How We Successfully Treat Headaches, Face Pain and Related Conditions

The Basis of Diagnosis and Treatment

Summary of Treatment

If you broke your arm, would you treat it so it could heal or would you take one pain medication after another to mask the pain for years at a time hoping that it would go away? Headaches and face pain are almost always a result of an injury or dysfunction involving muscles, ligaments and joints. Our goal is to find which ones are causing the problem, help them to heal, and discharge you from treatment free of pain so you don’t need us, and you don’t have to risk the side-effects of medications.

No doubt you and other pain sufferers are becoming more and more aware of the importance of avoiding medications whenever possible. Eighteen doctors from numerous medical schools reported in The Journal of the American Medical Association*, that adverse drug and device reactions “account for as many as 100,000 deaths” per year. Even worse, only half of newly discovered side-effects are made public within seven years of drug approval. In other words, the fact that a medication has been used for many years does not automatically make it safe.

That's not to say that we disagree with the use of medication. We prescribe them too. However, they should be used for short periods while awaiting healing and not as a means of covering-up the problem.

The treatment which we employ is typically provided in up to three sequential stages. Most of our patients require only Stage I treatment to stop the pain, tinnitus, dizziness, etc. The procedures contained within these three stages are:

 

Stage I: Physical medicine procedures which are designed to bring about healing of injured and/or dysfunctional structures such as muscles and joints. Examples of procedures include:

• Specific exercises
• Use of electronic devices to gently stimulate healing
• Orthopedic appliances of different types which assist in reducing muscle spasm, etc.
• Procedures to facilitate joint mobilization
• Nutritional recommendations

Most patients' conditions resolve with these procedures. However, if dramatic improvement is not experienced within a few weeks, we discuss the possibility of going on to Stage II.

 

Stage II: These procedures involve introducing very safe substances to the dysfunctional muscle, tendon, ligament, joint or ganglia. In the rare cases (approximately 1% to 3%) where pain reduces but returns several times, we consider the possibility of going on to Stage III.

Stage III: Invasive measures which most often involve a procedure called Radiofrequency Thermoneurolysis. This is reserved for the most persistently painful problems and has been shown to resolve the residual head, face, eye and ear pain over 95% of the time.

In certain cases, none of the above is required, since many conditions resolve with simple home care instructions.

Over 90% of our patients provide statements indicating resolution of their symptoms at discharge. Comments can be seen at our photo gallery section. More extensive letters can be seen at the Comments from Our Patients section and letters from medical and dental specialists attesting to our ability to help our patients are contained in the Comments from Physicians section.

Treatment times vary according to the extent of the dysfunction, the presence of co-existing problems such as neck injury or thyroid dysfunction, patient compliance and age. Children generally require only minimal treatment while older and geriatric patients may heal more slowly.

*JAMA 2005;293:2131-2140

Billions of dollars are spent each year to diagnose and treat headaches and facial pain. Much of this expenditure is wasted!

Treatment outcomes are often very limited, with a high probability that the sufferer will seek yet another doctor, take more expensive tests, and purchase more medications in an effort to obtain relief.

The true costs are elevated even further by the millions of hours lost from work or school as a result of ongoing pain.

In our experience, approximately 90% of the total pool of headache patients can be treated in the fashion described below with a 90% probability of success. This success rate determination is based on approximately 30 years of experience with close to 20,000 patients.

Certainly, the procedures described below are not applicable to those suffering from headaches with neurological and other causes such as tumors, infections, hypertension, and the like. However, less than 3% are believed to suffer from pain for these reasons.

Diagnosis requires evaluation by a practitioner with extensive training and experience in treating the physical causes of head and facial pain. Unfortunately, most doctors do little more than prescribe aspirin, Tylenol, NSAIDS, codeine-related compounds, or medications with even worse potential side effects when they are confronted by chronic headache patients. However, this is far from ideal. Faculty at a university-based headache center have stated,

" The bottom line is this - there is really no role for use of chronic pain medication in the management of headache."

Some practitioners assume that chronic pain complaints are "due to stress", and refer the patient for costly diagnostic testing, psychotherapy, or biofeedback, without dealing with the treatable organic source of the pain.

This regrettable approach was brought home to us a few years ago, when a woman was referred two years after severe daily headaches developed following child birth. Throughout the years that followed, she underwent psychotherapy to help her "understand" and "deal with the "resentment" she was told that she had toward her newborn baby. After examining the woman, I suggested that the cause of her pain was probably a neck and TM joint injury. "Have you ever had a car accident?" I asked. "Yes", she replied, "On the way to the hospital when I gave birth". Minimal treatment relieved her suffering, and her relationship with her baby was no longer in doubt. How much misery could have been prevented, and how many thousands of dollars could have been saved if she had been examined sooner, after the onset of pain? An even more dramatic case is described in the following letter written by a patient who was in pain for 32 years:

" I was in an automobile accident at the age of 14 years and have had severe headaches several days a week since then. I also developed serious face, neck and shoulder pain in recent years. At the age of 45, I am almost totally without any of the pain mentioned and am thrilled not to be plagued with this discomfort anymore.

Following treatment, she has remained virtually pain free for over 10 years.

Our approach to diagnosis and treatment of head and facial pain is based on the following protocol:

Diagnosis A.

A detailed history is taken of the patient's complaints and general medical condition. Evaluation by a physician with appropriate neurological training is often also appropriate, especially for children and for patients with headaches of sudden onset, especially if associated with difficulty moving the head, vomiting or a drooping eye lid. Until proven otherwise, all such cases should be presumed to be due to a tumor or aneurysm ("blister" on a blood vessel) in the brain. Symptoms may include one or more of the following:

• Headaches (in any part of the head)
• Face pain
• Eye pain
• Ear pain
• Dizziness
• Ringing in the ears
• Pressure or blocked sensation in the ears
• Blurred vision (which comes and goes)
• Difficulty swallowing
• Frequent sore throat or a sensation that something is stuck in the throat
• Burning tongue

Clearly, each of the above symptoms can also be the result of a variety of causes. However, dysfunctions of the craniocervical musculoskeletal system (i.e. Temporomandibular joint and related muscles, ligaments and tendons in and around the head, face, neck and shoulders) should be ruled out especially when the patient complains of two or more symptoms, or if routine medical tests prove negative.

B.

Examination includes: Physical examination of the muscles of the head, face, neck and shoulder (technically described as the upper quarter), begins with manual palpation. The doctor should feel for muscle spasm and rule out "trigger points" which can refer pain to other areas. Range of Motion Studies measurements of jaw movement when moving side to side and on full opening of the mouth. In certain cases, additional objective tests may be required. These might include one or more of the following:

1. Radiographs may be taken from various angles as an aid in diagnosis. These can often be used to assist in ruling out tumors, cysts, fractures, infections, and developmental abnormalities.
2. In some cases, specific projections or "slices" called Tomographs are taken. This allows a more detailed evaluation of the skull or its various sections.
3. Doppler Sonogram - A high tech testing device which allows the doctor to hear blood flowing through the arteries and recognize the presence of stretched ligaments, and perforated or displaced discs.
4. EMG Using Surface Electrodes - This is a computerized system for determining electrical activity within specific muscles of the head, face, neck and shoulders. Surface electrodes are employed rather than needles, making this a totally painless procedure. Objective numerical, and graphic readings are provided by the EMG's computer.
5. If surgery is considered, then an MRI, CAT Scan, or Arthrogram is taken to visualize the location and condition of the TM Joint discs. Unlike MRI's of the brain, which can be relied on to an enormous extent in making treatment decisions, MRI's of the TM Joint should provide only a fraction of the total diagnostic input needed before considering surgery, and are practically unnecessary as a diagnostic aid prior to non-surgical treatment.

C.

The diagnosis arrived at should be reasonably specific. Just as you would never accept a diagnosis of "Elbow Syndrome" from an orthopedist, you should not accept a diagnosis of "TMJ" or "TMJ Syndrome", since TMJ is merely the name of a joint. It is not a diagnosis. There are far too many variations and nuances which should be investigated and treated specifically. Consequently, simplistic diagnoses such as those listed above are unacceptable.

Examples of specific diagnoses which are often involved include, but are by no means limited to:

• Myalgia
• Myofascitis
• Articular disc disorder (Disc dislocation)
• Inflammatory arthritis
• Muscle spasm
• Hyoid Bone Syndrome
• Posterior capsulitis
• Omohyoid Syndrome
• Temporal tendonitis (short head)
• Temporal tendonitis (long head)
• Rheumatoid arthritis
• Hemarthrosis
• Ernest Syndrome
• Stylomandibular Ligament Sprain
• Eagle's Syndrome
• Reflex sympathetic dystrophy
• Atypical Facial Pain
• Trigeminal Neuralgia
• Atypical Trigeminal Neuralgia
• Trigeminal Neuropathy
• Degenerative Osteoarthritis
• Psoriatic Arthritis
• Chondromalacia
• Anterior displacement of TMJ disc without reduction
• Anterior displacement of TMJ disc with reduction
• Intermittent Anterior displacement of TMJ disc without reduction
• Osteocavitational Necrosis
• Non-suppurative Osteomyelitis
• Neuralgia Inducing Osteocavintational Necrosis (NICO)
• Osteochondritis

D.

Treatment time and costs vary according to the extent of dysfunction, the presence of simultaneous related dysfunctions such as neck injury or thyroid dysfunction, patient compliance and age. Children generally require only minimal treatment while geriatric patients generally heal far more slowly.

Treatment for this condition is typically provided in three stages. These include Stage I, non-invasive physical medicine procedures. Stage II, invasive procedures such as muscle, tendon, ligament and joint treatment procedures or ganglia blocks and rehabilitation procedures, and Stage III, surgical procedures.

Many patients are given only home care instructions at a single visit, while others require 4-6 months of care (on average), and yet others require much lengthier treatment and even surgery.

In a small number of cases (perhaps 1% - 3%), Radiofrequency Surgery or other surgical procedures and/or Phase II care is required. With modification, most of the Stage I and II procedures employed, are part of the armamentarium used by specialists in Physical Medicine and Rehabilitation. Other approaches (Stage III) more closely resemble techniques used by orthopedists or neurosurgeons. All procedures which we employ have been accepted by relevant medical and scientific organizations, and are commonly covered by insurance carriers. A simplified list follows:

1. Orthopedic appliances - These are generally devices employed to alter joint position. A variety of different orthoses with various functions may be employed. These are worn in the mouth and may fall into numerous different design categories.
2. Physical Medicine Modalities - therapeutic devices which are employed to aid muscles and joints to return to normal function and reduce pain. a) Electrogalvanic Stimulation - an electronic device used to reduce muscle spasm and stimulate healing. b) Ultrasound - an electromechanical device which employs a crystal which vibrates at a high frequency. Its function is to provide heat to structures well below the skin. c) Hydrocollator - a device for providing moist heat. d) Cryotherapy - cold therapy.
3. Joint Mobilization Procedures and Physical Manipulation - active and passive movement of joints and muscles are employed to achieve or maintain normal motion, relieve spasm, and in some cases, to recapture displaced discs.
4. Medication - non-steroidal anti-inflammatory medication, analgesics, etc.
5. IIontophoresis - an electronic device which allows medications to pass through the skin into the muscle or joints without the use of an injection needle.
6. IIontophoresis - an electronic device which allows medications to pass through the skin into the muscle or joints without the use of an injection needle.
7. Radiofrequency Thermoneurolysis - a procedure which employs high frequency electrical energy to modify or eliminate pain impulses from injured structures. This technique, in particular, offers enormous promise for eliminating pain where other conservative procedures have failed to bring relief.
8. Arthroscopy - Under certain circumstances, surgical instruments which are passed through a tube inserted into the joint can be used for surgical alteration.
9. Open Joint Surgery - a means of joint repair in which the overlying skin and capsule are opened for reconstructive purposes, placement of a transplant or implant, or removal of damaged tissue - virtually none of our patient require these types of procedures.

It is important to remember that dysfunctions of the temporomandibular joints and related muscles can be objectively evaluated and documented with a high degree of certainty. Sequelae which can probably be minimized by appropriate treatment include a wide array of degenerative changes including osteoarthritis, localized osteoporosis, necrosis (i.e., death) of hard and soft tissues of the face, and, ultimately, alteration of facial appearance. Early referral of all individuals complaining of head or facial pain, or related symptoms, to knowledgeable doctors is certainly recommended. Early treatment is clearly beneficial to the patient who is relieved of pain, the unnecessary financial burden connected with seeking a successful treatment approach and the risks associated with long term use of medication.

Summary

Individuals suffering from headaches, facial pain and/or temporomandibular joint dysfunctions can be successfully treated with a high degree of probability using diagnostic and treatment procedures which have been available for many years. Most of these procedures are commonly employed by medical providers for musculoskeletal dysfunctions and pain in other parts of the body. Since most such patients, even if in pain for 20-40 years or more, experience resolution of pain, reduction or elimination of the use of medications, discontinuation of their search for a medical provider who can treat their problem, and elimination of repetitive and expensive diagnostic testing, early evaluation is beneficial to the patient in many ways, both medically and financially. Patients who have been relieved of chronic head and facial pain also return to more normal function at work and at home, thereby improving productivity and quality of life. Treatment outcomes are predictable in the vast majority of cases.

The Center for Headaches and Facial Pain accepts patients for the treatment of headaches, facial pain and temporomandibular joint dysfunctions. Patients have traveled to this office from across the United States and abroad. Many have been referred by Medical and Dental School faculty from as far as 2500 miles away.

The Center Director, Dr. Ira Klemons, was elected President of the American Board of Craniofacial Pain.

He obtained the D.D.S. degree from New York University in 1972, and Ph.D. from the Pennsylvania State University in 1981. His Ph.D. dissertation was entitled Chronic Head and Facial Pain and Dysfunction: Their Interrelationships Diagnosis and Treatment by Mandibular Orthopedic Repositioning. This is believed to be the first Ph.D. in this field in the United States.

We gratefully acknowledge with appreciation  the NJ Law Journal for permission to reprint an article by Dr. Klemons, part of which was excerpted in the above guidelines.

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Phone consultations with professionals are welcome, or click here to contact us. Dr. Klemons and our staff would love to meet you in person.  Call 732-727-5000 to set up an appointment today.

Patients are referred to us by physicians, dentists, chiropractors, psychologists, physical therapists and other professionals. However, many of our patients are referred by former patients or based on their own decision without the need for a referral.

 

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