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Contents

FOREWORD

PREFACE

ACKNOWLEDGMENTS

CONTRIBUTORS

PART I BASIC CONCEPTS OF HEAD, FACE AND NECK PAIN

CHAPTER 1 HEAD, FACE AND NECK PAIN, SCIENCE, EVALUATION AND MANAGEMENT—AN INTERDISCIPLINARY APPROACH

1.1 DIAGNOSTIC EVALUATION

1.2 INTERDISCIPLINARY MANAGEMENT APPROACH

REFERENCES

CHAPTER 2 THE EXPERIENCE OF PAIN: PSYCHOSOCIAL ASSESSMENT

2.1 PAIN AND THE “MIND–BODY” CONNECTION

2.2 ASSESSING HEAD, NECK, AND TMD PAIN

2.3 CONCLUSION AND SUMMARY

REFERENCES

CHAPTER 3 PSYCHOSOCIAL INTERVENTIONS IN THE TREATMENT OF PAIN

3.1 A CASE FOR TIMELY PSYCHOSOCIAL INTERVENTIONS

3.2 CBT

3.3 BIOFEEDBACK

3.4 RELAXATION TRAINING

3.5 BEHAVIORAL TREATMENT

REFERENCES

CHAPTER 4 PAIN, DISABILITY AND MEDICO-LEGAL ISSUES

4.1 LITIGATION, LEGAL ENTITLEMENTS, AND CHRONIC PAIN

4.2 WORK DISABILITY, CHRONIC HEADACHE, AND FACIAL PAIN

4.3 MALINGERING AND COMORBID PSYCHIATRIC DISORDERS

4.4 TESTIMONY AND FORENSIC ISSUES WITH CHRONIC HEADACHE AND FACIAL PAIN

4.5 GUIDES FOR PERMANENT IMPAIRMENT CASES

4.6 DAUBERT, “JUNK SCIENCE,” AND CRANIOFACIAL PAIN

4.7 PAIN PRACTICE AND RISK MANAGEMENT

REFERENCES

CHAPTER 5 STRUCTURAL AND FUNCTIONAL IMAGING OF THE TRIGEMINAL SYSTEM

5.1 INTRODUCTION

5.2 THE TRI GEMINAL SYSTEM: ANATOMY AND PHYSIOLOGY

5.3 IMAGING—THE BASICS

5.4 IMAGING THE TRIGEMINAL SYSTEM—A MODEL FOR UNDERSTANDING ACUTE AND CHRONIC PAIN

5.5 CURRENT AND FUTURE CLINICAL APPLICATIONS OF FUNCTIONAL IMAGING OF THE TRIGEMINAL SYSTEM

5.6 CONCLUSIONS

ACKNOWLEDGMENTS

REFERENCES

CHAPTER 6 NEUROSTIMULATION FOR HEAD AND FACE PAIN

6.1 INTRODUCTION

6.2 EVALUATION

6.3 PERIPHERAL STIMULATION

6.4 TRIGEMINAL GANGLION STIMULATION

6.5 MOTOR CORTICAL STIMULATION

6.6 DBS

6.7 CONCLUSION

REFERENCES

PART II HEAD PAIN

CHAPTER 7 HEADACHE—THE BEGINNINGS

7.1 INTRODUCTION

7.2 PREHISTORIC TIMES

7.3 HEADACHE IN ANCIENT CIVILIZATIONS

7.4 HEADACHE IN THE MIDDLE AGES

7.5 HEADACHE IN THE RENAISSANCE

7.6 HEADACHE IN THE VICTORIAN ERA

7.7 HEADACHE IN THE MOLECULAR ERA

REFERENCES

CHAPTER 8 EPIDEMIOLOGY OF HEADACHE

8.1 INTRODUCTION

8.3 TTH

8.4 CH AND OTHER TACs

8.5 OTHER PRIMARY HEADACHES

8.6 THE EPIDEMIOLOGY OF HEADACHES

REFERENCES

CHAPTER 9 CLASSIFICATION OF HEADACHE

9.1 INTRODUCTION

9.2 THE HISTORY OF CLASSIFICATION SYSTEMS IN HEADACHE

9.3 ICHD II—BASIC ORGANIZATION

9.4 CLASSIFICATION OF PRIMARY HEADACHES

9.5 CLASSIFICATION OF SECONDARY HEADACHES

9.6 THE ICHD II—CONCLUSIONS

REFERENCES

CHAPTER 10 MIGRAINE

10.1 INTRODUCTION

10.2 PATHOGENESIS

10.3 EPIDEMIOLOGY

10.4 CLINICAL ASPECTS

10.6 MANAGEMENT

REFERENCES

CHAPTER 11 TENSION-TYPE HEADACHE AND MYOFASCIAL PAIN

11.1 INTRODUCTION

11.2 SCIENCE

11.3 EVALUATION

11.4 MANAGEMENT

11.5 CONCLUSION

REFERENCES

CHAPTER 12 TRIGEMINAL AUTONOMIC CEPHALALGIAS

12.1 SCIENCE

12.2 CLUSTER HEADACHE

12.3 CHRONIC PAROXYSMAL HEMICRANIA (CPH)

12.4 SUNCT SYNDROME

12.5 HC

12.6 CONCLUSION

REFERENCES

CHAPTER 13 POST-TRAUMATIC HEADACHE

13.1 INTRODUCTION

13.2 INCIDENCE AND PREVALENCE

13.3 CLINICAL PRESENTATION

13.4 BIOLOGICAL MECHANISMS

13.5 THE ROLE OF THE NECK

13.6 TREATMENT

13.7 CONCLUSION

REFERENCES

CHAPTER 14 SECONDARY HEADACHE DISORDERS

14.1 INTRODUCTION

ICHD-II 6 HEADACHES ATTRIBUTED TO CRANIAL OR CERVICAL VASCULAR DISORDERS

ICHD-II 7 HEADACHE ATTRIBUTED TO NONVASCULAR INTRACRANIAL DISORDER

ICHD-II 8 HEADACHE ATTRIBUTED TO A SUBSTANCE OR ITS WITHDRAWAL

ICHD-II 10 HEADACHE ATTRIBUTED TO DISORDER OF HOMEOSTASIS

ICHD-II 11 HEADACHE OR FACIAL PAIN ATTRIBUTED TO DISORDER OF CRANIUM, NECK, EYES, EARS, NOSE, SINUSES, TEETH, MOUTH, OR OTHER FACIAL OR CRANIAL STRUCTURES

REFERENCES

CHAPTER 15 FACIAL STRUCTURES AND HEADACHE: EYE, EAR, NOSE SINUSES AND TEETH

15.1 OCULAR DISORDERS AND HEADACHE

15.2 DISORDERS OF THE EAR AND HEADACHE

15.3 DISORDERS OF THE NOSE AND PARANASAL SINUSES AND HEADACHE

15.4 HEADACHE AND DISORDERS OF THE TEETH AND ASSOCIATED STRUCTURES

REFERENCES

CHAPTER 16 JAW DYSFUNCTION AND HEADACHE

16.1 INTRODUCTION

16.2 EVALUATION

16.3 MANAGEMENT

REFERENCES

CHAPTER 17 SLEEP DISORDERS AND HEADACHE

17.1 INTRODUCTION

17.2 SCIENCE

17.3 EVALUATION

17.4 MANAGEMENT

17.5 CONCLUSION

REFERENCES

CHAPTER 18 SUBSTANCE USE AND HEADACHE

18.1 SCIENCE

18.2 EVALUATION

18.3 TREATMENT

18.4 RELAPSE

18.5 CONCLUSION

REFERENCES

CHAPTER 19 CHRONIC DAILY HEADACHE

19.1 INTRODUCTION

19.2 MAKING THE CORRECT DIAGNOSIS

19.3 PRIMARY CDH

19.4 LONG-DURATION CDHs

19.5 SHORT-DURATION CDHs

19.6 MEDICATION-OVERUSE HEADACHE (MOH)

19.7 TREATMENT

19.8 PROGNOSIS

19.9 CONCLUSION

REFERENCES

CHAPTER 20 PRIMARY HEADACHE DISORDERS IN WOMEN

20.1 SCIENCE

20.2 EVALUATION

20.3 MANAGEMENT

PART III FACIAL PAIN

CHAPTER 21 PREVALENCE OF CHRONIC OROFACIAL PAIN DISORDERS

21.1 PROBABILITY SAMPLING OF THE POPULATION FOR CHRONIC OROFACIAL PAIN

21.2 OROFACIAL PAIN: MUSCLE PAIN (MYALGIA, MYOFASCIAL PAIN, AND FIBROMYALGIA)

21.3 OROFACIAL PAIN: TMJ ARTICULAR DISORDERS (DERANGEMENT, LOCAL ARTHRITIS, POLYARTHRITIS)

21.4 OROFACIAL PAIN: VASCULAR ORIGIN

21.5 OROFACIAL PAIN: MIGRAINE, AUTONOMIC CEPHALGIAS, AND TENSION-TYPE HEADACHES (TTHS)

21.6 OROFACIAL PAIN: TRIGEMINAL NEUROGENOUS PAIN

REFERENCES

CHAPTER 22 TOOTH RELATED PAIN

22.1 ODONTOGENIC PAIN DISORDERS

22.2 NONODONTOGENIC PAIN DISORDERS

REFERENCES

CHAPTER 23 ORAL MEDICINE, ORAL PATHOLOGY AND FACIAL PAIN

23.1 INTRODUCTION

23.2 ACUTE SOLITARY ULCERATIONS

23.3 RECURRENT SOLITARY ULCERATIONS

23.4 CHRONIC SOLITARY ULCERATIONS

23.5 MULTIPLE ACUTE ULCERATIONS

23.6 MULTIPLE RECURRENT ULCERATIONS

23.7 MULTIPLE CHRONIC ULCERATIONS

REFERENCES

CHAPTER 24 MASTICATORY MYOFASCIAL PAIN DISORDERS

24.1 INTRODUCTION AND DEFINITION

24.2 CLINICAL PRESENTATION

24.3 ETIOLOGY AND PATHOPHYSIOLOGY

24.4 EVIDENCED-BASED MANAGEMENT

24.5 SUMMARY

REFERENCES

CHAPTER 25 TEMPOROMANDIBULAR JOINT DISORDERS

25.1 SCIENCE

25.2 EVALUATION

25.3 MANAGEMENT: TREATMENT FOR JOINT DISORDERS

REFERENCES

CHAPTER 26 MAXILLOFACIAL RELATIONSHIPS AND FACIAL PAIN

26.1 OCCLUSAL FENCE I: ANTERIOR/POSTERIOR POSITIONING

26.2 OCCLUSAL FENCE II: LATERAL POSITIONING

26.3 OCCLUSAL FENCE III: SUPERIOR/INFERIOR POSITIONING

REFERENCES

CHAPTER 27 NEUROPATHIC OROFACIAL PAIN

27.1 CLASSIFICATION

27.2 EPIDEMIOLOGY

27.3 ANATOMY AND PHYSIOLOGY

27.4 PATHOPHYSIOLOGY

27.5 CLINICAL EVALUATION

27.6 PHYSICAL EVALUATION

27.7 COMPLEMENTARY EXAMS

27.8 MANAGEMENT

27.9 THE FUTURE

REFERENCES

CHAPTER 28 TRIGEMINAL NEURALGIA

28.1 INTRODUCTION

28.2 HISTORY

28.3 DIAGNOSTIC CRITERIA

28.4 CLINICAL EVALUATION

28.4.2 CPA Tumor

28.5 PATHOPHYSIOLOGY

28.6 THERAPY

28.7 SUMMARY

REFERENCES

CHAPTER 29 DISORDERS DIAGNOSIS AND MANAGEMENT OF VARIOUS ORAL MOTOR DISORDERS

29.1 INTRODUCTION TO ORAL MOTOR DISORDERS

29.2 DIFFERENTIAL DIAGNOSIS OF OMD

29.3 OROMANDIBULAR DYSTONIA

29.4 BRUXISM

29.5 DRUG-INDUCED DYSTONIC-TYPE EXTRAPYRAMIDAL REACTIONS

29.6 SECONDARY MASTICATORY MUSCLE SPASM

29.7 HEMIFACIAL SPASM

29.8 SYNKINESIS

29.9 HMS

29.10 OROMANDIBULAR DYSKINESIA

29.11 HYPERACTIVITY OF THE TONGUE

29.12 MASSETERIC AND/OR TEMPORALIS MUSCLE HYPERTROPHY

29.13 OROFACIAL MOTOR TICS

29.14 CONCLUSION

REFERENCES

PART IV NECK PAIN

CHAPTER 30 POST-TRAUMATIC NECK PAIN

30.1 INTRODUCTION

30.2 SCIENCE

30.3 EVALUATION AND MANAGEMENT OF A POST-TRAUMATIC CERVICAL SPINE PAIN PATIENT

30.4 SUMMARY

REFERENCES

CHAPTER 31 CERVICAL DISC DISORDERS

31.1 ANATOMY

31.2 HISTORY AND PHYSICAL EXAM

31.3 LABORATORY EVALUATION

31.4 TREATMENT

REFERENCES

CHAPTER 32 MYOFASCIAL NECK PAIN DISORDERS

32.1 INTRODUCTION

32.2 EPIDEMIOLOGY OF CHRONIC MYOFASCIAL NECK PAIN

32.3 ANATOMY AND PATHOGENESIS OF MYOFASCIAL NECK PAIN

32.4 CLINICAL FEATURES AND DIAGNOSIS OF MYOFASCIAL NECK PAIN

32.5 MANAGEMENT OF MYOFASCIAL NECK PAIN

32.6 PREVENTION

32.7 CONCLUSION

REFERENCES

CHAPTER 33 RHEUMATIC AND ARTHRITIC DISORDERS

33.1 INTRODUCTION

33.2 RHEUMATOID ARTHRITIS AND THE CERVICAL SPINE

33.3 OSTEOARTHRITIS AND THE CERVICAL SPINE

33.4 INTERVENTIONAL MANAGEMENT OF ARTHRITIC CAUSES OF CERVICAL PAIN

33.5 AO JOINT BLOCKS

33.6 AA JOINT BLOCKS

33.7 TON BLOCKS

33.8 CERVICAL FACETS

33.9 OUTCOME STUDIES

33.10 RADIO-FREQUENCY ABLATION

REFERENCES

CHAPTER 34 EVALUATION AND TREATMENT OF CERVICOGENIC HEADACHE

34.1 INTRODUCTION

34.2 ANATOMICAL BASIS

34.3 EPIDEMIOLOGY

34.4 CERVICOGENIC HEADACHE

34.5 DIAGNOSTIC CRITERIA

34.6 DIAGNOSTIC EVALUATION

34.7 DIFFERENTIAL DIAGNOSIS

34.8 TREATMENT

34.9 SUMMARY

REFERENCES

CHAPTER 35 NEUROMUSCULAR DISORDERS

35.1 MOTOR NEURON DISEASE/AMYOTROPHIC LATERAL SCLEROSIS

35.2 SPINAL MUSCULAR ATROPHY (SMA)

35.3 BRACHIAL PLEXOPATHIES

35.4 CHRONIC INFLAMMATORY DEMYELINATING POLYNEUROPATHY (CIDP)

35.5 MYASTHENIA GRAVIS

35.6 ANTI-MUSK POSITIVE MYASTHENIA GRAVIS

35.7 MYOPATHIES

35.8 ISOLATED NECK EXTENSOR MYOPATHY (INEM)

35.9 MANAGEMENT OF PAIN RELATED TO NECK WEAKNESS

REFERENCES

CHAPTER 36 VASCULAR CAUSES OF NECK PAIN

36.1 ARTERIAL DISSECTIONS

36.2 INTERNAL JUGULAR VEIN (IJV) THROMBOSIS

36.3 CAROTIDYNIA

36.4 OTHER VASCULAR DISORDERS

REFERENCES

CHAPTER 37 JAW DYSFUNCTION AND NECK PAIN

37.1 SCIENCE

37.2 EVALUATION

37.3 MANAGEMENT

REFERENCES

APPENDIXES CURRENT ACADEMIC AND PROFESSIONAL KNOWLEDGE GUIDELINES FOR PAIN

APPENDIX 1 EVIDENCE-BASED GUIDELINES FOR MIGRAINE HEADACHE: OVERVIEW OF PROGRAM DESCRIPTION AND METHODOLOGY

Outline Summary

APPENDIX 2 EVIDENCE-BASED GUIDELINES IN THE PRIMARY CARE SETTING: NEUROIMAGING IN PATIENTS WITH NONACUTE HEADACHE

IASP ad hoc Subcommittee on Medical School Courses and Curriculum

Outline Summary

Management

Proposed Curriculum on Pain for Medical Undergraduates

Topics

APPENDIX 3 EVIDENCE-BASED GUIDELINES FOR MIGRAINE HEADACHE IN THE PRIMARY CARE SETTING: PHARMACOLOGICAL MANAGEMENT OF ACUTE ATTACKS

OUTLINE SUMMARY

INTRODUCTION

PRINCIPLES

OBJECTIVES

CURRICULUM CONTENT OUTLINE

REFERENCES

APPENDIX 4 EVIDENCE-BASED GUIDELINES FOR MIGRAINE HEADACHE: BEHAVIORAL AND PHYSICAL TREATMENTS

Prepared by the IASP ad hoc Subcommittee on University Courses and Curricula

Outline Summary (see below for details)

Formal comments were received from the following persons

The Curriculum

APPENDIX 5 EVIDENCE-BASED GUIDELINES IN THE PRIMARY CARE SETTING: PHARMACOLOGICAL MANAGEMENT FOR PREVENTION OF MIGRAINE

INTRODUCTION

COURSE OBJECTIVES

COURSE OUTLINE

REFERENCES

COLOR PLATES

INDEX

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We would like to dedicate this book first and foremost to our patients, who have given us the insight to continue our pursuit of knowledge, the humility to continue caring, and the patience to accept their suffering.

Being in Boston, it is only appropriate that we also dedicate this book to our many wonderful pain clinicians with whom we work with, learn from, and interact with regularly. These individuals are among the leaders in the field of head, face, and neck pain and hold a special place in our hearts.

We also dedicate this book to our friends and colleagues at the Craniofacial Pain, Headache and Sleep Center at Tufts University School of Dental Medicine, Boston, Massachusetts. Their support and dedication in the education of a new generation of pain providers is only surpassed by their compassion for our patients in pain.

In memoriam:

We would like to make a special dedication of the Head Pain Section of this book to a dear friend, colleague, and teacher, John Edmeads, MD (April 15, 1936-November 16, 2006).

Noshir R. Mehta

George E. Maloney

Dhirendra S. Bana

Steven J. Scrivani

FOREWORD

Joel R. Saper

Pain and its treatment pose many extraordinary challenges to the professional who takes on this important responsibility. Chronic pain disorders are often difficult to diagnose and sometimes harder to treat. The most striking complication is that many, if not most, pain disorders are subjective conditions, without the objective markers and diagnostic clues that facilitate the task of diagnosis and treatment of many other medical conditions. The clinician is almost entirely reliant on patient reports and descriptions, the accuracy and reliability of which can vary based on personality, culture, psychological stability, emotional state, and life circumstances. Moreover, pain conditions can manifest in both acute and chronic forms. Chronic pain, as most experts know, is not just an extension of acute pain but is likely to be a reflection of distinctive pathophysiological, psychological, and therapeutic disturbances.

Perhaps the most significant of all challenges related to pain treatment is that different disciplines and backgrounds of professional training converge to treat the same condition. The very same complaint in the same patient can be diagnosed entirely differently and treated entirely differently by highly qualified pain specialists. Each of these specialists reflects different training and employs different scientific perspectives, terminology, concepts and strategies of approach, and tools. They may have different economic realities and practice domains.

A patient presenting with occipitocervical pain with radiation to the temporalis muscle may be treated by the dental professional with splint therapy, by the anesthesiologist with blocks, by the neurologist with anticonvulsants and antidepressants, by the physiatrist with physical therapy, by the psychologist with cognitive behavioral treatments, by the primary care physician with opioids, and by another with craniosacral manipulation. One discipline may call it temporomandibular disorder; another facet pathology; another cervicogenic headache; another myofascial pain; and yet another chronic migraine.

Professor Jeffrey Okeson, the esteemed Chairman of the Department of Oral Health Science at the University of Kentucky and a pioneering clinician, has called treating pain a "thinking sport." It certainly is. I would add that given the realities of pain treatment in the United States today and the confounding variables that influence diagnosis and treatment, as well as the often distinctive and powerful personalities (both professional and patient) that enter the pain arena, treating pain can be a "blood sport"!

How then do we deliver reliable diagnoses and effective treatments across the spectrum of the pain field? How do we avoid disconnected, assembly line, and misapplied treatments, ballooning costs, and turning treatable and reversible illnesses into chronic ones? How do we encourage innovation and creative therapies while protecting this important and emerging field of medicine from the charlatans who seep into professional domains when legitimate scientific differences exist or knowledge seriously lags behind patient needs?

The solution begins with the provision of reliable and scholarly information to those who seek to learn more. What Dr. Mehta and his colleagues have created is just that—an interdisciplinary and scholarly collection of authoritative perspectives to effectively confront and address the challenges facing clinicians treating head, face, and neck pain disorders. The authors are highly regarded professionals, and several straddle more than one discipline, bringing refreshing perspective and depth to the topic. Each of the chapters provides an important and interesting scholarly review, and each addresses an area of primary importance to those evaluating and treating head, face, and neck pain.

This scholarly work makes an important contribution to the diagnosis and treatment of pain and should be at the fingertips of every serious clinician treating head, face, and neck pain. Congratulations to the editors, its authors, its readers, and most importantly to the patients to whom these many pages are devoted.

PREFACE

The inspiration for this textbook has come from over 90years of combined observation by the senior authors over the last four decades. The observation has been that head, face, and neck pains are rarely separate entities but very often coexist.

While there are numerous textbooks specifically dedicated to headache, orofacial pain, and cervical pain disorders, there has not been a comprehensive textbook dedicated to their interrelationships. In addition, such a textbook needed to be based upon current core educational guidelines, classifications schemes, and evidence-based teaching curriculum from a broad, interdisciplinary but integrated background.

The majority of disciplines that cut across the diagnosis and management of the chronic head, face, and neck pain patient is based on the medical model utilizing both standard as well as complementary medical techniques. It has only been recently that evidence has begun to link the profession of dental medicine to the overall health of an individual especially in the field of chronic head, face, and neck pain.

This textbook takes a more integrative road by incorporating different models of pain management to encourage our medical and dental colleagues to work together for the overall health and well-being of all our patients.

It is our hope that this first edition will be a learning experience for all involved and that subsequent edition will build on these concepts and continue to expand our knowledge base to better evaluate and manage these difficult problems.

Noshir R. Mehta

George E. Maloney

Dhirendra S. Bana

Steven J. Scrivani

ACKNOWLEDGMENTS

I personally dedicate this to my wife, Dara, who has been the wind beneath my wings for the past 30 years. Your constant support and encouragement without question never cease to humble me. To my children, Larina and Aaron, thank you for the love and support that fill my life with joy and make me wake up each day with optimism in the younger generation.

To two of the best teachers one could ask for, Dr. Irving Glickman, remarkable periodontist, and Dr. Harold Gelb, mentor and friend, to whom I owe much of my learning and professional skills. To my colleague, Dr. Albert Forgione, and my fellow workers, M.J. Sands and Kay Langley, who were there at the start, I thank you for the years.

To my parents, you made me who I am. To my brother and his family, I thank you for your help in times of trouble and for your love always.

To Dean Lonnie Norris, thank you for the trust and freedom you have provided over the years. I am deeply grateful.

Dr. Noshir R. Mehta

I would like to acknowledge that any and all success I have achieved in this life is directly due to the love and support of my father, Dr. George E. Maloney, and my mother, Marie F. Maloney.

I would also like to publicly thank the two individuals who introduced me to this field, Dr. Albert Forgione and Dr. Noshir R. Mehta. Thank you for the introduction to the study and management of pain and for your continued support over these many years.

Lastly, I would like to thank my fellow faculty members, who have contributed greatly to my development and to the holistic manner in which we attempt to manage patients in pain.

Dr. George E. Maloney

It is with deep sense of gratitude that I acknowledge the encouragement given by my parents, Smt. Vidya Wati and Shree Baljit Singh. Although they are no longer with me, their memory is omnipresent. I also dedicate this book to my mentor and teacher, and a great human being Dr. John R. Graham. To him, his family came first. Included in his extended family were his colleagues and his patients. We all feel privileged that we knew him. A special thank you to my wife, Cora, whose support and smile always act as a tonic to energize me.

Dr. Dhirendra S. Bana

The success of my personal life is due to the love and care of my wife, Mary Lou, and my parents, Dr. and Mrs. Steven S. Scrivani.

The success of my professional life is due to the endeavors of my teachers, colleagues, and dear friends: David Borsook, MD, PhD; Leonard B. Kaban, DMD, MD; David A. Keith, BDS, FDSRCS, DMD; Ernest S. Mathews, MD; Steven M. Roser, DMD, MD; and most especially, Raymond J. Maciewicz, MD, PhD.

Dr. Steven J. Scrivani

CONTRIBUTORS

Emad F. Abdallah, BDS, MS, The Craniofacial Pain Center, Tufts University, Boston, MA; E-mail: Emad.abdallah@tufts.edu

Salahadin Abdi, MD, PhD, MGH Pain Center, Boston, MA; E-mail: sabdi@partners.org

Martin Acquadro, MD, DMD, FACP, FACPM, Anesthesiology and Pain Services, Caritas Carney Hospital, Boston, MA; E-mail: Martin.acquadro@caritaschristi.org

James U. Adelman, MD, FACP, FAAN, FAHS, Headache Wellness Center, Greensboro, NC; E-mail: jadelman@triad.rr.com

Lainie Andrew, PhD, The Craniofacial Pain Center, Tufts University, Boston, MA; E-mail: Lainie.andrew@tufts.edu

Joseph F. Audette, MA, MD, Spaulding Medford, Medford, MA; E-mail: j audette@ partners.org

Zahid H. Bajwa, MD, Assistant Professor of Anesthesia and Neurology, Harvard Medical School, Boston, MA; E-mail: zbajwa@bidmc.harvard.edu

Dhirendra S. Bana, MD, John R. Graham Headache Center, The Faulkner Hospital, Boston, MA; The Craniofacial Pain and Headache Center, Tufts University, Boston, MA; E-mail: dbana@faulknerhospital.org

Lino Becerra, PhD, P.A.I.N. Group, Brain Imaging Center, McLean Hospital, Belmont, MA; E-mail: lbecerra@mclean.harvard.edu

Marcelo E. Bigal, MD, PhD, Merck Research Laboratories, West Point, PA; E-mail: marcbigal@aol.com

David M. Biondi, DO, Clinical Development, Ortho-McNeil Janssen Scientific Affairs, Raritan, NJ; E-mail: dbiondi@its.jnj.com

Don Bivins, MD, Virginia College of Osteopathic Medicine, Blacksburg, VA; E-mail: dbivins@vcom.vt.edu

Jonathan M. Borkum, PhD, Health Psych Maine, Waterville, ME; E-mail: j borkum@ hpmaine.com

David Borsook, MD, PhD, P.A.I.N. Group, Brain Imaging Center, McLean Hospital, Belmont, MA; E-mail: dborsook@mclean.harvard.edu

Robert Burns, MD, MPH, Pain Management Specialists, Tallahassee, FL; University of Miami, Miami, FL; E-mail: robertburns.md.pa@gmail.com

Caroline Ceneviz, DDS, MS, The Craniofacial Pain Center, Tufts University, Boston, MA; E-mail: caroline.ceneviz@tufts.edu

Glenn T. Clark, DDS, MS, Division of Diagnostic Sciences, Orofacial Pain and Oral Medicine, University of Southern California, School of Dentistry, Los Angeles, CA; E-mail: gtc@usc.edu

Alexandre F.M. DaSilva, DDS, DMSc, Headache and Orofacial Pain Effort Group, Biologic and Material Sciences, School of Dentristy, University of Michigan, Ann Arbor, MI; E-mail: adasilva@umich.edu

Juna M. deVries, MD, Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands; Brigham and Women's Hospital, Harvard Medical School, Boston, MA

John G. Edmeads (deceased), MD, Sunnybrook and Woman's Health Science Center, Toronto, ON, Canada

Marshall C. Freeman, MD, Headache Wellness Center, Greensboro, NC; E-mail: mfreeman212 @ yahoo.com

James R. Fricton, DDS, MS, University of Minnesota, Minneapolis, MN; E-mail: frict001 @umn.edu

Daniel Green, DMD, Department of Endodontology, Tufts University, School of Dental Medicine, Boston, MA; E-mail: Daniel.green@tufts.edu

Padma Gulur, MD, 60 Independence Lane, Ashland, MA; E-mail: pgulur@partners.org

Gunnar Hasselgren, DDS, PhD, Division of Endodontics, College of Dental Medicine, Columbia University, New York, NY; E-mail: bgh1@columbia.edu

Basem T. Jamal, BDS, Thomas Jefferson University, Department of Oral and Maxillofacial Surgery, 909 Walnut Street, 3rd floor, Philadelphia, PA

David A. Keith, BDS, FDSRCS, DMD, Harvard School of Dental Medicine; Massachusetts General Hospital; Harvard Vanguard Medical Associates, Boston, MA; E-mail: David_keith @ vmed.org

Lisa Stroud Krivickas, MD, Spaulding Rehabilitation Hospital, Boston, MA; E-mail: lkrivickas@partners.org

Ronald J. Kulich, PhD, The Craniofacial Pain Center, Tufts University, Boston, MA; E-mail: rkulich@partners.org

Morris Levin, MD, Dartmouth Hitchcock Medical Center, Section of Neurology, Lebanon, NH; E-mail: mo.levin@Hitchcock.org

Silvia Lobo Lobo, DDS, MS, The Craniofacial Pain Center, Tufts University, Boston, MA; E-mail: silvia.lobo_lobo@tufts.edu

Elizabeth Loder, MD, Spaulding Rehabilitation Hospital, Boston, MA; E-mail: eloder@ partners.org

Raymond J. Maciewicz, MD, PhD, PBS Medical Consulting, Boston, MA; E-mail: rmaciewicz @ comcast.net

George E. Maloney, DMD, MAc, The Craniofacial Pain and Headache Center, Tufts University, Boston, MA; E-mail: gemaloney@aol.com

Ernest S. Mathews, MD, Harvard Medical School, Department of Neurological Surgery, Massachusetts General Hospital, Boston, MA; E-mail: rhamer@partners.org

Brian E. McGeeney, MD, MPH, Boston University Neurology Department, Department of Neurology, C329, Boston, MA; E-mail: mcgeeney@aol.com

Noshir R. Mehta, BDS, DMD, MDS, MS, The Craniofacial Pain and Headache Center and Department of General Dentistry, Tufts University, Boston, MA; E-mail: noshir. mehta@tufts.edu

Eric Moulton, PhD, P.A.I.N. Group, Brain Imaging Center, McLean Hospital, Belmont, MA; E-mail: emoulton@mclean.harvard.edu

Vikram Patel, MD, FIPP, ACMI Pain Care, Algonquin, IL; E-mail: vikpatel1@yahoo.com

Jeanetta C. Rains, PhD, Center for Sleep Evaluation, Elliot Hospital, Manchester, NH; E-mail: jrains@elliot-hs.org

Saravanan Ram, BDS, MDS, University of Southern California, School of Dentistry, Los Angeles, CA

Alan M. Rapoport, MD, The David Geffen School of Medicine at UCLA, Los Angeles, CA; The New England Center for Headache, Stamford, CT; E-mail: alanrapoport@ nech.net

Joshua M. Rosenow, MD, Functional Neurosurgery, Northwestern Memorial Hospital, Feinberg School of Medicine, Northwestern University, Chicago, IL; E-mail: jrosenow @nmff.org

Todd D. Rozen, MD, Geisinger Medical Center, Geisinger Headache Center, Danville, PA; E-mail: tdrozmigraine@yahoo.com

Joel R. Saper, MD, FACP, FAAN, Michigan Head Pain & Neurological Institute, Ann Arbor, MI; E-mail: jrsaper@aol.com

Steven J. Scrivani, DDS, DMedSc, The Craniofacial Pain and Headache Center, Tufts University, Boston, MA; Pain and Analgesia Imaging and Neuroscience Group, Brain Imaging Center, McLean Hospital; E-mail: Steven.scrivani@tufts.edu

Jeffry Shaefer, DDS, MS, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital; Harvard School of Dental Medicine, Boston, MA; E-mail: jshaefer@ partners.org

Fred D. Sheftell, MD, New England Center for Headache, Stamford, CT; Departments of Neurology and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY; E-mail: ninotores1@aol.com

David A. Sirois, DMD, PhD, New York University College of Dentistry, New York, NY; E-mail: ds62@nyu.edu

Egilius L.H. Spierings, MD, PhD, 25 Walnut Street, Suite 400, Wellesley Hills, MA; E-mail: espierings@partners.org

Andy Stadler, MD, Department of Neurosurgery, 676 N. St. Clair St., Suite 2210, Chicago, IL

Steven Stanos, DO, Chronic Pain Center, Rehabilitation Institute of Chicago, Chicago, IL; E-mail: sstanos@rehabchicago.org

Marlind Alan Stiles, DMD, Facial Pain Management, Thomas Jefferson University, Department of Oral Maxillofacial Surgery, Philadelphia, PA; E-mail: Alan.stiles@ jefferson.edu

Milan P. Stojanovic, MD, MGH Pain Center ACC 333, Boston, MA; E-mail: mstojanovic@partners.org

Piedad Suarez, DMD, Department of Disease Prevention and Health Promotion, University of Southern California, School of Dentistry, 925 W. 34th Street, Rm B-14, Los Angeles, CA

Christina Sun-Edelstein, The New York Headache Center, New York, NY; E-mail: christinaksun @ yahoo.com

Marketa van den Elzen, MD, 20 Chapel Street, A309, Brookline, MA; E-mail: makielzen @ yahoo.com

Ana-Maria Vranceanu, PhD, Massachusetts General Hospital, Department of Orthopaedic Surgery; E-mail: avranceanu@partners.org

Michael Weinberger, MD, Division of Pain Medicine, Department of Anesthesiology, Pain Center, PH5 East, Columbia University Medical Center, New York, NY; E-mail: Mlw45 @ columbia.edu

PART I

BASIC CONCEPTS OF HEAD, FACE AND NECK PAIN

Ronald J. Kulich

Raymond J. Maciewicz

CHAPTER 1

HEAD, FACE AND NECK PAIN, SCIENCE, EVALUATION AND MANAGEMENT—AN INTERDISCIPLINARY APPROACH

Noshir R. Mehta

Steven J. Scrivani

It is more important to know what sort of person has a disease than to know what disease a person has.

—Sir William Osler

Pain is a complex sensory, emotional, and behavioral process. Pain can range from being a protective process (acute pain) to a destructive process (chronic pain). Depending upon the underlying anatomical process, acute pain can often be effectively treated, and pain often resolves when healing or resolution of the problem occurs. In the case of chronic pain conditions, the initial underlying process may have little to do with factors that maintain the patient’ s pain. With chronic pain, common epiphenomena include suffering, disability, and depression. As well-meaning clinicians struggle with the patient to find a “cure,” the patient often develops iatrogenic problems secondary to multiple destructive interventions.

The number of patients suffering from chronic pain conditions is great, with as many as 75 million in the United States suffering from serious pain and 50 million experiencing some level of disability due to their pain. While facial pain conditions represent a small portion of all chronic pain conditions, the financial costs still amount to $1.9 billion per year, and the quality of life costs for the facial pain patient are often incalculable.

The complex anatomy, physiology, and neurobiology of the head, face, and neck combines to make the differential diagnosis of pain disorders of this area of the body significantly broad and complex. While there are numerous classification schemes for pain disorders, the most comprehensive classification of pain disorders of the head, face, and neck is the 2004 International Headache Society (IHS), International Classification of Headache Disorders II (ICHD II) (1). While generalized classification schemes are helpful for clinical research and consistency of diagnostic criteria, they can often be confusing, are often over- or underutilized, and are not always universally accepted.

In this book, we reference the ICHD II when appropriate and discuss the many pain problems separately as part of a more comprehensive differential diagnostic approach to pain disorders of the head, face, and neck. Many of the chapters on specific pain disorders expand on the ICHD II as appropriate and discuss the pros and cons of its use.

Several pain organizations have established guidelines for the classification, evaluation, and management of chronic pain disorders. These educational guidelines are typically developed by scholarly panels of pain experts from numerous backgrounds and healthcare disciplines. These guidelines form the basis of the core knowledge base needed for postdoctoral programs and for appropriate board examinations and board certification. We have incorporated the guidelines and organized classifications from several national academic groups and societies to form the basis of the body of knowledge covered in this book. (These guidelines are found in the Appendix.)

The individual chapters in each section discuss the relationship of the biological, psychological, social, and personal factors that are affected by pain disorders of the head, face, and neck. There is a unified focus of the interdisciplinary approach to these complex chronic pain disorders. The senior editors have gathered the leading experts in their respective fields from varied backgrounds and disciplines to author individual chapters.

Pain disorders of the head, face, and neck are numerous, diverse, and complicated. While certain of these pain disorders occur in isolation, they are very often interrelated. Many of the headache disorders have associated face, jaw, and neck pain, and these can often be the trigger or perpetuating factor for the headaches. Conversely, primary pain disorders of the face, jaw, and neck very often have headache as a major associated finding. In addition, there are abundant data to show that treatment approaches for one isolated disorder very often alleviate another associated pain disorder or dysfunction of the head, face, and neck.

While numerous therapeutic options are available to treat the multitude of pain disorders of the head, face, and neck, typically, no one therapeutic option is maximally effective. Patients with these chronic pain disorders need to have a comprehensive, interdisciplinary diagnostic evaluation, be given a definitive diagnosis where possible, and have the most appropriate multidisciplinary treatment for the chronic pain and suffering, associated symptoms, family, social, and work-related disabilities.

When a patient presents with a complaint of head, face, and neck pain, the clinician must gather all of the pertinent information necessary to define a differential diagnosis (the problem list). Many times, it is necessary for the primary clinician to have the patient evaluated by other healthcare professionals in order to more appropriately define the primary pain disorder and its associated and comorbid conditions. This is the essence of the integrative approach to the evaluation and management of chronic pain disorders.

1.1 DIAGNOSTIC EVALUATION

The diagnostic medical evaluation includes a comprehensive review of the following:

1. Chief complaints

2. History of the present complaint

3. General medical and psychosocial history

4. Review of systems

5. Physical examination including oral and maxillofacial examination

After this information is collected and analyzed, additional components of the diagnostic evaluation may be needed, including:

1. dental and medical diagnostic imaging,

2. blood studies,

3. lumbar puncture and cerebrospinal fluid analysis,

4. electromyography and nerve conduction studies,

5. electroencephalography, and

6. diagnostic injections.

1.2 INTERDISCIPLINARY MANAGEMENT APPROACH

Based upon this multidisciplinary collection of data, a sequencing of the treatment requires a reasoned approach as to the following factors.

Predisposing. Factors that include genetic and growth and development variants that could predispose an individual to a later problem.

Precipitating. Factors such as trauma, acute stress, and dental or medical interventions that can “trigger” a subclinical potential pain problem into a constellation of symptoms.

Perpetuating. Factors that prevent the normal course of biological healing processes. These are often related to a balance of disease or dysfunctional irritants versus the body’ s resistance and innate immune system levels.

It is this approach to the diagnosis and management of head, neck, and face pain that forms the basis of this text. In each of the preceding areas, a full understanding of the neuralgic, structural, and musculoskeletal features blending with the biopsychosocial issues affecting the individual will lead to a more comprehensive and reasoned management strategy.

Constant advances in medicine and dentistry have made it almost impossible for one individual to be knowledgeable in all aspects of pain management as it relates to the trigeminal craniocervical complex. Furthermore, the interaction between these fields and those of physical, behavioral, and complementary medicine requires an interdisciplinary interaction among the many practitioners. The dualist view of mind versus body as proposed by Descartes offers little in the way of understanding chronic pain, whereas an intergrated or perhaps Spinozian approach is consistent with the contributions of modern neuroscience (2,3).

It is our hope that this text will give the reader a broad understanding of the many comorbid conditions that present to the practitioner on a daily basis and in doing so help to expand the diagnostic and management options for the benefit of our patients.

REFERENCES

1. International Headache Society (2004). Headache classification subcommittee, The International Classification of Headache Disorders II, 2nd ed., Cephalalgia, 24.

2. Rhy E. (1910). Spinoza’s Ethics and De Intellectus Emendatione. New York: E.P. Dutton.

3. Stewart M. (2006). The Courtier and the Heretic: Leibniz, Spinoza, and the Fate of God in the Modern World. New York: W.W. Norton.