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Wexley Headache & Medical Clinic
739 N. Fairfax Ave.
Los Angeles, CA 90046
Tel. (323) 655-3933

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Orofacial Pain Education

Orofacial Pain HeadacheTriggers do not cause migraine but, rather, turn on the central switch to initiate the process. Many migraine patients are unusually sensitive to internal (within the body) and external (outside the body) changes. See table #1.

TABLE #1 Triggers of Migraine


Chronic fatigue, too little sleep, too much sleep

Change in sleep-wake cycle from travel or shift work

Emotional stress, letdown after the stress is over

Hormonal fluctuations (menstrual cycle)


Weather and seasonal changes

Travel through time zones


Skipping or delaying meals

Sensory stimuli

Flickering or bright lights, sunlight

Odors, including perfume, chemicals, cigarette smoke

Heat, loud noises



Tetracycline (an antibiotic)

High doses of vitamin A

Some antidepressant medications (selective serotonin reuptake inhibitors or SSRI)

Some blood pressure medications

Monosodium glutamate (MSG)(a food ingredient)

NutraSweet  (a food ingredient), Equal (a sugar substitute, possibly Splenda (an artificial sweetener)

A variety of factors can trigger an explosive migraine attack. The menstrual cycle is clearly a significant trigger in the great majority of women with migraine, and this is associated with and may be caused by a decrease in estrogen levels; however, hormonal triggers are rarely a cause of chronic daily headache.

A second trigger for migraine is food; many food types can trigger migraine in susceptible  patients. While many alcoholic beverages are common triggers, red wine, beer and champagne are the drinks most frequently mentioned by patients. The dark-colored alcohols (scotch, bourbon, dark run, and red wine) appear more likely to trigger migraine attacks then the light-colored ones (gin, vodka, white, run, and white wine). 

Many foods (see Table #2), particularly those that contain tyramine (such as strong cheddar cheese), trigger migraine, but only in some people. Patients seem to have individual sets of triggers that are problematic for them and not necessarily for other.  To reiterate, food triggers bring on migraines, but are not generally a cause of daily headaches.

Caffeine is a double-edged sword. Because caffeine may help constrict the dilated blood vessels during a migraine attack, it is used in combination medicines to increase relief from headache (eg, Excedrin Migraine is a combination of acetylsalicylic Acid (Aspirin), acetaminophen (the analgesic in Tylenol), and caffeine; Fiorinal contains caffeine; Cafergot contains caffeine, as does Anacin).


Table #2 Dietary Triggers

Chocolate, onions, NutraSweet, Equal (aspartame), Splenda (sucralose)

Nuts, pizza, canned figs, peanut butter, avocado, aged cheese

Bananas, processed meats, caffeine

Alcoholic beverage, eg, red wine

Hot dogs, pepperoni, sausages, bacon, ham, bologna, salami,

Pickled or fermented foods


Sour cream

However, habitual consumption of too much caffeine can make headaches worse.

How much caffeine is too much? Some patients are sensitive to the small amount of caffeine (approximately 100mg) in one small (8oz) cup of strongly brewed coffee.  Many patients who complain of headaches on Saturday or Sunday mornings take in their coffee later in the morning.  Headaches that occur under these circumstances could be due to caffeine withdrawal and are more likely to occur in people who are accustomed to drinking more then 300mg of caffeine per day (about three cups of coffee).  At 500mg per day or above, caffeinism, with symptoms that include disturbed sleep, anxiety, nervousness, rapid or irregular heartbeat, and irritability, may occur. Table #3 lists the caffeine content of various products and foods.  Gourmet coffees can have over 500 mg of caffeine per large-sized beverage.

Some triggers, such as caffeine when exposure is frequent, can actually lead to the transformation from occasional headaches to chronic daily headache.  That is, if people with migraine consume excessive caffeine frequently or analgesics often, especially those containing caffeine such as Excedrin and Anacin, then these substances actually result in daily headaches.  It takes only about 10 days of overuse of these substances per month over several months to take a patient susceptible to this transformation to daily headache. When consumption of these medications is at 10 or more days per month, and the headaches worsens in terms of frequency, severity or duration then medication-overuse headache, as manifestation of daily headache, is likely.

Thus, it is important to remember that caffeine is a medication and that overuse of caffeine can lead to a headache.

Perhaps overuse of caffeine turns on the central generator as a cause of daily headache, or the patient with excessive caffeine use is in constant caffeine withdrawal, thus developing daily headache as a manifestation of daily withdrawal.



Many people think that sinus disease is a common cause of their frequent headaches, but it is not.

Headache is a minor feature of acute sinus infection,and occurs rarely. Headache is not usually a feature of chronic sinus disease. Migraine is commonly associated with red eyes, tearing, nasal stuffiness, postnasal drip, and congestion, as the parts of the brain that cause migraine also causse these phenomena. 

The term sinus headache was invented by advertisers to sell decongestants and over-the counter antihistamines. In fact, ear, nose, and throuat doctors do not recognize "sinus headaches" in their llist of diagnoses. People commonly mistake migraines for "sinus headaches", and a study in 2004 of close to 3,000 people with either self-diagnosed or doctor-diagnosed "sinus headaches" found that around 90% of these headaches were migraine, while only 8 patients out of 2,991 people evaluated with "sinus headaches" had acute sinus infections.  Thus, diabling headaches that last for 1 to 3 days, that occur several times per months, and that are associated with weather treggers, nasal stuffiness, clear drainage, tearing eyes, or postnasal drip are usually migraine.

Acute sinusities is generally associated with fever, red-hot skin over the involved sinus, and a yellow-green, bad-tasting or -smelling discharge from the nostrils and back of the throat.  Any headache associated with fever or infection must be treated immediately as an emergency.  A severe acute sinus problem may trigger a typical migraine attack.

The rare forms of sinusitis that can cause very serious headaches and can be life-threatening.  These infections usually cause a change in headache pattern and a lock of response to previously effective treatment, which should always prompt a consult with a doctor.  One such type is called sphenoid sinusitis, and it is diagnosed by CT or MRI of the sinuses. 

Chronic sinusitis is not a cause of chronic daily headaches.  This remarkable fact, validated by the International Headache society, should reassure those with daily or frequent headahces and help them look for other causes for their headaches or start treatment for one of the primary headache disorders, such as chronic migraine.

There is a rare cause of daily headche related to the sinuses that may be difficult to diagnose. This ocurs when a small bone sticks into a part of the sinuses, and is called contact point headache.  It is very rare, and those with this disorder have one-sided headache that must be distinguished from hemocrania continua (another headache disorder).


Orofacial Pain Treatment

Alternative Headache Treatments

Safe and Effective Ways to Treat Your Headaches

Many traditional treatments for headaches are common and well-known, and finding alternative headache treatments will give you so many more options for treating your pain. At least eight separate alternative treatments have been studied, documented and considered to be not only safe, but effective. 

1. Feverfew

Feverfew (Tanacetum parthenium) is a common medicinal herb. It has been used for centuries to treat conditions, such as fever, arthritis and digestive problems. Feverfew interacts with serotonin and prostaglandin pathways, two substances in the body thought to contribute to blood vessel spasm and subsequent headaches. Multiple double-blind trials and safety studies have shown Feverfew to be an effective and safe treatment for headaches. One caution with feverfew is that it increases bleeding times (blood takes longer to clot) and may interact with Warfarin (Coumadin). 

2. Butterbur Root Extract

Butterbur root extract (Petasites hybridus) is another common medicinal herb used historically to treat pain, fever and spasms. It is mainly used today to treat asthma and headache. It has been shown through research trials to prevent migraine as well. It is an anti-inflammatory substance, inhibiting the COX enzymes as well as interacting with calcium channels. COX enzymes are involved in inflammatory processes in the body. Since butterbur contains chemicals toxic to the liver, it has to be prepared through a patented process. This safe herbal extract is marketed under the name Petadolex.

3. Riboflavin 

Riboflavin (Vitamin B2) has been studied using a daily dose of 400 mg. It is typically split into smaller doses taken multiple times daily. Your healthcare practitioner can help you determine the best way for you to use it. Riboflavin is considered safe to use in pregnancy and is a common alternative treatment for headaches during pregnancy. One drawback is that Riboflavin can take several months to produce the maximal effect.

4. Magnesium

Magnesium is a mineral necessary to our diet. It can also be used to treat and prevent headaches. Intravenous (IV) magnesium seems to be quite effective in treating an acute headache. Magnesium can also be taken orally in doses of 400 mg to 600 mg per day. One potential drawback in using magnesium orally is that one study found patients had an increased chance of developing diarrhea.

5. Acupunture

Acupuncture is an ancient form of Traditional Chinese Medicine (TCM) that is gaining popularity in the Western medical community. The National Headache Foundation used 14 separate clinical trials discussing acupuncture in the treatment of headaches. While no single study definitively shows acupuncture to be effective, some patients are experiencing relief from their headaches through its use. Acupuncture is considered a safe treatment for headache.

6. Congnitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a counseling technique effective in treating a variety of mood disorders, including anxiety and depression. It involves identifying negative thoughts and attitudes that may contribute to a headache, developing an action plan to deal with the headache and encouraging patients to come up with a long-term treatment solution. CBT has been used with other behavioral techniques, but is quite effective on its own.

7. Biofeedback 

Biofeedback is a technique that uses external monitoring to help a patient discover how his body responds physiologically to certain situations or stimuli. The patient can then learn, with the help of an experienced practitioner, to alter his own body's response to these outside forces, producing an effective coping strategy. Biofeedback can effectively be combined with other prescription or nonprescription treatments for headaches.

8. Relaxation Training

Relaxation training involves progressive muscle relaxation, breathing exercises and/or guided imagery. Various studies suggest that relaxation training can be as effective as biofeedback for treating headaches. It can also be combined with other forms of headache treatment to provide a more effective and lasting result.

9. Herbs, Vitamins & Minerals (MIGRELIEF)

MigreLief is a product that combines magnesium, riboflavin and feverfew, three natural ingredients that have been shown in scientific trials to prevent migraine headaches. Some people have poor magnesium absorption and require an intravenous injection of magnesium.  MigreLief is made by Natural Science Corporation of America, a company based in Encino, California (800-758-8746). From our office experience MigreLief offers high quality ingredients, the convenience of not having to take a large number of pills (you need 2 tablets of MigreLief daily) and moderate cost. MigreLief is available at Duane-Reade ( and some other independent pharmacies. If you wish to try individual ingredients separately you should take 300-500 mg of magnesium (magnesium oxide or chelated preferred), 400 mg of riboflavin and 100 mg of feverfew. Feverfew often can be of poor quality with low parthenolide content. Stick with well-known American brands or European manufacturers. Other herbal remedies that may help include ginger (root) and peppermint (tea and essential oil applied to forehead). 

10. Vitamins B12

Vitamin B12 and the disorders of the nervous system.

Vitamin B12, also called cobalamine because it contains the rare metal cobalt, is extremely important for the functioning of the nervous system and the production of red blood cells. The medical and scientific communities have recognized the importance of this vitamin for almost 50 years; in fact, two Nobel prizes have been awarded for research on vitamin B12.

Severe deficiency of vitamin B12 can result in serious illness, or even death. Mild deficiency is associated with a lot of pain conditions.Foods that are especially high in vitamin B12 include liver, fish, and dairy products.  There are several conditions, however, that may predispose people to vitamin B12 deficiency. Strict vegetarians and their infants are at risk of vitamin B12 deficiency, as are smokers, people with gastro-intestinal problems or poor absorption of nutrients, or those infested with fish tapeworms.  Several congenital diseases or chronic diseases and certain drugs have also been associated with vitamin B12 deficiency.  For example, the peripheral nerve damage frequently seen in people with diabetes has been attributed to the effect of high sugar levels in the blood; however diabetics have also been found to have lower levels of B vitamins. Although supplementation of these vitamins has not cured peripheral nerve damage in these patients, some improvements have been reported. Recent reports have also described an association of AIDS and multiple sclerosis with vitamin B12 deficiency.  Other neurological problems that are associated with severe deficiency of vitamin B12 include psychosis and dementia as well as symptoms of spinal cord and peripheral nerve damage. Aside from neurological problems, vitamin B12 deficiency can also cause a severe (pernicious) anemia.The effects of mild vitamin B12 deficiency are not so clear. In the past, it was very common for a family doctor to give a patient vitamin B12 injections for a variety of vague symptoms that were assumed to be caused by a mild vitamin B12 deficiency. The injections were necessary because, unlike most other vitamins, vitamin B12 is poorly absorbed when taken by mouth. In recent years, the development of a test to measure the amount of vitamin B12 in the blood has essentially put a stop to this practice, since the test has shown most people to have normal levels of vitamin B12.

A 1988 study published in The New England Journal of Medicine, however, suggested that this test might not be as accurate as was originally thought. The authors of that paper found that people with such symptoms as "pins-and-needles" sensations, unsteadiness, memory impairment, weakness, personality and mood changes, and fatigue had vitamin B12 deficiency that was not detected by the usual test. Only special, more sensitive tests revealed the true level of this vitamin. The editorial that accompanied this article asked, "Could it be that the many cobalamine injections given over the years for vague symptoms were in fact justified?"

Vitamin B12 is inexpensive, has no side effects and very often makes people feel better. In view of this latest information, it may, in fact, make sense for doctors to resume the practice of recommending vitamin B12 for certain vague symptoms.

In our office, when doctor recommends B12, we utilize use the latest development in B12 administration that are alternatives to the injections.

11. Dental Appliances

Many patients with headaches and facial pain are being diagnosed with TMJ syndrome or temporo-mandibular joint disorder. While people who clench or grind their teeth in sleep may have a disorder of the TM joint, it is usually the result of stress and muscle tension.

The intent of the oral or dental appliance as outlined by the American Academy of Orofacial Pain guidelines is to "provide joint stabilizationk protect the teeth, relax the facial muscles, and decrease bruxism.  

In patient's experience it translates to decrese or desapearance of head and face pain, as well as in pain and tension of the neck.

TMJ syndrome often coexists with migraines and tension headaches due to this common trigger. We find that treating the underlying muscle tension with biofeedback, dental appliance, regular aerobic exercise and/or medications relieves all symptoms. 

Another theory is that the jaw muscle pain generated by night time tooth grinding (or bruxism) may serve as a trigger to both Tension Type headaches and migraine headaches in susceptible patients. 

Several studies have found associations between TMDs and headaches.  In patients referred for treatment of TMDs, headache has been reported in more than 70%. This complicates differential diagnosis of head and facial pain, but fortunately there is an extensive classification of headache disorder with detailed diagnostic criteria that has been developed by the International Headache Society.

12. Nerve Blocks and Trigger Point Injections

Many headache patients have muscle spasms around the neck and shoulders. Trigger Point Injections of lidocaine often provide temporary or long term relief, which may be needed prior to starting a program of neck-strengthening exercises and other treatments. 

Headaches can result from "pinched" nerves around the head. This condition is particularly common in elderly headache sufferers and in the case of headaches caused by head or neck injury. The occipital nerve is one of the most commonly affected nerves. Blocking the involved nerve with lidocaine can be very effective in relieving this type of headache.


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