headaches ,orthodontics ,approach ,symptom ,classification, therapy,trigger point,tmj disorders

1. Università degli studi di Cagliari
Scuola di Specializzazione di Ortognatodonzia
Prof Vincenzo Piras
Headaches in adults and
orthodontics: reality or chimera?
Enza Robotti Morena Toselli

2. APPROACH TO HEADACHES
•Nearly everyone will
experience headaches at
some time in their lives.
•Up to 10 million people
•World Health Organisation
as being among the most
disabling disorders.
Cefalea is a symtom
that may indicate situational pathological differences

3. WHY DO HEADACHES NEED A
CLASSIFICATION?
• Uniformity
• Communication
• Standardized approach to research
• Formulating treatment guidelines

4. HISTORY
• Thomas Willis, in De Cephalalgia
in 1672
• 1787 C. Baur: idiopatic and
symptomatic
• 1960 World FEDERATION of
NEUROLOGY
• 1988 ICHD I
• 2004 ICHD II
• 2013 ICHD III beta January

5. What should be discussed when you
see a patient with a headache during
the first consultation.
• How many different headaches
you have
• How often you get them
• How old you were when they
started
• A list of current and previous
treatments and medications
• Trigger factors

6. DIAGNOSIS
• NO specific diagnostic tests for
primary headaches
• exclusively in the case of
secondary headaches
YES if there are any danger signs
• Depends on the patient’s history
Family history, Allergies, Life habits

7. AN OVERVIEW OF INTERNATIONAL
CLASSIFICATION 2013 ICHD III beta
Headache
Primary Secondary
Migraine
Tension type headache
Cluster
Miscellaneous
Intracranial
Paracranial
Extracranial

8. What is a “Migraine”?
Migraine without aura Migraine with aura
•duration 4 – 72 hours
•At least two of the following
are experienced
-Unilateral location
- Pulsating quality
- Moderate/severe intensity
- Aggravated by activity
•Accompanied by at least one of
the following:
- Nausea
- Vomiting
- Photophobia and/or
phonophobia
•No evidence of organic disease
•Patients with migraine
experiences many
symptoms have other
than headaches.
•Some of these occur
during headaches, some
occur before and some
after the headache has
stopped.

9. • vision(visual aura)
• sensations (sensory aura)
• Strength (motor aura
Typical migrainous visual distortion -
"Alice in Wonderland Syndrome”

10. Tension-type headaches
• > 10 attacks lasting 30 min/7 days
• > 2 of the following four: bilateral, not pulsating, mild
or moderate intensity, not aggravated by routine
physical activity
• No nausea or vomiting
• One or neither of photophobia or phonophobia
• Not attributable to another disorder

11. Secondary Headaches
Intracranial
Paracranial
Extracranial
•Head trauma
•Vascular
disorders
•Nonvascular
disorders
•Disorder of :
-cranium
-neck
-eyes
-nose
-sinuses
-teeth
•Substances or
their withdrawal
•Noncephalic
infection
•Metabolic
disorder

12. “Worst headache of my life”
Subarachnoid hemorrhage
•Headache occurs in
about 90% of
Subarachnoid
hemorrhage patients
•Classic: acute, severe,
continuous
•Associated with
nausea, vomiting.
•Can be fatal.

13. HEADACHE treatments
•Reassure and educate patient
•Pharmacotherapy
-Identify and remove triggers
•Start a wellness programme: exercise,
balanced meals, adequate sleep, smoking
cessation
•Physical therapy
•Psychological therapy

14. Migraine Triggers
•Stress and emotion
•Hormonal changes
•Diet
•Environmental factors
•Too much or too little
sleep
•Physical factors

15. COMORBIDITIES
MIGRAINE
DEPRESSIONSLEEP

16. THE MIGRAINE PERSONALITY
•Intelligent
•Compulsive
•Perfectionistic
•Working hard
• Life stresses
• Weekend or during a vacation
• Headache attack.

17. Temporomandibular Disorders
American Academy of Orofacial Pain: “Guidelines for Assessment,
Diagnosis, and Management”
General management principles for TMD include:
• Pain control
•Increasing mandibular mobility with exercise
•Splint therapy
•Behaviour interventions
•Surgical intervention with arthrocentesis or
arthroscopy

18. THERAPY
• Improve the patient’s
quality of life.
• Key to effective
managment of an acute
migraine attack is
• EARLY RECOGNITION
•EARLY TREATMENT.
•Mistake is to wait
•ALLODYNIA

19. Triptan
•Identify the migraine process/early intervention
•Select the best medication for each patient
•Instruct in proper medication use
•Encourage headache diares
•Achieve a pain response by 2 hours

20. SPREADING DEPRESSION(SD)
J Headache Pain. 2013 Jul 23;14:62. doi: 10.1186/1129-
2377-14-62.
Cortical spreading depression as a target for anti-migraine
agents.
Costa C1, Tozzi A, Rainero I, Cupini LM, Calabresi P, Ayata C,
Sarchielli P.
• Is a slowly propagating wave of neuronal and glial
depolarization lasting a few minutes, that can develop
within the cerebral cortex or other brain areas after
• electrical
• mechanical
• chemical depolarizing stimulations.
• SD has been shown to be a common therapeutic target
for currently prescribed migraine prophylactic drugs.

21. BEHIND CEPHALOMETRIC TRACING IS THE BRAIN OF THE
PATIENT
ORTHODONZIA
HEADACHE

22. TAKE HOME MESSAGE
• NO diagnosis in the first consultation
• Patient to compile a history diary of headaches
suffered
• Classify the patient’s information to correspond
with ICHDIII
• Key to effective managment of an acute migraine
attack is EARLY RECOGNITION and EARLY
TREATMENT
• Palliative care
• Headaches and orthodontic therapies can work
together but in specific ways.

23. THANK YOU
FOR YOUR KIND ATTENTION