James P. Boyd, DDS, developer of the NTI Therapeutic protocol and the NTI device, the first dental device to be cleared by the FDA for the prevention of medically diagnosed migraine pain, discusses one of the most important and over-looked aspect of the diagnosis of chronic migraine and headache pain.
"When you wake up, do you feel fabulous?"
Seems like a silly
question, doesn't it? If I had to boil it down
to one concept that has made NTI therapy successful,
it's the acknowledgement that most chronic migraine
and headache sufferers don't (or won't) admit that
upon waking in the morning, having some degree of
discomfort above their shoulders is completely
"normal" for them. Not just headache or even
full blow migraine. It could be the
facial/forehead and back-of-the-neck combination
pain, sore and stiff jaw, or "sinus" headache.
In comparison to the
migraine episodes they experience, their morning
headaches are somehow "manageable", and therefore in
their mind, not worthy of including in their
complaints to their health care provider.
They've seen plenty of
doctors for their headaches. They're asked
specific questions regarding the degree of pain that
alters their normal function like, "When you get
your worst headaches...", and "What makes your
headache worse?", or "How many times per week/month
do you have a migraine?". Rarely,
if ever, is a chronic migraine or headache sufferer
asked, "Exactly when DON'T you have any degree
of headache, even the slightest?".
There are two simple questions to ask in a interview of a headache patient.
Question 1: On a scale of 0-10, with 10 being the worst discomfort above the shoulders that you could imagine (includes neck, jaw, sinus, headache or migraine pain), and 0 being no pain at all, how many mornings per week do you wake with a ZERO, that is, you feel fabulous?
That last part needs
to be emphasized. To anyone else, not having
pain upon waking is normal. Sure, you can
still feel tired, but a lack of pain isn't
remarkable to the normal
person. For the chronic headache and migraine
pain sufferer, a degree of pain IS normal. For
them, having no discomfort at all would be, well,
fabulous. Perhaps unintentionally, the chronic
headache and migraine pain sufferer avoids that
Most chronic migraine sufferers will hesitate with their reply, and then begin to rationalize their their answer before they provide it. They'll begin by stating, "Well, when I get my really bad headaches...", or, "Nobody ever really feels fabulous", or some justification as to why it's "within normal limits" for them to have discomfort upon waking. The practitioner must press on, and confirm how many mornings per week that the patient wakes with ZERO pain.
Experienced practitioners will soon find that being pain free is quite rare for the chronic migraine sufferer, especially upon waking. The practitioner can remind the sufferer that waking daily with, say, liver pain, or kidney pain, is certainly not normal, and so it is with chronic headache pain. They can't be helped to the fullest extent if their entire presentation is not understood.
Question 2: On those days that you don't wake with a ZERO (that is, you have "a number"), what's the average "number" that you have?
Waking 5 days per week
with a level 4 headache, to some chronic sufferers, is
not worthy of reporting. They have
learned that they must deal with their discomfort
and reserve their complaints for the degree of
migraine pain that alters their daily lives.
They are wary of being labeled "drug overuse"
patients, because in some practitioner's minds,
constant headache, especially upon waking, could
only be due to medication overuse.
The chronic sufferer
figures that their worst headaches and migraine
attacks are far more important to try and manage
than their chronic "normal discomfort"
existence. Besides, no one has been able to
diagnose and alleviate their normal discomfort,
anyway. However, to the practitioner,
this information is critical in the assessment of
the cause and/or perpetuation of their patient's
entirely unlike teeth
grinding. When the intensity of jaw clenching
achieves pathologic intensities, it is impossible to
grind one's teeth, therefore, the chronic
jaw-clencher's teeth will not look considerably
worn. Their lower jaw is typically not sore,
as the most powerful jaw-clenching muscle is the
temporalis, which covers the sides of the head. With
no objective findings of jaw-clenching, the degree
and frequency of headache upon waking is the most
compelling symptom of nocturnal jaw-clenching.
This is not to suggest
that chronic nocturnal masticatory parafunction (ie,
intense jaw-clenching) is the lone cause of chronic
headache or migraine pain. On the contrary, it
is better considered as being a primary complicating
factor and/or perpetuating influence on chronic
migraine and headache pain. Better stated,
while habitual nocturnal jaw clenching may not be
the cause chronic headache or migraine pain, chronic
migraine and headache pain cannot be completely
managed in the presence of undiagnosed and
uncontrolled nocturnal jaw clenching. In
fact, without controlling nocturnal jaw clenching,
traditional medical management of chronic migraine
and headache pain typically fails altogether.
As Andrew Blumenfeld, MD, likes to say, "Controlling
chronic jaw clenching doesn't cure migriaine, but it
can help reduce the frequency of migraine
attacks...sometimes to zero".
Following the first
month of NTI therapy, the practitioner can re-ask
the two question above. Although the patient
might first proclaim, "I'm still having headaches"
(as if no improvement had occurred), the
practitioner may discover that the patient is now
waking less frequently "with a number" and that the
level of that number is reduced..
Continually using the two questions above is a handy
tool to follow a patient's progress.
Ask your dentist if
he/she is an NTI provider. If not, and they're
interested, a complementary NTI Trail Kit can be
sent them. Ask your dentist to send a request
for their NTI Trial Kit to:
Developer of the NTI therapeutic protocol.