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 acknowledgement.

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 condition. 

Jaw-clenching is 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:  Help.ChairsideSplint@gmail.com