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
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Posts Tagged ‘headaches’

Dentists Should Not Use Botox For Chronic Pain

Posted on: May 12th, 2014 by Dr. Rich Hirschinger 6 Comments

Yes, I admit the title is somewhat misleading but not by much. What is missing is the word “first.” A dentist, or any physician, should not use Botox as a first choice to treat patients with chronic head and neck pain and/or headaches. I believe that if Botox is used, it should be used last. I do use Botox to treat patients in my private oral facial pain practice in Beverly Hills, CA but if I do use it, I use it last after I have tried other more effective and less expensive treatment options.

If the doctor suspects the cause of their patient’s pain is muscle pain, he/she should try several things before using a medication that might or might not work, that is extremely expensive, and that lasts for about three months. If the diagnosis is not correct and/or if the Botox does not work, the patient spent a lot of money, and the effect of the medication will last for several months.

What can be tried first? The first, and most important step is to establish a diagnosis. If the doctor can replicate the patient’s pain with muscle palpation, then a diagnosis of myalgia, which is muscle pain that does not refer to a remote site, or myofascial pain, which is muscle pain that does refer to a remote site, can be made. I recommend trying basic physical therapy that the patient can do at home. Basic jaw and neck stretching exercises are a great place to start, and I routinely give my Beverly Hills chronic pain patients a cork so that they know how wide they are actually stretching.

Beverly Hills TMJ Cork Rich Hirschinger

A cork is an excellent therapy device. It can be cut with a ramp to give the patient guidance to where they need to be stretching to help reduce their muscle pain. When the return for their follow up visit, they should be able to comfortably open the full length of the cork. If they cannot, they have not been doing their part to help themselves.

A standard cork is 45 mm and it can be cut down in case the patient cannot open that wide. In addition, the doctor needs to try to find what the patient is possibly doing to contribute to their pain. Are they clenching, and/or grinding their teeth? Are they doing an excessive amount of chewing such as using chewing gum? If they cannot stop the clenching habit on their own, I refer them to a pain psychologist who can help them identify what they are doing to contribute to their pain, and and the pain psychologist can do  some cognitive behavior therapy to help make the patients aware of the bad habits that are contributing to their chronic pain.

Ethyl chloride should be tried in the office to see what effect that has on the patient’s pain. If it is beneficial, teach the patient how to use it and write them a prescription. I prefer the bottle to the can since the bottle is colder, and, I believe, much more effective. If you ask me what one “toy” I cannot live without to help my Beverly Hills orofacial pain patients, I would answer, “ethyl chloride.”

During this time a stabilization splint should likely be made. I prefer hard, full coverage appliances. Patients tend to treat soft appliances like a gummy bear by clenching and releasing, clenching and releasing, etc., which can actually increase their pain. Additionally, a nighttime muscle relaxer such as tizanidine or cyclobenzaprine can be considered.

If those steps have not helped reduce the pain, then I recommend trigger point injections using 1% lidocaine without epinephrine. Trigger points are not simply an injection of anesthetic into the muscle so a doctor should understand how to give trigger point injections if they want to treat chronic muscle pain. Epinephrine is myotoxic to muscles and should never be injected into a muscle. It is well known that plain lidocaine only lasts from two to four hours but a trigger point injection can provide pain relief for a week or even longer. The needle is repeatedly inserted into the muscle, which is called “peppering,” and it is the action of the needle that breaks up the pain mediators such as CGRP, Substance P, glutamate and others. If the trigger point injection helps but only for a week, then repeat the trigger point injection and see how long the benefit lasts. If the second round of trigger points only lasts one week that is when I would consider using Botox.

Lastly, the research does not conclusively support the use of Botox for myofascial pain. I’m not saying that it cannot work, and I’m not saying that the pain relief that some patients report after Botox injections does not decrease their pain. What I’m saying is that Botox should be used last after you have tried everything else. I will also state that any doctor who states that they use Botox for TMJ treatment does not know what they are treating since the TM joint is not made up of muscles, and it is important to left the patient know they do not have TMJ but they have muscle pain. The TM joint is a disc. Yes, muscles attach to the joint but the superior head of the lateral pterygoid attaches to the disc, which is almost never the cause of a patient’s pain. The inferior head of the lateral pterygoid can be the cause of a patient’s pain but Botox should never be injected into the inferior head of the lateral pterygoid without electronic muscle guidance and ultrasound. If a doctor is not using guidance to inject into that muscle, there is no way to know where the Botox is actually being injected. Lastly, if a doctor does inject Botox into the superficial masseter, a short needle should not be used since the needle might not penetrate past the parotid gland.

Be safe, be careful, and use Botox last if nothing else works.

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


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.


Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine

What is OFP – Orofacial Pain

Posted on: October 6th, 2013 by Dr. Rich Hirschinger 4 Comments

What is Orofacial Pain?

OFP, which stands for orofacial pain, is a unique branch of dentistry practiced by Dr. Rich Hirschinger at his office in Beverly Hills, California that involves the diagnosis, and management of chronic head and neck pain using very conservative treatment methods. The types of conditions that OFP doctors treat include primary headaches such as episodic or chronic migraines, tension-type headaches, and cluster headaches, myofascial pain, which is a fancy way of saying pain caused by muscles, neuropathic pain such as trigeminal neuralgia, which is pain caused by damage or irritation of a nerve, TMJ, which stands for temporomandibular joint, and obstructive sleep apnea. What OFP does not involve is the treatment of teeth since evidenced-based research shows that chronic head and neck pain is not related to the occlusion, which is how the teeth come together.

Beverly Hills TMJ Migraine Heacaches

Woman suffering from chronic head and neck pain

There are dentists who practice what they call neuromuscular dentistry, which is not taught in any accredited dental school in the United States, who argue that a lot of the chronic pain patients report is caused by the “bite.” They claim that teeth touch about 2,000 times a day when we swallow, and when we chew food. I agree teeth touch when we swallow but it is a light touch that does not involve a full contraction of the muscles that close the jaw and cause the teeth to meet, and teeth rarely touch when chewing since there is food between the teeth. Additionally, we should not walk around with our teeth clenched during the day so we teach patients the “n rest position” so that addresses the issue of any daytime pain being caused by how teeth meet. Both OFP doctors and neuromuscular dentists agree that patients clench and/or grind their teeth at night but this can be addressed by covering the teeth at night with a nightguard, which should be a hard appliance that covers all of the teeth, is not designed to change the bite, and it only worn at night. This addresses the issue of any nighttime chronic pain being caused by how teeth meet since the teeth contact the appliance instead of other teeth. Lastly, Dr. Hirschinger and most orofacial pain colleagues do not use a dental drill to alter or adjust the teeth. That begs the question that if OFP doctors can treat patients with chronic head and neck pain without touching or drilling teeth, why wouldn’t every doctor try treating patients using the same conservative, reversible procedures before trying any other approach?

The goal of this blog will be to educate doctors as well as the public about orofacial pain by discussing the treatment approach I use as well as posting some very interesting cases. Since very few doctors are aware of OFP, very few patients are aware of it. However, orofacial pain is getting more recognition because starting in 2011, the Commission on Dental Accreditation of the American Dental Association has accredited ten post graduate programs in orofacial pain. The first two in 2011 were UCLA, where orofacial pain was founded by Dr. James Fricton, and Kentucky. Dr. Hirschinger was the first graduate from UCLA’s Orofacial Pain and Dental Sleep Medicine residency after it received CODA recognition.

The key part of treating anyone with chronic pain is getting a diagnosis before treatment is started. For the patients I see, headache and TMJ are not considered enough of a diagnosis to initiate treatment. What type of headache is it, and what is causing the pain? If your doctor does not know, then I would suggest that you find someone who can give you a diagnosis.

Please spread the word about this blog by telling your colleagues and friends to sign up to receive notifications of new posts. I look forward to answering any questions you have about any chronic head and neck pain you are personally experiencing, or if you have a question about a patient of yours.

Rich Hirschinger, DDS, MBA
Diplomate, American Board of Orofacial Pain
Member American Academy of Orofacial Pain
Lecturer, UCLA Orofacial Pain and Dental Sleep Medicine