Caring for Face Pain and Sleep Apnea
Rich Hirschinger, DDS, MBA
Diplomate American Board of Orofacial Pain
9615 Brighton Way, Suite 323
Beverly Hills, CA 90210
888.981.8981
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Archive for the ‘Headaches’ Category

How to Do a Quick Brain Concussion Assessment

Posted on: March 31st, 2017 by Dr. Rich Hirschinger No Comments

After a head injury, such as those that occur after being involved in a bike accident, any layman can do a quick assessment of the injured person to check for a sign of a possible brain concussion.

It is not important that you remember all the information below. If you only remember some of these questions, and you get responses that seem abnormal, you should get the person emergency medical care as soon as possible.

The first step is to determine if they are “alert and oriented times four” by asking them the following questions:

  1. What is their name?
  2. Where are they?
  3. What are the time and date?
  4. What just happened?

Then ask them some or all of the following questions and observe their responses.

  • Ask them to repeat back to you, and remember, three simple words such as, “dog, boat, and orange.” Then have a 5-minute conversation with them. At the end of the conversation, ask them to repeat the three words you told them to remember.
  • Ask them to spell the word “world” backwards.
  • Have them follow your finger with just their eyes. Move your fingers up and down and make an “X.” Both eyes should be able to track the movement of your fingers.
  • Ask they dizzy, nauseous, or do they have a headache?
  • Is their speech is normal?
  • Is their behavior normal?
  • Are their pupils the same size?
  • Are they sensitive to light and/or sound?
  • Are they getting more and more confused, restless, or agitated with your questions?
  • Do they have any weakness, numbness, or decreased coordination?

Again, it is not critical that you remember everything listed on this page. This is a quick assessment to check for a brain concussion, and it is always better to error on the side of caution and have the injured party evaluated by a medical professional if you get any sense that something is not normal.

It is also important that you stay with someone who was injured until professional help arrives. Just think if the roles were reversed and your head was involved in the accident, or even if your head was fine but you were injured. Wouldn’t you want someone to stay with you?

What is a migraine?

Posted on: February 28th, 2017 by Dr. Rich Hirschinger No Comments
migraine, dr. rich hirschinger, beverly hills headache

This is a typical location for a migraine.

A migraine is a primary headache, which means there is no other cause of the headache such as a tumor or a stroke. The following is based on the criteria developed by the International Headache Society. If you memorize “5472 PUMA PPNV” then you know how to diagnose a migraine. Let me break down the acronym.

5472 – a history of 5 headaches lasting between 4 and 72 hours.

PUMA – at least two of these four features must be met.

  1. Pulsating
  2. One-sided
  3. Moderate to severe
  4. Aggravated by exertion or the avoidance thereof

Some people think a migraine must be one-sided but that is not the case.

PPNV – if the above criteria are met then the headache must also meet one of the following two criteria:

  1. Photophobia (light) and phonophobia (sound) sensitivity. It must have both to meet the criteria.
  2. Nausea and/or vomiting

To clarify, nausea alone meets the criteria. If you don’t have nausea then you must have light and sound sensitivity or vomiting to meet the criteria.

A study in 2003 asked migraineurs these three questions.

  1. Has a headache limited your activities for a day or more in the last three months?
  2. Are you nauseated or sick to your stomach when you have a headache?
  3. Does light bother you when you have a headache?

Patients who answer positively to two out of these three symptom questions have a 93% chance of a migraine diagnosis and, if all three are answered positively, there is a 98% chance of a migraine diagnosis.

Aura

Some migraineurs experience an aura. An aura can be visual such as seeing flashing lights, sensory such as tingling, or motor such as slurred speech. Here is a very unique video of a CBS reporter in Los Angeles having a motor aura, which preceded a migraine, on live TV.

There are many different options when treating migraines, which I treat at my Beverly Hills office. There are abortive medications to stop an existing migraine, and there are preventative medications, which are drugs taken daily to reduce or prevent the migraines from occurring. One thing I do know is that migraines are not typically related to how your teeth meet so I would never recommend a dentist grinding your teeth to help with your migraine headaches. I would be happy to answer any questions you might about your migraine or other type of headache.

Putting Enough Force on Anything Is Not Good

Posted on: September 30th, 2014 by Dr. Rich Hirschinger No Comments

The rage the past few days has been that the new iPhone 6 Plus bends if you put enough force on it, or if you sit on it when it is in your pocket. Here is the YouTube video that brought it to the attention of millions of people:

What does that have to do with facial pain? Everything. Most people who own an iPhone are not going to deliberately try to bend their phone just like most people will not try to deliberately overwork their facial muscles. My point is that everything has a tipping point, which is a point at which something will break, or in the case of facial muscles, a point that will cause pain.

Dr. Rich Hirschinger Beverly Hills Facial Pain Migraines Headaches

The superficial masseter is the strongest muscle in our body in pounds per square inch.

The superficial masseter, which is a very strong muscle, and is one of four closing muscles, is a muscle that does a lot of work during the day due to chewing, talking, and swallowing, and, it is working extra if you clench your teeth during the day, bite your nails, chew gum, etc. At night, it really goes to work since most people clench and/or grind their teeth at night. We really do not know why people clench and/or grind their teeth. There are a lot of theories but there is no definitive answer, and there is no medication that we can give to a patient to get them to stop the habit. There are medications that can increase clenching and/or grinding such as SSRI’s, which stands for selective serotonin reuptake inhibitors. These are anti-depressant medications, and the common brand names are Prozac, Celexa, Zoloft,Paxil, and Lexapro.

If you start to feel pain in your jaw or in your temples, you are likely overworking your closing muscles, and they need a break. Stretching is something that I have almost every patient  in my Beverly Hills facial pain and migraine headahce practice do, and my favorite way to have them stretch is to use a wine cork. It must be measured to the appropriate length so don’t just try sticking a cork in your mouth and expect to get better.

I do not recommend that you try to bend your new, or old, iPhone to see if you can bend it because there will be a point at which it will bend. For the same reason, I do not recommend that you clench your teeth during the day and chew gum for three to four hours a day for months on end since you will likely end up with facial pain and/or headaches. If you do have facial pain, please feel free to give me a call at 888.981.8981. In the meantime, I guarantee you that you can bend a paper clip if you try but if you use it for its intended purpose, it will be useful as a paper clip for many years. Treat your mobile phone, and your facial muscles the same way.

But Doc I Take That Medication For My Headache

Posted on: August 18th, 2014 by Dr. Rich Hirschinger No Comments

“Yes, I agree with you. You are taking that medication for your headache. In other words, the medication you are taking is what is causing  your headache.” I have have that conversation with many patients in my Beverly Hills facial pain practice for people who suffer from migraines, tension-type headaches, cluster headaches and many other headaches. A medication is not always safe to take just because it is over-the-counter or because your doctor prescribed it for you. We name these headaches “medication overuse headaches” or MOH for short. MOH’s are also called rebound headaches because as your body eliminates the medication you have been taking, it starts to crave the medication, you get another headache so you take more of the medication, which helps the headache until your body starts eliminating the medication again, and you are stuck on a vicious cycle.

Medication that are combinations of different drugs are the usual culprits. These include Excedrin for Migraine, Excedrin Extra Strength , Fiorinal, Fioricet, and medications with Soma. As a matter of fact, Excedrin for Migraine and Excedrin Extra Strength are the exact same medication even though Excedrin for Migraine usually costs more as you can see below.

Fiorinal and Fioricet both contain butalbital, which is a barbiturate, and caffeine plus an analgesic. The difference between these two medications is that Fiorinal contains aspirin, and Fioricet contains acetaminophen, which is known as Tylenol.

As a point of trivia, the Rolling Stones wrote a song named, “Mother’s Little Helper,” which is about Soma. It does help but it is short lasting, so you take another pill, which then wears off. This cycle continues until you need to take yet another one for the headache that will be caused by your body wanting more of the medication.

Many other drugs taken in excess can cause a medication overuse headache. Triptans, such as Imitrex, Maxalt, and Replax, which are designer drugs specially targeted to abort migraines, should not be taken more than nine times a month. If you are taking more than that, part of your headache could be due to medication overuse headache.

If you have a headache for more than 15 days in a month, if you overuse medications on a regular basis for more than 3 months, and if your headache has developed or markedly worsened during that time you have been taking the medication, then your headache could be completely or partly due to medication overuse headache.

Excedrin for Migraine Excedrin Extra Strength Beverly Hills Headaches

Marketing, and the color of the box, is the only difference between these two products.

Excedrin for Migraine and Excedrin Extra Strength have the same ingredients milligram for milligram.

Excedrin for Migraine and Extra Strength Excedrin have the same ingredients milligram for milligram.

Excedrin for Migraine usually costs more than Excedrin Extra Strength. Why? Maybe because it has the word "migraine" and maybe because red ink costs more.

Excedrin for Migraine usually costs more than Excedrin Extra Strength. Why? Maybe because it has the word “migraine” and maybe because red ink costs more. Both boxes contain 300 caplets. The price per caplet for Excedrin Extra Strength is 4.7 cents and the cost per caplet for Excedrin for Migraine is 5.1 cents. That equals a 10% premium for Excedrin for Migraine.

References:
Current Opinion in Neurology:
June 2004 – Volume 17 – Issue 3 – pp 301-306
Medication overuse headache
Limmroth, Volker; Katsarava, Zaza

Drug Safety
October 2001, Volume 24, Issue 12, pp 921-927
21 Nov 2012
Medication overuse headache
Zaza Katsarava, Hans-Christoph Diener, Dr Volker Limmroth

CONTINUUM: Lifelong Learning in Neurology:
August 2012 – Volume 18 – Issue 4, Headache – p 807–822
Medication-Overuse Headache
Tepper, Stewart J. MD

Tension-Type Cluster Paroxysmal Hemicrania Continua and SUNCT Headaches

Posted on: November 17th, 2013 by Dr. Rich Hirschinger 1 Comment

Tension-Type Headaches and TAC Headaches

In my last post, I explained how to diagnose a migraine based on the International Headache Society criteria. This post will focus on two other categories of primary headaches that I treat at my headache and chronic head and neck pain practice in Beverly Hills, CA. The two are tension type headaches, and the trigeminal autonomic cephalgias, which is a very fancy term that describes several headaches that I will explain below.

Beverly Hills near Los Angeles tension type headaches

Tension-type headaches feel like a tight band around your head.

Tension-type Headaches

Tension-type headaches are the most common type of primary headache known to man. Primary headaches are headaches without any other cause such as a tumor, a stroke, head trauma, etc. The diagnosis of a tension-type headache is based on the follow criteria:

  1. The headache lasts between 30 minutes and one week.
  2. The headahces has two of the following four criteria:
    1. bilateral location
    2. Pressing/tightening (non-pulsating) quality
    3. Mild or moderate intensity
    4. Not aggravated by routine physical activity such as walking or climbing stairs
  3. And both of the following:
    1. It can have either photophobia (light sensitivity) or phonophobia (sound sensitivity) but not both.
    2. No nausea or vomiting.

If the criteria above is met, then a diagnosis of tension-type headache is made.

Trigeminal Autonomic Cephalgias

Three are four headaches in this category. All are one-sided headaches, which have autonomic involvement. The autonomic nervous system is the type of reaction that humans cannot typically control such as heart rate, respiratory rate, digestion, salivation, perspiration, pupillary dilation, urination, and sexual arousal. When it comes to the trigeminal autonomic cephalgias, the signs that occur are eye redness, eye tearing, runny nose, droopy eyelid, nasal congestion, and forehead and facial sweating on only one side of the face.

Cluster headache Dr. Rich Hirschinger Beverly Hills

Cluster headaches occur in and around the eye on one side of the face.

Cluster Headache

The diagnosis of a cluster headache is based on the following criteria:

  1. A history of at least 5 attacks
  2. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated
  3. Headache is accompanied by at least one of the following:
    1. Same side eye redness and/or tearing
    2. Same side nasal congestion and/or stuffy nose
    3. Same side eyelid swelling
    4. Same side forehead and facial sweating
    5. Same side constriction of the pupil and/or droopy eyelid
    6. Sense of restlessness or agitation
  4. The attacks have a frequency from one every other day to eight per day.
  5. The headache is not attributed to another disorder.

Paroxysmal Hemicrania

The attacks of paroxysmal hemicrania are similar in characteristics of pain and associated symptoms and signs to those of cluster headache, but they are shorter-lasting, more frequent, occur more commonly in females and respond absolutely to indomethacin, which is a non-steroidal anti-inflammatory medication in the same class as aspirin.

The diagnosis of a paroxysmal hemicrania is based on the following criteria:

  1. At least 20 attacks fulfilling criteria 2-4
  2. The attacks of severe same side orbital, supraorbital (above the eye) or temporal pain (pain in the temples) lasting between two to thirty minutes.
  3. Headache is accompanied by at least one of the following, which must occur on the same side as the headache:
    1. Same side eye redness and/or tearing
    2. nasal congestion and/or stuffy nose
    3. eyelid swelling
    4. forehead and facial sweating
    5. constriction of the pupil and/or droopy eyelid
  4. The attacks have a frequency above 5 per day for more than half of the time although periods with lower frequency may occur
  5. The attacks are prevented completely by therapeutic doses of indomethacin.
  6. The headache is not attributed to another disorder.

SUNCT

SUNCT is an acronym that stands for “Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing.” This headache is very rare and is characterized by short-lasting attacks of same-sided pain that are much briefer than those seen in any other trigeminal autonomic cephalgias, and very often accompanied by prominent eye tearing and redness of the eye on the same side as the headache.
The diagnosis of a paroxysmal hemicrania is based on the following criteria:

  1. At least 20 attacks fulfilling criteria 2-4
  2. Attacks of unilateral orbital, supraorbital  (above the eye), or temporal stabbing or pulsating pain lasting 5-240 seconds
  3. Pain is accompanied by same side eye redness and/or tearing
  4. The attacks occur with a frequency from 3 to 200 per day.
  5. The headache is not attributed to another disorder.

Hemicrania Continua

This headache is persistent strictly one-sided headache responsive to indomethacin, which is a non-steroidal anti-inflammatory medication in the same class as aspirin.
The diagnosis of a hemicrania hemicrania is based on the following criteria:

  1. A headache for greater than 3 months fulfilling criteria 2-4
  2. All of the following characteristics:
    1. same-sided pain without changing sides
    2. daily and continuous, without pain-free periods
    3. moderate intensity, but with exacerbations of severe pain
  3. At least one of the following autonomic features occurs during exacerbations and on the same side of pain:
    1. redness and/or tearing
    2. nasal congestion and/or stuffy nose
    3. constriction of the pupil and/or droopy eyelid
  4. Complete response to therapeutic doses of indomethacin
  5. Not attributed to another disorder

Next weeks post will discuss the fourth category of primary headaches, which are the Other Primary Headaches, and the following week I will start to discuss the different ways to treat all of the primary headaches.

Respectfully,

Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine
www.LoveOFP.com
888.981.8981

Headache is Not a Diagnosis

Posted on: October 13th, 2013 by Dr. Rich Hirschinger 2 Comments

Headaches Explained by Dr. Rich Hirschinger Beverly Hills

I learned very early in the first few days of my two year orofacial pain residency at UCLA that “headache is not a diagnosis.” Every time I make a diagnosis of a type of headache it is based on the criteria of the International Headache Society. This post will help you  understand what type of headache you might have and will focus primarily on migraines.

It is very important to understand the difference between a primary headache, and a secondary headache. A primary headache is a headache that is not attributed to another disorder. A secondary headache is a headache that is attributed to another disorder such as a tumor, a stroke, a brain bleed, etc. In other words, there is nothing else causing a primary headache whereas a secondary headache is caused by something else.

I use several acronyms to remember the various types of headaches, some of which I learned from others and a few that I created myself. One of the acronyms I learned from others is SNOOPS. These are the “red flag” signs of headaches that require immediate attention.

S stands for systemic, which include symptoms such as a fever, and weight loss.
N stands for neurological, which includes symptoms such as confusion, altered level of consciousness, or numbness.
O stands for onset such as a very sudden, abrupt, split second onset of the headache.
O stands for older. If you are older than approximately 50 years of age, and the headache is a new onset or progressive, that is a red flag.
P stands for previous history of headaches. If you have a previous history of a headache but this headache is new or different, if there is a change in attack frequency, severity or clinical features then that is a red flag.
S stands for secondary risk factors. If you have a systemic condition such as HIV, or systemic cancer along with the headache that is a red flag.

If you have any of these red flags, immediate attention in an emergency room is the best course of action.

Primary Headaches

There are four categories of primary headaches, which are:

  1. Migraine
  2. Tension-type headaches
  3. Cluster headache and other trigeminal autonomic cephalalgias
  4. Other primary headaches

Migraine

Beverly HIlls Migraine Headaches

Over 60% of migraines are unilateral

There are many types of migraine headaches but the main type of migraine headache is easy to diagnose based on the International Headache Society criteria. The acronym I created to remember the criteria is 5472 PUMA PPNV ACE. Let me explain how to interpret the acronym so that it makes sense.

Many people think that since they have a headache it is a migraine. This could not be further from the truth. Just like headache is a not a diagnosis, if you have a headache, it does not necessarily mean you have migraines. If you meet the following criteria, then you have a migraine.

Migraine Criteria 5472 PUMA PPNV ACE

5472 – If you have had 5 headaches in your life lasting between 4 and 72 hours that was untreated or did not respond to treatment, then move to the next set of criteria to see if you have a migraine headache.

PUMA – If you have two of the four PUMA criteria during the headache, then move to the next criteria to see if you have a migraine headache.

  1. P stands for pulsating, throbbing type of headache.
  2. U stands for unilateral. Over 60% of migraines are unilateral, which means a one sided headache.
  3. M stands for moderate to severe.
  4. A stands for aggravation with exertion meaning the headache gets worse if you walk, run, work out or exert yourself.

PPNV – If you have one of the following criteria during the headache, including the above criteria, then you have met the diagnosis of a migraine.

  1. Photophobia and phonophobia. Photophobia means that the headache causes you to be sensitive to light, and phonophobia means that the headache causes you to be sensitive to sound.
  2. Nausea and/or vomiting.

ACE – If the criteria for migraine has been met then ask if there is an aura, and how frequent the migraine headaches occur.

A stands for aura. Aura’s can be positive or negative, and they can be visual or sensory, and the symptoms are completely reversible.
C stands for chronic. If you get 15 or more migraines a month, it is a chronic migraine.
E stands for episodic. If you get less than 15 migraines a month, it is an episodic migraine.

Aura – An aura gradually develops over a period of about 5-20 minutes and lasts for less than an hour.The aura can be fully reversible visual symptoms like lines, spots, or beautiful colors, which are all positive auras meaning you see something extra, or holes in the visual field called scotomas, or gray spots, which are all negative auras meaning you see something less than you usually see. The aura can also be fully reversible sensory symptoms such as like pins and needles, or numbness, which is a positive aura, or slurred speech, which is a negative aura.

Based on the above criteria, you should be able to know if you truly suffer from migraines. In the next post, I will discuss how to treat migraines, which is based on both abortive treatments, meaning how to treat the migraine after it starts, and preventative treatments, meaning how to help prevent migraines from occurring.

Quick Migraine Symptom Diagnosis

Having stated all of the above, research shows a very simple way to determine if you have a migraine by answering the following questions.

  1. Has the headache limited your activities for a day or more in the last three months?
  2. Are you nauseated or sick to your stomach when you have a headache?
  3. Does light bother you when you have a headache?

Patients who answer positively to two out of these three symptom questions have a 93% chance of a migraine diagnosis and, if all three are answered positively, a 98% chance of a migraine diagnosis. If think you have a migraine, or if you know you have migraines but the previous treatments have not been helpful, you can request an appointment at my Beverly Hills migraine headache office. As always, I’m happy to try to answer any questions you might have.

Respectfully,

Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine
www.LoveOFP.com
888.981.8981