running a mile on a sprained ankle, giving the medication no chance to be effective. If distinct trigger points are detected that radiate and produce the patient’s familiar pain, trigger-point injections can be performed. After preparing the skin with an alcohol wipe, the practitioner can inject a small amount (0.5 mL to 1 mL) of 2% lidocaine without epinephrine or 3% mepivacaine into the trigger point of the patient’s pain. Products containing epinephrine and long-acting medications such as bupivacaine should be avoided because of myotoxicity. No evidence exists that adding steroids has any additional or longer lasting effect. In fact, some care providers use saline or dry needling techniques, which appear equally as effective as trigger-point injections with lidocaine (Hammi, et al., 2021). Physical therapy may be considered as an alternative treatment, and some physical therapists are licensed to perform dry needling techniques. If the pain is originating from the neck, proper posture should be advocated, and a referral to physical therapy might be in order. Headaches are often treated with behavioral modifications, such as avoidance of triggers, and with medications. It is a good idea to have a patient with headaches keep a diary to reveal patterns, identify triggers, and provide a better idea of the frequency and duration of the headaches. Frequent headache triggers include stress, irregular sleep patterns, skipping meals, eating certain foods, consuming alcohol, and changes in barometric pressure. Neuropathic pain conditions are almost exclusively treated with medications. On occasion, microvascular decompression or Gamma Knife radiosurgery may be indicated for trigeminal neuralgia. Patients with neuropathic pain may also benefit from complementary and alternative approaches. (These approaches are discussed in a later section of this course.) masseter, temporalis and lateral pterygoid muscles (Colgate, 2021; Gn and Nag, 2017). Headaches Pharmacologic treatment for headaches is divided into abortive (to stop the headache after it has started) and preventive medications. Which type of treatment is indicated depends on the frequency of and impairment associated with the headache. Preventive medication is recommended if a patient experiences: ● 6 or more days with headaches per month regardless of impairment. ● 4 or more days with headaches per month with some impairment/need for bed rest. ● More than 1 day per month with severe impairment. (Rizzoli and Mullally, 2017) Medications with established evidence of efficacy for the treatment of migraine include the anticonvulsant drugs divalproex sodium, sodium valproate, topiramate, and several beta blockers such as propranolol, metoprolol, and timolol. The antidepressants amitriptyline (Elavil) and venlafaxine (Effexor XR) have also proven effective (Rizzoli and Mullally, 2017). The shrub Butterbur (Petasites) and magnesium also may be considered in the preventive treatment of migraine headaches (Gotter, 2017; NCCIH, 2017). To abort migraine headache, selective serotonin receptor agonists such as sumatriptan, eletriptan, and rizatriptan (the so-called triptans ) are often used. However, non-selective medications such as aspirin; naproxen; ibuprofen; or a combination of aspirin, acetaminophen, and caffeine may be used as well (Starling, 2018). Frequent use of abortive medications may result in medication overuse headaches. To abort tension-type headaches, nonsteroidal anti-inflammatory medications or acetaminophen are recommended. For prevention of these headaches, the antidepressant amitriptyline is considered first choice, followed by the antidepressants mirtazapine or venlafaxine as second-tier choices (Rizzoli and Mullally, 2017). The dosage of medications used to prevent headaches is typically much lower than the dosage used to reach an antidepressant effect.
jaw joints and resting the jaw muscles. These goals can be accomplished by having patients eat a soft – or softer – diet or having them become aware of whether they are clenching their teeth and, if so, when they are engaging in this behavior. If patients are clenching their teeth, the dental practitioner can initiate simple exercises to keep the teeth apart, the lips loosely together, and the tongue resting with gravity and not pushing against the teeth or the roof of the mouth. Other offending behaviors such as biting cheeks, pens, or pencils, or crushing ice with the teeth should be avoided. The patient may have to refrain from singing or using wind instruments until the pain has resolved. If the patient wakes up in the morning with jaw pain or headaches that are attributed to temporomandibular disorders, a full coverage, hard acrylic oral appliance might be indicated. If the patient does not wake up with the pain, an appliance is not indicated. To help patients understand the mechanics of their pain and the influence of clenching and grinding teeth as a perpetuating factor, the dental practitioner can employ the following analogy: Compare running 3 miles daily with clenching the teeth all day long. A runner who sprains an ankle will have to give up running until the ankle heals. Continuing to run will not allow the ankle to get better any more than continuing to clench the teeth will allow the temporomandibular disorder to heal. It is irrelevant that running – or clenching the teeth – caused no problems before. Now there is a problem, and even reducing the distance run to 1 mile is not enough of a change to allow the runner’s ankle sufficient rest to heal. In the same way, giving up hard foods and nail biting but continuing to clench the teeth will not provide sufficient rest for the jaw to heal. Many patient complaints that “ibuprofen does nothing for my pain” may result from only partially unloading the system. Such patients are still analgesics such as acetaminophen, as well as nonsteroidal anti-inflammatory (NSAID) medications such as ibuprofen, are frequently prescribed for chronic musculoskeletal pain conditions. Although nonopioid analgesics are freely available over the counter in many countries, caution must be taken when advising or prescribing these medications for prolonged periods of time because acetaminophen has been linked to liver toxicity (Black 2019; Yoon 2016) and NSAIDs have been linked to nephrotoxicity (Wynn, et al., 2019). NSAIDs have numerous other side effects such as gastric bleeding and ulcers. Furthermore, they can interact with selective serotonin reuptake inhibitors SSRIs such as fluoxetine and paroxetine and with antihypertensives such as lisinopril and losartan, classes of drugs chronic pain patients are likely to be prescribed and can decrease the efficacy of these medications. Both NSAIDs and SSRIs can inhibit platelet aggregation and can increase the potential for gastrointestinal bleeding (Wynn, et al., 2019). Muscle relaxants such as cyclobenzaprine and antispasmodics such as tizanidine or baclofen may be used as these agents are effective against spasticity, skeletal muscle spasms or both (Fudin and Raouf, 2017). Oromandibular dystonias or dyskinesias are debilitating Pharmacological treatment Musculoskeletal pain Regarding pharmacological interventions, nonopioid conditions characterized by involuntary repetitive or sustained muscle contractions resulting in abnormal posturing or choreatic jaw or facial movements. These conditions are often a side effect of antipsychotic medications; eliminating the offending drug may reduce or eliminate the dystonia or dyskinesia, although it may take weeks for the medication side effects to wear off. Non-drug-related dystonias and dyskinesias can be signs of central nervous system diseases such as Parkinson’s disease, but could be idiopathic as well. These dystonias may be treated with drugs used in Parkinson’s disease such as benztropine or trihexyphenidyl (Mayo Clinc, 2020). or with motor-suppressive medications such as clonazepam (Yoshida, 2017). There is some evidence to support the use of botulinum toxin type A (BTX-A) for oromandibular dystonias with injections placed into the
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