, also known as the pterygopalatine ganglion (PPG), is a large extracranial parasympathetic ganglion (THE SPG IS THE LARGEST PARASYMPATHETIC GANGLION OF THE HEAD)with multiple neural connections (Figure 1), including autonomic, motor, and sensory []. This complex neural structure is located deeply in the pterygopalatine fossa (PPF) posterior to the middle turbinate and maxillary sinus [], on each side of the face. The parasympathetic preganglionic cell bodies originate in the superior salivatory nucleus in the pons, and the parasympathetic fibers run in the nervus intermedius (a branch from the facial nerve) through the geniculate ganglion, forming the greater petrosal nerve (GPN). The sympathetic fibers originate in the superior cervical ganglion (THE SYMPATHETIC FIBERS OF THE SUPERIOR CERVICAL SYMPATHETIC CHAIN ARE VERY IMPORTANT IN THE ABILITY OF THESE BLOCKS TO TURN OFF THE “FIGHT OR FLIGHT” REFLEX) around the internal carotid artery and give rise to the deep petrosal nerve, which joins the GPN to form the Vidian nerve, which enters the SPG. The sensory input to the SPG is via branches from the maxillary nerve, carrying sensations from the palate, buccal cavity, gingival, and tonsils [].

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Saggital view of the nasopharynx, showing the sphenopalatine ganglion and its neural connections. Reproduced with permission from Robbins et al. (2016) [under the Creative Commons Attribution License number 4318850197898 (Wiley).

The parasympathetic fibers synapse in the SPG and second-order neurons provide secretomotor function to the mucous membranes of nose, mouth, pharynx, and lacrimal glands, as well as branches to the meningeal and cerebral blood vessels []. The sympathetic fibers pass through the SPG without synapsing and provide innervations to the palate, nasal cavity, and pharynx.

As acute migraine attacks, as well as other primary headache disorders like cluster headache, are often associated with signs of parasympathetic activation, including lacrimation, nasal congestion, and conjunctival injection, blocking the SPG, which is the major parasympathetic outflow to the cranial and facial structures, is a reasonable target to help relief pain and autonomic features seen in these disorders []. It is proposed that various migraine triggers activate brain areas related to superior salivatory nucleus, leading to stimulation of the trigemino-autonomic reflex. This results in increased parasympathetic outflow from the SPG, causing vasodilatation of cranial blood vessels that happens during migraine [], with the release of inflammatory mediators from blood vessels and activation of meningeal nociceptors, causing migraine pain []. Another possible effect of SPG block is modulation of sensory processes in the trigeminal nucleus caudalis via the afferent sensory fibers, which may change pain processing center and reduce central sensitization to pain that is commonly seen in migraine [].

SPG blocks have been used for the treatment of headache since a long time []. In 1908, Sluder described the use of transnasal SPG block using a long needle to inject cocaine, treating what was called Sluder’s neuralgia []. The technique was further developed by Simon Ruskin [], and in 1925 he used it to treat trigeminal neuralgia. Since then, the indications for SPG block have expanded to include cluster headache, migraine, trigeminal neuralgia, and many more [].

SPG blocks have been achieved with various techniques, including the use of lidocaine-soaked cotton tip applicator through the nose, transorally, transnasal endoscopic, infratemporal approach, and more recently using various noninvasive transnasal devices to inject anesthetics into the SPG [].

The objective of this study is to assess the efficacy of SPG block, using the Sphenocath device, for the treatment of acute migraine headaches in the outpatient setting. We also report the safety of this novel technique for migraine treatment.

2. Methods

2.1. Study Design and Setting

We conducted an open, uncontrolled, retrospective study in the neurology clinic at a university medical center. The patients were treated between March 2017 and September 2017. The study was approved by the institutional review board of University Medical Center at King Abdullah Medical City.

2.2. Study Population

The patients were recruited to the study if they were between 18 and 60 years of age, have been diagnosed with migraine headache according to International Classification of Headache Disorders-3 Beta [] since at least one year, and present with moderate to severe headache lasting between 4 and 72 hours not responding to abortive medications. Patients with medication overuse headache, bleeding disorders, abnormal neurological examination, and history of allergy to local anesthetics were not included in the study. All patients gave an informed written consent.

2.3. Methods of Measurement

Pain was assessed using numeric rating scale (NRS), where 0 is no pain and 10 is worst pain imaginable; this was recorded at baseline, 15 minutes, 2 hours, and 24 hours after the procedure. We also recorded patient global impression of change (PGIC; very poor, poor, no change, good, and very good) at 2 hours and 24 hours after procedure.

2.4. Outcome Measures

The primary efficacy measure was the percentage of patients free of headache at 15 minutes, 2 hours, and 24 hours after the procedure. Secondary endpoints were

  1. headache relief rate, defined as percentage of patients with 50% or more reduction in headache intensity at 15 minutes, 2 hours, and 24 hours;
  2. change in NRS from baseline to 15 minutes, 2 hours, and 24 hours after treatment;
  3. PGIC (effects on headache and its associated symptoms and tolerability) at 2 hours and 24 hours;
  4. all adverse events up to 24 hours after procedure.

Statistical analysis was done using SPSS Statistics Version 23.

3. Procedure

Prior to procedure, the nose was inspected for any obstruction, and xylometazoline 0.05% nasal drops( AFRIN NASAL SPRAY, OXYMETAZOLINE SPRAY IS EXTREMELY EFFECTIVE IN SHRINKING NASAL MUCOSAL TISSUES) ) (one drop in each nostril) were used to help open the nasal passages. Face temperature was recorded using temperature sensor skin probes put on both cheeks. A small amount of 2% lidocaine jelly was installed in each nostril for patients’ comfort, using a needless syringe. (AN ALTERNATIVE IS TO USE 2% LIDOCAINE IN A SPRAY FORM ONE MINUTE BEFORE PLACEMENT) Each patient received a single treatment of transnasal SPG block with 2 cc of 2% lidocaine in each nostril in the supine position with head extension, delivered using the Sphenocath device.  (I UTILIZE PRIMARILY A COTTON-TIPPED NASAL CATHETER THAT ALLOWS CONTINUAL CAPILLARY FEED OF LIDOCAINE FOR MOST PATIENTS.  I ALSO UTILIZE THE SPHENOCATH AND THE TX360 DEVICES IN MY OFFICE.  THE ALLEVIO DEVICE IS SIMILAR TO THE SPHENOCATH DEVICE) This is a small flexible sheath with a curved tip (Figure 2). It is inserted through the anterior nasal passage parallel to nasal septum and above the middle turbinate. Once in place, the inner catheter is advanced to administer 2 cc of 2% lidocaine. It is then removed and the procedure is repeated on the other side. Typically after the block, there is an increase in face temperature by 1 to 2 degrees Celsius and/or tearing []. The patient is instructed to remain in the same position for 10 minutes.  GENERALLY THERE IS LESS DISCOMFORT WITH THE COTTON TIPPED CATHETER BUT IN SOME PATIENTS WITH DIFFICULT ACCESS I UTILIZE DEVICE DELIVERY.

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ATERAL APPLICATIONThe Sphenocath device. Image provided courtesy of Dolor Technologies.

4. Results

55 patients received treatment with bilateral transnasal SPG blocks. 72.7% were females. The age range of patients was 19 to 58 years, with a mean age of 37.9 years. The baseline NRS range was 4 to 10, with a mean of 6.8. For the primary end point (headache freedom at 15 minutes, 2 hours, and 24 hours), the percentages were 70.9%, 78.2%, and 70.4%, respectively (Figure 3). Among the secondary efficacy measures, 27.3%, 20%, and 22.2% of patients reported headache relief at 15 minutes, 2 hours, and 24 hours after the procedure, respectively (Figure 3).  THE RAPID RELIEF IS TYPICAL OF PATIENTS RECEIVING SPG BLOCKS REGARDLESS OF THE METHOD OF DELIVERY.  THE COSTS OF THE DEVICES ARE HIGH APPROXIMATELY $75.00.  I PREFER THE COTTON-TIPPED NASAL CATHETERS WHICH COST LESS THAN $1.00 PER BILATERAL APPLICATION.  MORE IMPORTANT THEY ARE VERY EASY FOR MOST PATIENTS TO UTILIZE FOR SELF ADMINISTRATION AT HOME.

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The percentage of patients reaching headache freedom (pain numeric rating scale 0) and patients with headache relief (50% or more reduction in headache intensity), at 15 minutes, 2 hours, and 24 hours.

The mean NRS scores decreased significantly from a baseline of 6.8 to 0.9, 0.6, and 0.8 at 15 minutes, 2 hours, and 24 hours after procedure, respectively (Figure 4).

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The mean pain numeric rating scale at baseline and 15 minutes, 2 hours, and 24 hours after treatment, showing significant and sustained reduction in pain intensity.

Regarding PGIC, the majority of patients (98.1% at 2 hours, 98.1% at 24 hours) reported feeling very good or good (Figure 5). Only one patient reported “no change” in PGIC scale at 2 hours, but “very good” at 24 hours, and another patient rated her PGIC as “good” at 2 hours and “poor” at 24 hours due to return of headache which was slightly worse than before.

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Patient global impression of change after the procedure at 2 hours and 24 hours. The majority of patients rated the treatment result as very good or good.  PATIENTS SIMILARLY RATE RELIEF FROM TRANS-NASAL COTTON-TIPPED CATHETERS VERY HIGH.

Overall, the procedure was well-tolerated. Adverse events reported by the study population were mild (Figure 6), including transient throat numbness (100%), nausea (10.9%), dizziness (10.9%), vomiting (1.8%), nasal discomfort (18.2%), and worsening of preexisting headache (1.8%). These adverse events were transient and lasted less than 24 hours.  I RARELY SEE ADVERSE REACTIONS THOUGH THERE IS LIMITED COMPLAINTS ABOUT TASTE AND THROAT NUMBNESS BUT BECAUSE OF THE SLOWER DELIVERY THIS IS LESS OF A PROBLEM.  CHIEF COMPLAINT IS NASAL DISCOMFORT THAT CAN USUALLY BE ELIMINATED WITH AFRIN NASAL SPRAY AND LIDOCAINE SPRAY. THOSE SPRAYS.

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Adverse events recorded in the first 24 hours after the procedure.

5. Discussion

This retrospective case series demonstrated that transnasal SPG block with 2% lidocaine, using the Sphenocath device, is an effective and safe treatment for acute migraine headaches. There was a rapid relief of headaches observed at 15 minutes and 2 hours, and treatment effect was sustained at 24 hours after procedure in most patients. 70.9%, 78.2%, and 70.9% of patients were completely headache-free at 15 minutes, 2 hours, and 24 hours, respectively, while further 27%, 20%, and 27% achieved 50% or more headache relief at 15 minutes, 2 hours, and 24 hours, respectively. The majority of study population reported either very good or good response on PGIC at 2 hours and 24 hours.

A number of studies were published over the years regarding SPG blockade in acute migraine, with variable results []. Kudrow et al. [] conducted a noncontrolled study in migraine patients using 4% intranasal lidocaine and showed that 12 out of 23 patients achieved complete headache relief, and the effect was sustained at 24 hours. Maizels and Geiger [] evaluated the efficacy of 4% intranasal lidocaine as a treatment for acute migraine attacks, which was administered by the patient at home, in a double-blind, randomized controlled study. There was a significant reduction in headache severity at 15 minutes compared to placebo, but there was headache recurrence in 21% of patients receiving lidocaine.

Another placebo-controlled study compared outcomes for acute treatment of chronic migraine patients with intranasal 0.5% bupivacaine (n = 26) or saline (n = 12) using the Tx 360® device to block the SPG []. The injection was given twice a week for 6 weeks. The trial revealed significant reduction in pain numeric rating scores in the bupivacaine group at 15 minutes, 30 minutes, and 24 hours after each treatment. A randomized, double-blind, placebo-controlled study using intranasal bupivacaine or saline injections in patients presenting to the emergency department with acute frontal-based headache [specific classification was not required] demonstrated no significant difference in the proportion of patients achieving 50% or more headache relief at 15 minutes [].

Other studies used different agents for SPG blockade. For example, Bratbak et al. used onabotulinum toxin A injections into the SPG in 10 patients with intractable chronic migraine in an open, uncontrolled study []. This was done through a percutaneous infrazygomatic approach with a novel injection device. A statistically significant reduction of moderate and severe headaches was observed at 2 months after treatment; there were a total of 25 adverse events, mostly local discomfort, but none were classified as severe.

The SPG unique position in the PPF, as well as its multiple neural connections to sensory and autonomic systems involved in pain generation and propagation and the associated autonomic manifestations seen in many primary headache and facial pain syndromes, makes it a promising target for the treatment of these conditions. Inhibition of parasympathetic outflow from the SPG causes reduced activation of perivascular pain receptors in the cranial and meningeal blood vessels, with resultant reduction in the release of neuroinflammatory mediators (acetylcholine, nitric oxide, vasoactive intestinal peptide, substance P, and calcitonin gene-related peptide) from sensory fibers supplying the cranial and meningeal vasculature. This, in turn, reduces pain intensity and intracranial hypersensitivity observed in migraine [].

In our study, SPG blockade produced a rapid relief of headache at 15 minutes, with a significant treatment effect observed at 24 hours and high patient satisfaction. In general, the treatment was well-tolerated. We recorded few adverse events, which were mild and transient, similar to those seen in previous studies [].

The main limitation of our study included the lack of a placebo group, as subjective pain response might have a significant placebo component []. However, the high treatment response and satisfaction rates in this study were both encouraging and clinically meaningful for our patients. We did not assess the use of analgesics after two hours of receiving the SPG block, which might have influenced the headache relief percentage at 24 hours. However, this is allowed in acute headache trials guidelines [].

6. Conclusion

Transnasal SPG blockade is emerging as an effective and safe option for the treatment of several disabling headache and facial pain conditions such as migraine, cluster headache, and trigeminal neuralgia. Its ease of administration using noninvasive devices, safety profile, and quick pain relief makes it an attractive treatment option for these conditions. More well-designed studies are needed to further explore the efficacy of this treatment modality and its use as part of a comprehensive headache management program.

Conflicts of Interest

The authors report no conflicts of interest related to this paper.

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Dr Shapira Awarded Diplomate Status with American Board of Sleep and Breathing. Currently in Boston Learning Advance Pain Management at Harvard Medical School.

Dr. Shapira Blog, Lake Forest, Sleep, TMJ 1 Comment

I am pleased to announce that I am now a new Diplomate of the American Board of Sleep and Breathing. I am a long term Diplomate of the American Board of Dental Sleep Medicine, Credentialed by the Sleep Disorder Dental Society (SDDS) and a Founding member of both the SDDS (Now AADSM) and Dosa , the Dental Organization for Sleep Apnea.

I did research into jaw position and sleep apnea as a visiting Assistant Professor at Rush Medical School from 1985 until 1991 and returned as an Assistant Professor from 1998 until 2001.  I had the pleasure of  working with Dr Rosalind Cartwright who was responsible for the growth of Dental Sleep Medicine.

I am currently in day two of my Harvard Medical School course on Advanced Pain Management. I am spending all of this week in Boston to improve on my skills in pain management.

The program is on Advanced Pain Management continuing Education with Academy of Integrative Pain Management and Harvard Medical School’s Top Pain Doctors.

Updates and Practice Recommendations to
Optimize the Assessment and Treatment of Pain
Headache, Fibromyalgia, Neuropathic, Myofascial, Cancer, Abdominal, Pelvic, Musculoskeletal, Spinal Pain.

https://americansleepandbreathingacademy.com/

Chicago: Intractable/ Refractory Headaches and Migraines: SPG Blocks (Sphenopalatine Ganglion Blocks) May be the Fastest Safest Treatment

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Intractable Headaches destroy the lives of both patients and families. The medical costs often become prohibitive and relief is often impossible to find..

Combination of techniques including SPG Blocks and Neuromuscular Dentistry can reduce of eliminate the pain in Chron Headache.

This is reprinted from Dr Shapira’s other website.

Intractable/ Refractory Headaches and Migraines: SPG Blocks (Sphenopalatine Ganglion Blocks) May be the Fastest Safest Treatment

This is just an introductory page to the use of Sphenopalatine Ganglion Blocks for intractable headaches and other conditions.

While there are no universal answers to pain the use of Self Administered Sphenopalatine Ganglion Blocks can be the answer many patients are seeking. My previous post on this site has an extensive review of SPG Blocks and a wide bibliography of scientific literature.

Sphenopalatine Ganglion Block: An Underutilized Tool in Pain Management

Intractable / Refractory Headaches: SPG Blocks are used in the ER when other treatments have failed: https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/

Intractable / Refractory Headaches: Patients can use SPG Blocks without trip to ER. Quality of life is horrible traveling to and waiting in ER. Treatment in your own home is more comfortable and is more timely.

Intractable Refractory Headaches: Elimination of the majority of physician visits for headaches and migraines is obtainable.

Intractable / Refractory headaches: SPG Blocks can prevent headaches and migraines and be used prophylactically to prevent or eliminate headaches and migraines.

Intractable / Refractory Headache: Self Administration of SPG Blocks allows patients to titrate frequency of treatment based on their needs to improve quality of life.

Cancer Pain: Self Administration or caretaker administration improves quality of life: https://www.sphenopalatineganglionblocks.com/sphenopalatine-ganglion-block-head-neck-cancer-pain-self-administered-blocks-key-improving-quality-life/

Intractable / Refractory Headaches Costs: After initial visits the Cost of Self Administered Sphenopalatine Ganglion Blocks is under $1.00

Rebound headaches and Migraines: SPG Bl0cks can treat and prevent rebound headaches and migraines. Rebound Headache is not an issue with SPG Blocks

SPG Block Testimonials on Reddit : https://www.reddit.com/r/SPGBlocks/

Anxiety & Panic Attacks: SPG Blocks turn off Fight or Flight Sympathetic Reflex (stress) and turn on Feed and Breed Parasympathetic reflex (good feeling of playing with babies, puppies or kittens….Love and affection)

Additional effects of SPG Blocks: Feelings of Well Being and safety.

Physiologic Effects SPG Blocks: Can treat HBP and Essential Hypertension

Insomnia Treatment with SPG Blocks: No medication side effects or morning hangovers.

Allergic Rhinitis Treatment with SPG Blocks: https://thinkbetterlife.com/vasomotor-rhinitis-treatment-spg-block/

Treatment of TMJ Blocks: Patient testimonials SPG Blocks and Neuromuscular dentistry. The Myomonitor utilized by Neuromuscular Dentists stimulates the Sphenopalatine Ganglion while addressing trigeminal and facial nerves. Patient Testimonials on Neuromuscular Dentistry on Reddit.

https://www.reddit.com/r/NeuroMuscularDent/

Te book “Miracles on Park Avenue” describes the amazing practice of Dr Milton Reder who treated a wide variety of chroni health and pain conditions including intractable headaches using Sphenopalatine Ganglion Blocks (SPG Blocks)…

Jaw Joint and Muscle Sprain/Strain: JAMSS

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A new article in Inside Dentistry (reference below) reveals research that 50% of patients with TMJ disorders (TMDs) the initial onset was a result of Dental Care.
These problems may occur due to direct trauma to the jaw muscles or joints, sustained contractions of jaw muscles, and/or prolonged stretching of the masticatory muscles and joints, ligaments and tendons.
In my experience, this is especially true with procedures like lower molar extractions when bite blocks are not used, root canal therapy on second and third molars and other long appointments.
It is likely that most patients experiencing this were predisposed in some fashion to having jaw issues.

There are many things that can be done to help prevent these problems:
1. The judicious use of Travell Spray and Stretch technique following a long dental appointment can often relax the muscles and allow healing especially if done early. I frequently do this immediately after an appointment and before and/or aftyer on patients with pre-existing issues. Most pain related to TMJ dysfunction is actually Myofascial Pain and Dysfuntion or MPD.

2.Ice and or heat packs over jaw and neck muscles. This is similr to a post exercise muscle pain. Moist heat or heat alternated with ice can be extremely helpful.

3. I am an enormous advocate of the Aqualizer, an oral appliance that utilizes hydraulics to equalize the bite and relax musles. It has been shown to relax not just the jaw muscles but also neck, shoulder and back muscles over a couple of hours.

The use of ULF-TENS is amazing for preventing and allowing rapid healing of this type of problem. the ULF-TENS preconditions the muscles for their “Work Out” and afterward gentle pulsing helps relax muscles by increasing blood flow and pumping out waste products, such as lactic acid.

The Myomonitor is the original ULF-TENS and has an exceptional 50 year safety record. It has been show to be extremely efficient at relaxing muscles physiologically and this has beeen confirmed by surface EMG. The Myomonitor has a second aspect that is also very important, it acts as a SphenoPalatine Ganglion Stimulator and prevents onset of Axis two issues related to stress, anxiety and pain.

Axis two is H-P-A action or Hypothalamus-Pituitary-Adrenal System. This has been known since the work of Hans Selye first opened the medical communities eye to the effect of stress on the human body. SPG Blocks or Sphenopalatine Ganglion Blocks are also amazing at treating many TMJ issues as well as migraines, cluster headaches, anxiety and other pain issues.

It effectively helps turn off sympathetic overload and allow the parasympathetic system to predominate to allow healing.

Most TMJ disorders whether intracapsular or extracapsular are the result of repetitive strain injuries due to bit issues or patient behavior, ie cheerleaders joint or gum chewing. Adding a long dental procedure , trauma of extraction or injection thru muscle can be a significant factor in devloping long term problems.

Reference. Post Operative Jaw and Muscle Pain, a gGuide to Risk Assessment, Prevention and Treatment. Inside Dentistry April 2017 69-76
Brady LA, Fricton J, Eli B

J Am Dent Assoc. 2016 Dec;147(12):979-986. doi: 10.1016/j.adaj.2016.06.017. Epub 2016 Aug 31. Preventing chronic pain after acute jaw sprain or strain.
Fricton J, Eli B, Gupta A, Johnson N.…

Pain Is Destroying My Life! Pain Solutions Restore Your Quality Of Life.

Dr. Shapira Blog, Chicago, Chronic Daily Headache, Clicking & Popping, Cluster Headache, GURNEE OROFACIAL PAIN, Headaches and Migraines, SPG Block Anxiety, SPG Block Cluster Headache, SPG Block Migraine, SPG blocks, Sphenopalatine Ganglion Blocks, TMJ affects your posture, TMJ ARTHRITIS, TMJ Causes Stress, TMJ Dentist, TMJ Migraines, TMJ Neck & Back Pain, TMJ Numbness in Arms & Fingers, Uncategorized 0 Comments

Living day to day with severe or chronic pain can be agonizing to your spirit, your family and your life.

There is hope for patients with chronic head, neck, face and back pain.

Millions are disabled with chronic pain. It i estimated that 100 million Americans have chronic pain and as many as 11 million are disabled by chronic headaches and migraines.

Just outside Chicago in Highland Park is a small office dedicated to giving patients their lives back by freeing them from their painful prisons. Dr Shapira utilizes SPG (SphenoPalatine Ganglion) Blocks that were featured in the book “Miracles on Park Avenue” and was the story of Dr Milton Reder a New York ENT who saw thousands of patients from around the world seeking pain relief.

Dr Shapira has over 100 patient testimonials on his YouTube channel.

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

Many of the testimonials are from physicians or dentists who have taken Dr Shapira’s courses on techniques for utilizing these “Miracle” blocks.

Each and every patient is unique and different methods of giving the blocks are important to some patients. Self-Administration is the ideal method according to Dr Shapira because it frees the patient from trips to doctors offices and emergency rooms and gives them immediate access as needed.

The Sphenopalatine Ganglion is the largest Parasympthetic Ganglia of the head and lies in the Pterygopalatine fossa behind the palate and is attached to the maxillary division of the trigeminal nerve.

SPG Blocks are especially effective for chronic headaches, migraines, cluster headaches and other Trigeminal autonomiccephalgias because of its control of the autonomic nervous system of the head and throughout the body. Sympathetic fibers from the cervical ganglion chain also pass through the ganglion and travel along the course of the Trigeminal Nerve.

The Trigeminal nerve is the primary driver of all headaches and migraines but it is most commonly known as “The Dentist’s Nerve” If you suffer headaches, blame the trigeminal nerve and the autonomic nerves that travel down its fibers. https://www.sleepandhealth.com/disorders-and-treatments/

We are all familiar with trips to the dentist where we receive anesthetics for dental work and know the feeling of numbness when we leave. What many of us are not aware of is the the Trigeminal Nerve is actually part of the brain as are the other 11 cranial nerves.

The Trigeminal Nerve or fifth cranial nerve goes to the teeth, the jaw bones, the jaw joints or TMJ (TM Joints), the jaw muscles, the periodontal ligaments, the gingiva and mucosal surfaces of the mouth (the gums), the anterior 2/3 of the tongue. ENT’s are also extremely familiar because it goes to the mucosa of the nose and sinus linings and is responsible for sinus pain and sinus headaches as well. Many patients have hearing problems related to the Trigeminal nerve because it innervates the tensor muscle of the ear drum (Tympanic membrane) or Tensor Veli Tympani. It also controls the opening and closing of the eustacian tube thru the Tensor Veli Palatini muscle. This is the muscle that prevents food and liquids from entering the nose.

There are three branches of the trigeminal Nerve. The mandibular Branch and the maxillary branch are where Dentists are the acknowledged experts. The opthalmic branch is often thought of belonging to the opthamologists and facial surgeons but in truth dentists are primarily responsible for input to this part of the trigeminal nerve as well. Retro-orbital pain and the lower eyelid are controlled by the maxillary branch while the upper eyelid and forehead is the opthalmic branch.

Control of nociception into Trigeminal Nerve is the ideal method of reducing or eliminating headaches and migraines. The Sphenopalatine Ganglion is a tool to control the autonomic aspects of the Trigeminal Nerve.

The largest input to the brain is thru the proprioceptive aspects of the Trigeminal nerve that pass thru the mesencephalic nucleus of the brain. This is where Neuromuscular Dentistry becomes invaluable to correcting and eliminating long term chronic head and neck pain. While SPG Blocks address the autonomic nervous system neuromuscular dentistry addresses the Somato-Sensory nervous system that controls muscle function and posture. Myofascial Pain is the most common cause of pain anyhere in the body.

The Trigeminal nerve accounts for over 50% of all input to the brain after amplification in the Reticular Activating System. The Reticular Activating System is part of the Limbic (emotional Center of Brain) System and connects to the Hypothalamus-Pituitary-Adrenal complex. This is also where we experience anxiety, depression and symptoms form stress overload. SPG Blocks can eliminate many of those feelings.

Stress overload causes us to move into Sympathetic Overload and is frequently responsible for Sympathetically Maintained Pain seen in CRPS or Chronic Regional Pain Syndrome, previously called causalgia and RSD or Reflex Sympathetic Dystrophy. SPG Blocks help our bodies and mind reset from Sympathetic Overload and the “Fight or Flight reflex” and turns on the parasympathetic “Feed and Breed reflex” where we experience feelings such as well being and love. It invokes the feelings we have playing with puppies or babies, just the opposite of “being stressed out”.
“…

Facial Pain Relief: Sphenopalatine Ganglion (SPG) Block, ULF-TENS and a Diagnostic Neuromuscular Orthotic

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Chronic Facial Pain and Trigeminal Neuralgia are serious problems that rarely respond well to medication.  Facial Pain and Trigeminal Neuralgia respond especially well to Neuromuscular Dentistry because the Myomonitor, the ULF-TENS invented by Dr Barney Jankelson not only treats the Trigeminal and Facial Nerves but also acts as a stimulator to the sphenopalatine ganlion.

The Sphenopalatine Ganglion is the largest Parasympasthetic Ganglion of the head that also has sympathetic fibers running thru it.  The sympathetic nervous system is usually responsible for acute pain becoming chronic and the serendipitous positioning of the SPG on the maxillary branch of the Trigeminal nerve is probably a main reason for the enormous success with neuromuscular dentistry in treating chronic facial pain andf trigeminal neuralgia.

The use of SPG Blocks in conjunction with neuromuscular dentistry often makes treatment progress much faster with far better pain relief early on.

Patients who are taught self administration of SPG Blocks often do exceedingly well.

There are over 100 patient testimonial videos describing how treatment has helped them.  This includes help with facial pain and trigeminal neuralgia.

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

SPG Blocks lecture in Buenos Aires Presentation

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  1. 1. ICCMO THE INTERNATIONAL COLLEGE OF CRANIOMANDIBULAR ORTHOPEDICS BUENOS AIRES MARCH 2017 • SPHENOPALATINE GANGLION BLOCKS • Ira L Shapira DDS, FICCMO, D,ABDSM, D,AAPM
  2. 2. Sphenopalatine Ganglion Pterygopalatine Ganglion Meckels Ganglion Nasal Ganglion Sluder’s Ganglion
  3. 3. Parasympathetic Ganglia of Head
  4. 4. Anatomy PterygoPalatine Fossa SphenoPalatine Ganglion • The Trigeminal Nerve is often called the Dentist’s Nerve. • The Sphenopalatine Ganglion also belongs to Dentistry and is intamately associated with the trigeminal nerve • Dentists are experts in the anatomy of the Trigeminal Nerve
  5. 5. PterygoPalatine Fossa Maxilla and Sphenoid Bone
  6. 6. Sluder’s Neuralgia Sphenopalatine Ganglion Neuralgia • SPG Block First described in 1908 by Sluder • Autonomic Trigeminal Cephalgia • Cluster Headache • TMJ Symptoms • Contact Headache
  7. 7. Positive Side Effects SPG Block • Decreased Blood Pressure • Decreased Anxiety • Feeling of Calm and Well Being • Increased sexual desire and response
  8. 8. History
  9. 9. Limbic System • The limbic system includes the thalamus, hypothalamus and other structures. • Limbic system appears to be the memory site of emotions, including Fear, Anger, Joy, Remorse and of course Pain • Pain is our emotional response to nociceptive input.
  10. 10. Flight or Fight Reflex Acute Stress Reaction Sympathetic Response • Preparation for Action • Release of Catecholamines • More blood flow to brain and muscles • Shut Down of Parasympathetics • Less blood to gut
  11. 11. Fight of Flight Response • Adrenal Medula Releases Catecholamines Epinephrine and Norepinephrine • Hans Selye: General Adaptation Syndrome • Stage 1: Alarm • Stage 2: Resistance • Stage 3: Exhaustion
  12. 12. Parasympathetic Response: This is where we Eat and Digest, Sexual Response, Orgasm, Post- Orgasmic Bliss. Survival as a Species rather than an Individual. Feelings of love and Attachment Warm feelings from Babies, Puppies and Kittens FEED AND BREED RESPONSE
  13. 13. Reticular Activating System The reticular activating system is receives input from all parts of the sensory system as well as the cerebrum. • Amplification of input particularly concern to NMD is the Trigeminal Nerve • The major function of this system is to control the arousal level of the brain. Part of Limbic System • This system secretes norepinephrine and dampens the many stimuli coming through it, so new and different stimuli can be recognized by the rest of the brain.
  14. 14. Hypothalamus • Part of Limbic System • Links Nervous System to Endocrine System and Pituitary Gland • Controls Body Temperature, Hunger, Thirst Satiety, • Fatigue, Sleep and Arousal, Circadian Rhythms: Suprachiasmatic Nucleus • Memory and Learning • Blood Pressure, Heart Rate, GI Mobility
  15. 15. Sphenocath & Allevio
  16. 16. TX-360 s
  17. 17. Transnasal cotton tipped Applicator

Chicago Atypical Facial Pain: The Trigeminal Nerve Connection

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When patients have chronic headache or facial pain that doesn’t fit any other category it is often diagnosed as Atypical Facial Pain. Other terms used for this include Atypical facial neuralgia, Trigeminal Neuralgia or tic douloureux, atypical trigeminal neuralgia, Spenopalatine Ganglion neuralgia, Sluders neuralgia,idiopathic facial pain. It is often considered to be a “psychogenic pain”

Because the cause is often unknown the term idiopathic facial pain may be most accurate as it literally means “we are idiots at knowing the cause of this pain”

Atypical facial pain, is often compared to trigeminal neuralgia but is a separate and different entity. Symptoms can be very persistent often lasting months or years and can be described in terms including burning, sharp, dull, crushing, aching, scalding , twisting, pulling or squeezing.

With multiple possible causes of atypical facial pain the diagnosis is usually reached through a process of elimination. Some cases are related to the Sphenopalatine Ganglion and present with multiple autonomic symptoms.

Trigeminal Neuralgia Referral: https://thinkbetterlife.com/referrals/

Atypical facial pain was once considered to be a strictly psychological disorder or psychogenic disorder. Many practitioners still consider patients pain as psychogenic and downplay neurological causes. it is unquestionably a disorder wholly or partially of the trigeminal nervous system. Possible cause include:
Sinus infections
Dental infections
Ernest Syndrome (inflammation of a ligament in the jaw)
Neuralgia inducing cavitational osteonecrosis
Temporal tendonitis
Trigeminal ganglia compression
Trigeminal nerve trauma
The above are all structures innervated primarily by the Trigeminal nerve.

Vagus nerve tumors: A rare cause of pain

Facial trauma: Trauma to Facial and/or Trigeminal Nerve

Cervical spine disorders: As related to Trigeminal Cerical Complex

 

Treatment options by neurologists are usually prescription drugs used for depression, seizures such as:

Amitriptyline (antidepressant)

Gabapentin (anticonvulsant)

Carbamazepine (anticonvulsant)

Baclofen (muscle relaxant/antispasmodic)

Clonazepam (muscle relaxant/anticonvulsant)

Valproic (anticonvulsant)

Invasive therapies include Microvascular decompression, Balloon compression, Glycerol injection, Peripheral nerve stimulation (ULF-TENS utilized in physiologic dentistry), Stereotactic radiosurgery, Percutaneous trigeminal tractotomy, Motor cortex stimulation.  One excelent approach that often has success without defining the actual disorder is the SPG Block or Sphenopalatine Ganglion Block.

Self Administered SPG Blocks can frequently give almost miraculous relief to Trigeminal Neuralgia.  Learn more at:  https://www.sphenopalatineganglionblocks.com/trigeminal-neuralgia-first-line-approach-spg-blocks-can-safe-effective/

 

Physiologic Dentistry can often provide answers by correcting the underlying triggers of this type of pain.  ULF-TENS, SPG Blocks, Trigger Point Injections and Diagnostic Physiologic Orthotics often provide relief without a definitive diagnosis.

The nature of Atypical Facial Pain is NO DIAGNOSIS.  If the tretment is treated successfully it is usually assumed that treatment addressed the underlying cause and therefore the patient did not actually have atypical facial pain.…