Health Chat with Melissa Young, MD, and Andrew Bang, DC

Friday, December 12, 2014

Description

TMJ and migraine pain can be debilitating for many people. This pain can often stem from overly tight muscles in your head, neck and shoulders. Certain chiropractic and functional medicine techniques can treat the muscular and bone problems that can cause this pain. Join our integrative medicine specialists as they discuss the causes, symptoms, diagnosis and treatment options for this type of pain.

The temporomandibular joint (TMJ) connects the lower jaw (mandible) with the temporal bone of the skull. This flexible, hinging joint allows you to talk, chew and yawn. When this joint along with the muscles on the side of the head and neck are injured, pain can sometimes be felt in the form of headaches, neck pain and pain on the side of the face or head.

Migraines can oftentimes be brought on by clenching or grinding your teeth together. Treating the muscles of the jaw can help you stop your clenching and grinding habits. From the functional medicine perspective, another way to treat migraines is assessing and balancing a sufferer’s diet, nutrient and hormone levels, and gut health based on the results from blood, saliva, urine and stool samples.


About the Speakers

Melissa Young, MD, is an integrative medicine specialist. She completed a two-year integrative medicine fellowship with the Arizona Center for Integrative Medicine at the University of Arizona, Tucson, studying with Dr. Andrew Weil, a pioneer in the field of integrative medicine. To help bridge the mental and emotional aspects of healing, she has done additional training in mind-body medicine with The Chopra Center, The Center for Mind Body Medicine and the University of Massachusetts Center for Mindfulness.

Dr. Young received her medical degree from Albert Einstein College of Medicine in New York in 1995 and completed residency training in internal medicine at Lenox Hill Hospital in New York City in 1998. She is board-certified in internal medicine. In addition to her integrative medicine background, she has training and experience in functional medicine. Dr. Young has written chapters on the Integrative Medicine Approach to the Prevention of Colon Cancer in the first and second editions of the textbook Integrative Medicine by Dave Rakel, MD.

Andrew Bang, DC, joined the staff of the Center for Integrative Medicine in January of 2013. Dr. Bang graduated from Parker College of Chiropractic in Dallas, TX. While completing his clinical internship, he lived in Bogota, Colombia, for three months treating professional and Olympic athletes in all types of sports and was recognized as the top intern of that rotation. Before moving to Cleveland, he also had the opportunity to be one of the team chiropractors for the Texas Wranglers (semi-pro basketball team).

Dr. Bang treats back and neck pain, pelvic pain, shoulder, elbow and wrist pain, hip, knee and ankle pain, as well as guides patients in diet and lifestyle modification. He has advanced training in muscle work, nutritional therapy and extremity manipulation.


Let’s Chat About TMJ & Migraine Pain Relief: A Chiropractic & Functional Medicine Approach


Functional Fundamentals

HM4307: What is functional medicine? A very basic question but I am not sure I know what it means.

Melissa_Young,_MD: Functional medicine (FM) addresses the underlying causes of disease using a systems-biology approach and emphasizes the therapeutic partnership between physician (provider) and patient. FM shifts from the traditional disease-centered model of medicine to a more patient-centered approach, which addresses the whole person, not just an isolated set of symptoms. There is an emphasis on health, wellness and vitality for each person. Functional medicine physicians look at the interactions among genetic, environmental and lifestyle factors that can influence health and chronic disease. It also emphasizes the individuality of each person and is at the cutting edge of personalized medicine.

violetp: Can a functional medicine approach help with dementia? Would you give some insight and ways family members can help an affected person?

Melissa_Young,_MD: It may be helpful in assessing underlying genetic susceptibilities and triggers of an individual's development of dementia. In some cases, treatment recommendations may improve functioning of an individual. I would recommend the patient and family see a functional medicine provider in consultation for this problem.

violetp: Does a D.O. (Doctorate of Osteopathic Medicine) fall under functional medicine? Also, would you explain how the manipulations done to the skull, jaw and face help with TMJ and migraines? Do they lessen or prevent?

Andrew_C._Bang,_DC: A D.O. must go through an additional functional medicine certificate program to claim they use functional medicine in their practice. The TMJ, neck, skull and shoulder work together as a unit. When one dysfunctions, it will affect the other parts of the unit. Migraines are understood as additional pressure in the skull that puts pressure onto the small vessels of the brain, causing pain. When the skull is gently manipulated, it can relieve the pressure off of the vessels and possibly provide relief from the migraine. Because the TMJ, neck, skull and shoulders work together, sometimes you can work on the neck and that will positively affect the pressure in the skull, leading to relief.


Totally TMJ

Gail Ann: Is it possible to have TMJ without migraine headaches? Thank you for answering my question.

Andrew_C._Bang,_DC: They are commonly seen together, but yes you can have one without the other. Some things you should look for when assessing if you have some TMJ pain or discomfort are:

  • Clicking with opening and closing the jaw
  • Pain and tightness in the TMJ muscles with palpation
  • Inability to open your mouth fully
  • Your dentist tells you that you are grinding your teeth down

willes: Can TMJ disorder cause pain at the base of the skull and neck and neuralgia in my face?

Andrew_C._Bang,_DC: Yes. They are called radicular pains. That is when the pain is traveling away from the location of the dysfunction. One way to see on your own if they are related is to press with firm pressure around the muscles where the TMJ is and see if that increases or decreases the symptoms you have listed.

abu63122: Can you recommend any centers in the New York metropolitan area that treat TMJ. My daughter lives near White Plains, works in the Bronx and can easily get into Manhattan. Thank you.

Melissa_Young,_MD:

  • Dr. Frank Lipman, MD, Eleven Eleven Wellness Center
  • Susan Blum, MD, Blum Center for Health
  • Beth Israel Integrative Medicine Center

willes: Can activator chiropractic help TMJ?

Andrew_C._Bang,_DC: Most chiropractic techniques help with TMJ. But in addition to that, exercises are needed to strengthen and create symmetry so the joint works optimally.


Mainly Migraines

violetp: Please explain some remedies that could be done by oneself when there is no functional medicine practice anywhere nearby. How can you find a functional medicine practitioner? Does your Cleveland Clinic Las Vegas location provide services of this sort?

Melissa_Young,_MD: There are many things that someone with migraines can start on their own. The first is to keep a regular schedule. It is important to go to bed and rise at the same time every day and get adequate sleep. It is also important to eat regularly to keep blood sugar levels stable. Inadequate sleep and irregular eating patterns are common triggers of migraine. Certain foods can also be triggers, from foods that have bioactive amines, which dilate blood vessels, such as wine, aged cheese, bananas and avocado, to food intolerances such as gluten, dairy, egg, yeast, corn and soy. I recommend eliminating foods from the diet for three to four weeks, then reintroducing them one at a time to assess the impact on your headaches. Also, stress management techniques such as meditation, yoga and tai chi can be helpful.

B-Bops: What kind of underlying causes might you discover for migraines or TMJ?

Melissa_Young,_MD: There are many potential underlying causes of migraine, which include chemicals in our food that are neurotoxins such as MSG, NutraSweet and artificial flavors and colorings, or chemicals that dilate blood vessels such as aged cheese, wine and chocolate. Food intolerances, stress, nutrient deficiencies and imbalances in cellular energy production are additional triggers of migraine in a genetically susceptible person.

nutzy: I had different kinds of head pain in my life, including that provoked by high blood pressure. With time, I learned how to recognize them and more or less how to treat them. The most difficult pain to handle is the migraine pain. Usually, I have migraine pain in the small side of my head, and it is difficult to continue my activities. Sometimes, I can see an “aura.” It’s best to go into a dark room and close everything if possible. Several years ago, there was a big change in the medical treatment. Could you inform as to what rest in the large use of people with less secondary effects? Thanks a lot.

Melissa_Young,_MD: I am not clear on the question being asked, but there are many treatments of migraine that have few to no side effects, including therapeutic elimination diets, vitamins and mineral supplementation, stress management techniques, exercise, regular lifestyle habits related to sleep and eating regularly, acupuncture and massage therapy.

ohsodizzy22: What do you recommend for those who are sensitive to changes in barometric pressure? I have migraines and chronic headaches and have responded well to BOTOX injections and stress management.

Andrew_C._Bang,_DC: You have a couple of options. 1- You could move to a desert climate where the pressure stays relatively the same.2- There are exercises, stretches or treatments that you could use on an as needed basis to help when the pressure changes.

Abigailcat: Does caffeine play a role in headaches and migraines?

Melissa_Young,_MD: Yes, caffeine can play a significant role as a migraine trigger. I recommend anyone who suffers from migraine avoid caffeine on a regular basis and then have the option to use it for acute treatment of headache, though it is important to remember not to overuse caffeine, as you can get rebound headaches from rebound dilation of blood vessels.

RobinHoodwink: Can you talk about overuse of pain medications as a possible cause of migraines? And what can be done about it?

Melissa_Young,_MD: Migraine sufferers can develop chronic daily headache from overuse of analgesic medications such as acetaminophen, ibuprofen and triptans. Caffeine is included as well. It is important to use these medications no more than two to three times weekly. If you are having more frequent migraines, then a preventive medication or herbal medication is recommended.


Grinding Gridlock

SteveH: I grind my teeth badly. Are there any tools/aids to assist me in breaking the habit? How much does the grinding contribute to my TMJ?

Andrew_C._Bang,_DC: The TMJ muscles are what help you chew. So, the grinding is coming from your TMJ muscles’ inability to relax. To break the habit, you have to retrain the muscles and teach them how to relax. It is hard to know what exercises you need because we have to customize the exercises for each person so the exercises target only the muscles that are dysfunctioning.

LucyintheSkies: Dr. Bang or Dr. Young, you mentioned that teeth-grinding is the result of the TMJ muscles not being able to relax. If I am grinding my teeth, would that correlate to other muscles in my body not relaxing also?

Melissa_Young,_MD: I see systemic (body-wide) impact on muscle tension related to chronic stress, chronic inflammation and magnesium deficiency. I would ask your physician to check a RBC (red blood cell) magnesium level, which assesses cellular stores of magnesium and should be over 6.0. Our soil in the US is very depleted of magnesium, so it can be difficult to get the RDA (smallest dose to prevent frank disease), even if you are eating a healthy diet. I also see a lot of muscle tension and pain related to low-grade, chronic inflammation from a SAD (standard American diet) high in processed foods and sugar, which is depleted of nutrients. It is important for everyone to follow a nutrient-dense, whole-food diet, assess for individual nutrient needs and manage stress to improve pain.

Gail Ann: Is grinding one's teeth always a symptom of TMJ? Thank you for answering my question.

Andrew_C._Bang,_DC: Over time, grinding your teeth will lead to TMJ joint destruction and pain. If you are grinding your teeth and don't have pain yet, it is only a matter of time before the pain will come on. If you let the grinding continue, major damage can be done to the joint.


Asking About Acupuncture

mountaingirl3: What is the best way to use acupuncture with regard to migraines? Is it only effective for relieving migraines once they start or can acupuncture help prevent migraines? I am looking for alternative, non-medicinal therapies to help prevent migraines for my 11-year-old daughter. Is there a recommended protocol for acupuncture for migraine prevention? Her neurologist does not want her to do chiropractic work, but she is OK with acupuncture.

Melissa_Young,_MD: Acupuncture has been shown to be effective at both preventing migraines and in reducing the intensity and frequency of migraines. In traditional Chinese medicine, each patient is assessed by history and physical exam, which guides the recommended treatment and protocol.


Tools for Treatment

Laura Martin: I hit my head on one side more than a year ago and now suffer from a constant cervicogenic headache on the other side along with a sore, stiff neck. My pain level is 7/10 without medications. I've tried nerve ablation and BOTOX® injections, but these have not helped. An MRI of my neck showed no problems, but I was wondering if chiropractic therapy might help. Thank you.

Andrew_C._Bang,_DC: From of the information you have given me, you sound like a great candidate for chiropractic care. There are many people in pain who have no x-ray or MRI findings, and that can be very frustrating, but you should look at it in a positive way. Be grateful that you don’t have significant findings, because your pain would most likely be even worse than what you are experiencing now. It sounds to me that there may be something in your daily life at home or work or with your sleep that is continuing to aggravate the neck and cause the recurrent headaches. We will find out which activity is aggravating your neck, and retrain the neck, shoulder and head muscles so you can receive some longer-lasting relief.

Winter70: I have just gone to a chiropractor for TMJ pain and underwent thermal imaging testing in preparation for my upcoming treatment. I have now done some research on this technique and have found a lot of negative information, which has caused me to have second thoughts about this tool being used. This is an example of the negative information: “Despite their lack of scientific support, colorful thermographic images are still used by many chiropractors as a tool for selling spinal adjustments, and some chiropractors offer free thermography as a screening device. You should assume that any chiropractor who does this will find something that needs treatment.” What are your feelings?

Andrew_C._Bang,_DC: Thermography images can be helpful when using them as an extra tool along with other diagnostic tools. If you perform a thermography on any person, you will see areas of the spine that could benefit from manipulation, manual therapy or exercise because we are dynamic humans. I don't like when thermography is the only tool used to evaluate a person for treatment because there are so many variables to that technique. I do like thermography when the chiropractor is using it to try and find the root of the problem and get the most specific area of need. Concerning your TMJ pain, manual therapy and chiropractic is a proven, excellent treatment as well as minimally invasive. It should be one of the first therapies tried before others are sought out.

Gail Ann: What type of imaging would you recommend having done before an assessment can be made of a person who has neck pain, off-balance issues and head (base of skull) pain? Thank you for answering my question.

Andrew_C._Bang,_DC: More information is needed to know what imaging, if any, would be needed. X-rays are used to see the bones and bone alignment clearly. MRI is used when the muscles and soft tissue needs to be seen. After a physical exam, your physician will know if you need imaging because oftentimes you won’t.


Since surgery

halsea: I had a closed lock TMJ situation for about five months and had surgery to remove an adhesion. Now my TMJ is constantly sore and stiff, and the more I try to loosen it up, the more headaches I get. Muscle relaxers don't work and I hate being on pain medications. How can I get past this with a long-term solution?

Andrew_C._Bang,_DC: Just like you would go through rehabilitation therapy for a hip or knee replacement, you need to do some rehab therapy for the TMJ surgery. In my office, we not only work on the TMJ pain but teach you how to perform home care and exercises that can really help.

loveitaly: I received treatments from a very well-known chiropractor’s office for 10 years. I always had either hip discomfort or low back or neck, and they helped. Both my husband and I continued going for maintenance. This office also has a PT department, and they alternate traditional physical therapy and chiropractic. I had suffered for many years from Meniere's disease, and I stopped going due to fear of the neck manipulation and the vertigoes. My Meniere's became very bad a long time after I stopped going to the office, and just two months ago I had major ear surgery to alleviate the vertigoes. Is it safe to go back to the chiropractor in the future again? Thank you.

Andrew_C._Bang,_DC: If you are returning to the chiropractor for mid- and low-back pain, you are definitely safe to go. The type of vertigo you have will dictate if you should use chiropractic manipulation in the neck. Understand that there are very gentle chiropractic techniques that could be used if you feel uncomfortable with manipulation. In some vertigo cases, manipulation is the best treatment option.


General Information

Sylvester: What are some complementary and alternative medicine (CAM) treatments that can be used to treat migraines, TMJ?

Melissa_Young,_MD: CAM modalities can be very helpful in the treatment of migraines and TMJ. It is helpful to initially see an integrative or functional medicine physician who can guide you to therapies that would be most useful to you, but self-referral is an option. I have seen benefit in the scientific literature and clinically from the use of acupuncture and Chinese herbs, massage therapy, manual therapies such as chiropractic and osteopathy, diet, supplements and botanicals, stress management techniques, as well biofeedback and neurofeedback.

Winter70: You already answered my TMJ question, but only if you have time I thought I would add this question. I have also been diagnosed with what the neurologist "believes" to be a tension headache due to years of chronic stress that I have had for 20 years. I am off work again because of it. I have had my tonsils and adenoids out, had acupuncture, neurofeedback, electrical impulses attached to my head, seen several massage and physiotherapists, MRI, CT scans and seen many doctors including two neurologists, oral surgeons, and have purchased three different dental appliances for TMJ and sleep apnea. And still I have the constant ache from my jaw over my ears and down the back and sides of my neck. I have pretty much given up hope. Am I expecting too much by hoping that a chiropractor could help?

Andrew_C._Bang,_DC: Don't give up. Keep searching. There are so many different types of therapies and providers out there. Try chiropractic. That might be the key technique you need.


Closing

Moderator: That is all the time we have today for questions. Thank you everyone for participating today; and thank you, Dr. Young and Dr Bang, for your insightful answers to our questions about TMJ and migraine pain.

Melissa_Young,_MD: Thank you for the chat!

Andrew_C._Bang,_DC: Thanks. Keep looking for solutions to your health. Remember you are your body’s best physician.

Gail Ann: Thank you, Doctor Young and Doctor Bang, for your time and expertise in answering our questions today.

Moderator: On behalf of Cleveland Clinic, we want to thank you for attending our free online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for integrative medicine, visit us online at my.clevelandclinic.org/services/wellness/integrative-medicine.


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To make an appointment with Dr. Young, Dr. Bang or any of the other specialists in our Center for Integrative Medicine at Cleveland Clinic, please call 216.986.HEAL(4325). You can also visit us online at clevelandclinic.org/cim.

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On Cleveland Clinic

Integrative medicine techniques support the body's natural ability to heal, reducing stress and promoting a state of relaxation that leads to better health. It can help achieve optimal health by engaging your own healing and empowerment to make lifestyle changes. Incorporating one or more Integrative Medicine services into a health care regimen may help you regain control of your well-being.

The integrative functional medicine approach focuses on the patient and on treating the underlying cause of disease and can better address the chronic care crisis. Functional medicine looks at the interactions among genetic, environmental and lifestyle factors that can influence your long-term health. These factors can also lead to complex, chronic disease. Chronic disease has reached epidemic proportions in America. Millions of people suffer from chronic conditions such as fatigue, chronic pain, diabetes, obesity, depression, autoimmune disease, fibromyalgia and chronic headaches.

Wellness chiropractic physicians consider the “whole patient” and are established members of the mainstream medical team. They treat problems involving the muscles, tendons, ligaments, bones, cartilage and nervous system. Chiropractic physicians can perform soft-tissue therapies, prescribe corrective exercises and safely manipulate the spine or joints to help you potentially avoid surgery and medication.

Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for migraines and TMJ pain.

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