Predictive role of gnathological techniques for the treatment of persistent idiopathic facial pain (PIFP).

INTRODUCTION/BACKGROUND: Persistent idiopathic craniofacial pain (PIFP) is a heterogeneous group of pain syndromes whose main characteristic is the daily presence of persistent pain for at least 3 months. The pathophysiology of PIFP is still not entirely known and probably related to biological and psychological factors. Although PIFP has been attributed to the central neuron activity, the importance of masticatory muscles as a possible pathogenic mechanism was recently demonstrated. The main purpose of our paper was to identify the physiological rest position of the mandible with minimal tonus of both the elevator and depressor muscles and the neuromuscular trajectory of mouth closing obtained by transcutaneous electrical stimulation (TENS) and maintained with the use of an occlusal device, known as orthotic. MATERIALS AND METHODS: The VAS scale for facial pain and the migraine disability assessment score (MIDAS) index for patient quality of life were evaluated at the beginning of the study for the 38 subjects that came to our attention. Our research included two phases. The first phase consisted of kinesiographic and electromyographic (EMG) examinations of the masticatory muscles and a 45-min application of TENS in order to deprogram the muscular activity. Kinesio-electromyographic examinations were repeated in the second phase. The main evaluated parameter was jaw deflection or deviation on the sagittal and frontal planes before and after TENS during patient tooth occlusion. Patients that showed a significant modification of this parameter were treated with orthotics for 12 months. RESULTS: The results of a 12-month follow-up show a sharp reduction of the VAS (pre-orthotic 9.05, range 8-10, SD 0.8; post-orthotic 5.87, range 1-5, SD 0.7) and an improvement in the quality of life (MIDAS). CONCLUSIONS: Our study demonstrated the usefulness of TENS as a screening method for the application of orthotics. This non-invasive and/or non-painful procedure could be a useful complementary treatment in this patient population. The results of the study also confirm the role of masticatory muscle dynamics as a possible pathogenic mechanism in patients with PIFP.

The role of electrophysiological investigations of masticatory muscles in patients with persistent idiopathic facial pain.

INTRODUCTION: The authors tried to establish whether there is any electrophysiological difference of masticatory muscle activity between patients with persistent idiopathic facial pain (PIFP) and healthy subjects. METHODS: Twenty-eight PIFP patients (6 men and 22 women, mean age 40 years) and 28 normal subjects (12 men and 16 women, mean age 40 years) underwent EMG of temporal and masseter muscles before and after transcutaneous electric nerve stimulation (TENS). RESULTS: After TENS stimulation, the mean amplitude difference was found to be smaller than the baseline before TENS in the PIFP patients compared with healthy subjects. CONCLUSIONS: The peculiar behavior of masticatory muscles after TENS could be relevant in order to explain the well-known improvement of pain reported by some PIFP patients after orthosis positioning.

Electromyography data in chronic migraine patients by using neurostimulation with the Cefaly® device.

The objective of this observational study is to report clinical and instrumental results obtained in 23 chronic migraine sufferers treated with transcutaneous neurostimulation with the Cefaly(®) device. The electrom yography (EMG) parameters of the patients monitored before and during neurostimulation with the Cefaly(®) device showed a significant increase in the EMG amplitude and frequency values in the frontalis, anterior temporalis, auricularis posterior and middle trapezius muscles. The Cefaly(®) device could act on the inhibitory circuit in the spinal cord thus causing a neuromuscular facilitation and may help reduce contraction of frontalis muscles.

Is the brain of migraineurs "different" even in dreams?

Migraineurs brain is hyper-excitable and hypo-metabolic. Dreaming is a mental state characterized by hallucinatory features in which imagery, emotion, motor skills and memory are created de novo. To evaluate dreams in different kinds of headache. We included 219 controls; 148 migraineurs (66 with aura-MA, 82 without aura-MO); 45 tension type headache (TTH) patients. ICHD-II diagnostic criteria were used. Ad hoc questionnaire was used to evaluate oneiric activity. The Generalized Anxiety Disorder Questionnaire, and the Patient Health Questionnaire were administered to evaluate anxiety and mood. The prevalence of dreamers was similar in different groups. Frequency of visual and auditory dreams was not different between groups. Migraineurs, particularly MA, had an increased frequency of taste dreams (present in 19.6 % of controls, 40.9 % of MA, 23.2 % of MO, 11.1 % of TTH, p < 0.01), and of olfactory dreams (present in 20 % of controls, 36 % of MA, 35 % of MO and 20 % of TTH, p < 0.01). Anxiety and mood did not influence these results. The increased frequency of taste and olfactory dreams among migraineurs seems to be specific, possibly reflecting a particular sensitivity of gustative and olfactory brain structures, as suggested by osmofobia and nausea, typical of migraine. This may suggest the role of some cerebral structures, such as amygdala and hypothalamus, which are known to be involved in migraine mechanisms as well in the biology of sleep and dreaming.

Occipital neurostimulation in primary headaches: update.

A subset of headache patients are chronic and results refractory to standard medical treatments, they are unsatisfied or unable to tolerate the side effects of medications. In the lack of more effective prophylactic treatment, there is need of alternative approach. Migraine is conceptualized as a chronic and potentially progressive disorder. It is conceivable that more aggressive therapeutic efforts could be warranted in drug-refractory chronic migraine. In this prospective, the new, device-based therapies that allow to affect brain function in less invasive ways may represent a therapeutic opportunity. Peripheral occipital neurostimulation resulted in several trials and case reports to be beneficial in a large variety of headache and craniofacial pain disorders, with chronic primary headache the most studied. We comment on our experience in the application of ONS in drug-refractory chronic cluster headache and chronic migraine patients.

Positive outcome of occlusal freeway space reestablishment in patients with medication overuse due to chronic migraine.

Considering the great chapter of migraines, it is important to note the signs and symptoms caused by an alteration of the relationship of the facial musculature and the occlusal freeway space (FWS) that is the distance from maximal intercuspation to the habitual rest position (measurable in 1.4-2.5 mm). To any mandible position changing (detected by periodontal, muscle and joint proprioceptors), there is an influence on the neuromuscular system and then an alteration of the FWS. A group of 60 patients with chronic migraine (CM) underwent a withdrawal of overused medication and were subjected to electromyographic and kinesiographic evaluation. All those who presented an alteration of the FWS at rest position have been subjected to treatment with orthosis device for about 12 months. The aim of our work is to obtain and define a correct mandibular position, physiological, in agreement with the neuromuscular structures of the patient. Clinical results obtained on this pool of patients, in terms of reduction of the VAS, let us understand the importance of the inviolability of the FWS and to eliminate any type of mandibular deviation with respect to the closure trajectory induced by TENS in patients suffering from CM.

Chronic daily headache: suggestion for the neuromuscular oral therapy.

Tweny patients (M: 4, F: 16, mean age 37 ± 11 years) with diagnosis of chronic daily headache (CDH), after drug withdrawal, were under electromyography, kinesiography and masticatory muscle deprogramming by TENS to identify the physiological rest position of the mandible. Our purpose was to clarify a possible role of the neuromuscular stomatognathic system. Examinations showed that 17 patients needed a neuromuscular orthosis, an occlusal device, to provisionally correct the detected discrepancies of jaw position. Of those, the 10 patients who showed an occlusal sagittal discrepancy higher than 2 mm and/or a lateral deviation higher than 0.4 mm, associated with more than three parafunctional activities, had a meaningful decrease on frequency/intensity of migraine crisis and/or of days of headache. VAS pain score during crisis decreased from 9.0 ± 0.9 to 4.9 ± 2.7; frequency of crisis were from 20.7 ± 5.2 to 9.5 ± 7.7. Baseline pain were from 5.3 ± 1.2 to 3.0 ± 1.3. Satisfying clinical results can be reached combining behavioural education and neuromuscular orthosis. This can be very helpful in patients who show significant discrepancy of jaw position that only TENS deprogramming can reveal and kinesiography can detect with such accuracy.

Persistent idiopathic facial pain: multidisciplinary approach and assumption of comorbidity.

Persistent idiopathic facial pain (PIFP) is a complex and uncertain nosographic entity, which has many aspects that need to be explored. The 21 patients selected (male 4 and female 17, mean age 40 years) were under electromyography (EMG) to determine the efficiency of the masseter muscles (MM) and the anterior temporalis muscles (TA), during activity and at rest, and under kinesiography (CMS) to identify the physiological rest position of the mandible after TENS stimulation. These patients were rehabilitated with a neuromuscular orthosis to provisionally correct the discrepancies identified. The EMG mean values of the muscles at rest were significantly above the normal (two-sample t test) for all four muscles and were normalized after the TENS session (Wilcoxon rank test). CMS showed that all 21 patients needed a mandibular advancement and 90.5% a correction in the frontal plane, obtained with orthosis. The comparison between the values of the maximal clench on natural dentition and on the orthosis showed a decrease in the asymmetry of muscular strength (-30.21% for TA and -55.81% for MM; Wilcoxon rank test) and a net increase of the strength expressed (LTA +25.37; LMM +59.40%, RMM +40.80%, RTA +30.27; Wilcoxon rank test; sign test). Preliminary results show a net decrease also in VAS pain score with a mean shift from 9.5 to 3.1. The results suggest a role for the neuromuscular component of the craniomandibular system in the pathogenesis of chronic idiopathic facial pain. All patients with PIFP should undergo the CMS-EMg examination.

Costs of hypothalamic stimulation in chronic drug-resistant cluster headache: preliminary data.

In about 20% of chronic cluster headache (CH) cases, drugs may become ineffective. Under these circumstances, steroids and triptans are frequently employed leading to fearful side effects in one and high costs in the other. The direct costs of drug-resistant chronic CH are mainly due to frequent medical consultations and frequent use of expensive drugs. In recent years, hypothalamic stimulation has been employed to treat drug-resistant chronic CH patients suffering multiple daily attacks and long-term results from different centres show a 60% overall benefit. Nine years since the introduction of this technique, we attempt a preliminary analysis of the direct costs of hypothalamic stimulation based on patients treated at our centre. We estimated the following direct costs as follows: cost of neurosurgery plus cost of equipment (electrode, connection and impulse generator = 25,000 euro), cost of hospital admissions in long-term follow-up (2,000 euro per admission), cost of single sumatriptan injection (25 euro). Number of daily sumatriptan injections in the year before and for each year after hypothalamic implantation was obtained from headache diaries. To estimate the saving due to the reduction in sumatriptan consumption following hypothalamic stimulation, we calculated the following for each year of follow-up after surgery: number of sumatriptan injections in the year before surgery minus number of sumatriptan injections in each year, updated to December 2008. In our 19 implanted patients, the costs of neurosurgery plus cost of equipment were 475,000 euro; the costs of hospital admissions during follow up were 250,000 euro. Reduction in sumatriptan consumption resulted in a total saving of 3,573,125 euro. Hence, in our 19 patients, the sumatriptan saving (3,573,125 euro) minus the direct costs due to operation and follow up hospitalisations (475,000 + 250,000) euro is equal to 2,848,125 euro. These preliminary results indicate that hypothalamic stimulation is associated with marked reduction of direct costs in the management of complete drug-resistant chronic CH.

Effect of deep brain stimulation of the posterior hypothalamic area on the cardiovascular system in chronic cluster headache patients.

The objective of this study was to determine the cardiovascular effects of chronic stimulation of the posterior hypothalamic area (PHA) in cluster headache (CH) patients. Systolic and diastolic blood pressure (SBP, DBP), cardiac output, total peripheral resistance (TPR), heart rate (HR) and breathing were monitored at supine rest and during head-up tilt test (HUTT), Valsalva manoeuvre, deep breathing, cold face test and isometric handgrip in eight drug-resistant chronic CH patients who underwent monolateral electrode implantation in the PHA for therapeutic purposes. Autoregressive power spectral analysis (PSA) of HR variability (HRV) was calculated at rest and during HUTT. Each subject was studied before surgery (condition A) and after chronic deep brain stimulation (DBS) of PHA (condition B). Baseline SBP, DBP, HR and cardiovascular reflexes were normal and similar in both conditions. With respect to condition A, DBP, TPR and the LF/HF obtained from the PSA of HRV were significantly (P < 0.05) increased during HUTT in condition B. In conclusion, chronic DBS of the PHA in chronic CH patients is associated with an enhanced sympathoexcitatory drive on the cardiovascular system during HUTT.

Functional neuroimaging and headache pathophysiology: new findings and new prospects.

In the last ten years pathophysiology of primary headaches has received new insights from neuroimaging studies. Positron emission tomography (PET) showed activation of specific brain structures, brainstem in migraine and hypothalamic grey in trigeminal autonomic cephalalgias. This brain activation suggests it may intervene both in a permissive or triggering manner and as a response to pain driven by the first division of the trigeminal nerve. Voxel-based morphometry has suggested that there is a correlation between the brain area activated specifically in acute cluster headache - the posterior hypothalamic grey matter - and an increase in grey matter in the same region. New insights into mechanisms of head pain have emerged thanks to neuroimaging obtained in experimentally induced headaches, and during peripheral and central neurostimulation.

Pharmacological treatment compared to behavioural treatment for juvenile tension-type headache: results at two-year follow-up.

Recurrent headaches are common in children and adolescents. Most current investigations have employed limited modalities (either medication or behavioural) and few have included comparisons of different treatments. In this study relaxation training, administered in a limited contact format, and amitriptyline were compared for juvenile episodic tension-type headache. The clinical improvement was significant for both groups at 1- and 2-year follow-up; in particular for behavioural treatment, the patients came regularly for the sessions, practised routinely, and appeared to be compliant and accepting of treatment, although we did not assess this formally. In this group of patients the percentage of drop-outs was lower than in the pharmacological tratment. Although clinical results were similar in both groups, relaxation therapy seems to be more accepted than medication. The limited contact modality seems to be as useful as other behavioural approaches that require a greater investment of time (by patients and therapists), without unpleasant side effects. Because the sample sizes are small, these conclusions are tentative.

Acute hypothalamic stimulation and ongoing cluster headache attacks.

Long-term hypothalamic stimulation is effective in improving drug-resistant chronic cluster headache (CH). We assessed acute hypothalamic stimulation to resolve ongoing CH attacks in 16 patients implanted to prevent chronic CH, investigating 136 attacks. A pain intensity reduction of > or =50% occurred in 25 of 108 evaluable attacks (23.1%). Acute hypothalamic stimulation is not effective in resolving ongoing CH attacks, suggesting that hypothalamic stimulation acts by complex mechanisms in CH prevention.

Measuring responses to therapy in headache patients: new and traditional end-points.

Changes in numerical indices of the intensity, duration and frequency of attacks are traditionally used to assess the effectiveness of treatments for migraine and other primary headaches. However, recent clinical and therapeutic guidelines and guidelines for conducting clinical trials specify that the essential aim of symptomatic and prophylactic migraine treatments should be to reduce the global impact of the headaches on the patient's life. Some standardised instruments for assessing disability and health-related quality of life seem sensitive to treatment-induced changes in primary headache patients. However, further studies to determine the suitability of these instruments as outcome measures in clinical practice are necessary.

Pharmacological behavioural treatment for children and adolescents with tension-type headache: preliminary data.

Recurrent headaches are a significant health problem for young patients. Most current investigations have employed limited modalities (either medication or behavioural) and few have included treatment comparisons. The purpose of this study was to compare relaxation training (provided in a limited contact format) and amitriptyline in the treatment of young tension-type headache (TTH) sufferers. Follow-up is planned for 3, 6 and 12 months, at which time patients complete headache logs and an Italian version of the Migraine Disability Assessment (MIDAS) Questionnaire that has been adapted for this age group. Two groups of TTH sufferers of similar age and characteristics were studied. Clinical results, MIDAS total score, and individual values for items A and B were collected at the first follow-up (3 months). The clinical improvement is significant for both groups. Although the clinical results are similar in both groups, relaxation therapy seems to be more accepted than pharmacological therapy. These data, however, are preliminary and the sample sizes are small, so these conclusions are tentative. We will continue our data collection for 12 months.

Long-term follow-up of bilateral hypothalamic stimulation for intractable cluster headache.

We provide a detailed case history of the first patient to receive bilateral hypothalamic stimulation to control severe bilateral chronic intractable cluster headaches initially occurring mostly on the left. These attacks were accompanied by life-threatening hypertensive crises and a grave deterioration in the patient's psychological state. Destructive surgery to the left trigeminal was absolutely contraindicated. Electrode implantation and continuous stimulation of the left posterior inferior hypothalamus resolved the left attacks. After four destructive operations on the right trigeminal, right side attacks recurred. Electrode implantation (with continuous stimulation) to the right resulted in immediate resolution of the right side pain and the hypertensive crises. On several occasions, both known and unknown to the patient, the stimulators were turned off: in all cases, crises reappeared and in all instances disappeared relatively quickly after turning stimulation back on. Pain crises have never reappeared when ipsilateral stimulation is ongoing. The only side effects were observed during long-term bilateral stimulation, consisting of transient vertigo and bradycardia. After 42 months (left) and 31 months (right) of follow-up, the patient remains crisis free without the need for pharmacological prophylaxis.

Chronic headache in young patients: clinical aspects and treatment suggestions.

The term "chronic daily headache" (CDH) is used to describe a patient who suffers from recurrent headache, at an average frequency of 15 days per month without an underlying serious medical condition. CDH, sometimes referred to as chronic non-progressive headache, was described in adults by Mathew et al. in 1987. Estimating the incidence and prevalence of this disorder has been difficult, because universally agreed criteria regarding the classification of CDH in children and adolescents have not been reached. This condition is a source of concern and disability both for the patient as well as their family. CDH may be associated with comorbid anxiety or depression, resulting in a tremendous amount of dysfunction for the youngster and the family.

Hypothalamic deep brain stimulation for intractable chronic cluster headache: a 3-year follow-up.

Cluster headache is the most severe among primary headaches. Positron emission tomography and functional MRI studies have demonstrated that the ipsilateral posterior hypothalamus is activated during cluster headache attacks and is structurally asymmetric in these patients thus indicating that cluster headache may originate at that level. These hypothalamic abnormalities in cluster headache led to the suggestion that deep brain stimulation of ipsilateral posterior inferior hypothalamus might produce clinical improvement in otherwise treatment refractory chronic cluster headache patients. In a patient with severe intractable chronic cluster headache, hypothalamic electrical stimulation produced complete and long-term pain relief with no relevant side effects. So far other operations have been performed and the results are encouraging in terms of both pain relief and safety. The efficacy of hypothalamic electrical stimulation provides some hints into cluster headache pathophysiology.

Electromyographic biofeedback-assisted relaxation training in juvenile episodic tension-type headache: clinical outcome at three-year follow-up.

Although tension-type headaches are more common than migraine in children and adolescents, the limited studies that have been conducted with juveniles have focused chiefly on migraine treatment and its course. This report describes the clinical benefits for an electromyographic biofeedback-assisted relaxation treatment program for a group of children and adolescents experiencing episodic tension-type headache and examines whether the clinical presentation changed for headaches that remained. Of the 54 consecutive juveniles who began treatment, 38 completed and were available to participate in the 3-year follow-up. Headaches improved measurably immediately following treatment, with further gains being evident through 3 years. The few headaches that did occur at 3 years were nearly identical symptom-for-symptom to those that were experienced prior to treatment. This report suggests that behavioural treatment is a viable and durable intervention for juvenile episodic tension-type headache, but more definitive claims cannot be made due to the uncontrolled nature of the study. Further investigation is warranted.