you wake up...
...do you feel fabulous?
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 the most important and most 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.-James P. Boyd, DDS, Developer of the NTI therapeutic protocol.
|To find an NTI
|Dr. Boyd on Good Morning
American, September, 2001: