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Background
Headache is a common medical complaint and is generally categorized by one of three syndromes, (i) migraine headache, (ii) tension-type headache, and (iii) cluster headache. Migraine is characterizedby attacks of headache, nausea, vomiting, photophobia, phonophobia, and malaise. Tension-type headache is mild to moderate in intensity, bilateral, and non-throbbing without other associated features. Cluster headache is strictly unilateral, begins quickly without warning, and reaches maximal intensity within a few minutes. It is usually deep, excruciating, continuous, and explosive in quality, although occasionally it may be pulsatile and throbbing. Other headache syndromes may include sinus headache, post-traumatic headache, medication over-use, and temporomandibular joint (TMJ) dysfunction. The typical headache associated with TMJ presents as unilateral ear or pre-auricular pain that radiates to the jaw, temple, or neck. The pain is deep, dull, continuous, and usually worse in the morning. It is typically associated with a limitation of jaw motion and deviation of the jaw upon opening. Physical examination may reveal tenderness of the muscles of mastication and, less commonly, clicking of the joint. Many cases are difficult to distinguish from tension type headaches (Bajwa and Sabahat, 2008).
Pharmacological treatment of headaches is aimed at reversing, aborting, or reducing pain and the accompanying symptoms of an attack, and to optimize the patient's ability to function normally. Most attacks of mild migraine can be effectively treated by anti-emetics followed by analgesics such as aspirin, acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs). Moderate to severe attacks are successfully treated utilizing combinations of ergotamine tartrate, dihydroergotamine, and triptans with anti-emetics, simple analgesics, NSAIDs, and/or opiates. For severe migraine headaches, alternative medications include intravenous administration of neuroleptics such as chlorpromazine (Thorazine) and prochlorperazine (Compazine), occasionally corticosteroids such as prednisone, hydrocortisone, dexamethasone, and methylprednisone, and lastly parenteral narcotic analgesics such as meperidine and the nasal spray butorphanol tartrate (Stadol NS). The acute or abortive therapy of tension-type headache (TTH) ranges from non-pharmacologic therapies to analgesic medications. The treatment of headache due to TMJ primarily involves therapy of the joint disorder itself. Most cases can be treated with local heat, physical therapy, dental hygiene, NSAIDs, and dietary measures (Bajwa and Sabahat, 2008).
Complimentary and alternative therapies for headaches include acupuncture, aromatherapy, biofeedback, Bowen technique (remedial therapy tool to manage pain), chiropractic, cranial electrical stimulation, hyperbaric oxygen therapy, hypnotherapy, massage, nutrition, reflexology, Reiki, spinal/osteopathic manipulation, transcranial magnetic stimulation, and yoga although the effectiveness of many of these approaches has not been established. Recently, it has been suggested that intra-oral dental appliances that are used to reduce the intensity and the amount of jaw muscle activity may be beneficial in preventing headaches.
Advocates of intra-oral appliances for preventing headaches believe that stimulation of the trigeminal nerve through increased cervical as well as mandibular muscle activities (e.g., clenching or grinding the teeth), which can occur when the patient is awake or asleep, may trigger headaches. Intra-oral appliances are thought to aid in controlling clenching and grinding of the teeth, thus, decreasing the possibility of over-stimulating the trigeminal nerve system. These intra-oral dental appliances are pre-fabricated in different configurations covering all or some of either the upper or lower dentition.
An example of an intra-oral device for the prevention of headaches is the Nociceptive Trigeminal Inhibition - tension suppression system (NTI-tss, NTI-TSS, Inc., Mishawaka, IN). It was developed and patented by James P. Boyd, DDS. While the Standard NTI-tss device can be worn indefinitely (while sleeping), the NTI-tss Daytime device is recommended for patients with migraine (in addition to the use of the Standard device) for 4 to 8 weeks during waking hours. The inch-wide device is made of clear plastic and fits over 2 front teeth -- usually but not always the top teeth. It keeps the back teeth from coming together and thus prevents clenching. The NTI-tss is sold in a kit form, and dentists can mold and custom-fit the device to patients’ teeth in approximately 1 hour.
The NTI-tss was cleared by the Food and Drug Administration (FDA) through 510(k) premarket notification in June 2001 for the prevention of medically diagnosed migraine headaches as well as migraine associated with tension-type headaches, and for the prevention of bruxism and TMJ. Thus, the manufacturer was not required to submit to the FDA the evidence of efficacy that is necessary to support a premarket approval application (PMA).
Lamey, et al. (1996) studied the relationship between the nocturnal wearing of an acrylic appliance of 2 mm thickness covering all occlusal surfaces of the teeth (2 appliance designs) and the frequency of migraine attacks in 19 patients who had migraine with or without aura. One design covered the maxillary occlusal surfaces of the dentition while the other design contacted the palatal mucosa only and was free of the occlusion. Treatment outcome was expressed as the number of migraine attacks per week per patient. The occlusal cover appliance reduced the number of attacks on average to about 40% of that normally experienced. The improvement was most marked in those who had frequent migraine attacks (i.e., 2 attacks per week on a regular basis). The authors concluded that acrylic appliance therapy is of value in migraine sufferers who have attacks on waking but the appliance design has to involve covering of the occlusal surfaces of all of the teeth (note: the NTI-tss only covers the front 2 teeth). The drawbacks of this study were that it was a non-randomized study with a small sample size and no long-term follow-up.
Two studies comparing the NTI-tss splint with a standard stabilization splint in the treatment of TMJ have been published (Magnusson, et al., 2004; Jokstad, et al., 2005). Results obtained by Magnusson favored the use of a stabilization splint over the NTI splint. In addition, one subject treated with the NTI-tss splint exhibited an impaired occlusion at the 6-month follow-up. Jokstad found no differences between a standard stabilization splint versus the NTI splint regarding TMJ treatment efficacy over a 3-month period. Both comparative studies were small and neither focused on migraine as an outcome measure. Further studies are needed to determine the effects of the NTI-tss splint on the treatment of headaches, including migraine, as well as possible long-term side effects.
There is insufficient data on the effectiveness of oral appliances in the treatment of headaches. Randomized controlled studies are needed to determine the effectiveness of oral appliances in the treatment of headache.
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