A 43-year-old female presented to the clinic with daily migraines and headaches. Other chief complaints include jaw pain, jaw clicking, limited mouth opening, facial pain, neck pain, dizziness, and pain in and around the ear. Patient stated that she had suffered migraines of varying frequency since she was a teenager and has been under the care of a neurologist since then. Patient was currently prescribed and taking muscle relaxers twice daily, prescription NSAIDs once daily, prescription migraine medication once daily. Patient’s symptoms include parietal headaches, bilateral head pain, jaw pain while opening and chewing on both sides, frequent biting of cheek, pain in and behind the ear, pressure/pain behind the eyes, upper back pain, neck pain, shoulder pain and shoulder stiffness. Patient reported jaw pain at a level of 9 on a 0-10 scale, headaches are reported at a level of 8 on a 0-10 scale, neck pain is a 9 on a 0-10 scale, facial pain is a 9 on a 0-10 scale. Pains are reported as constant and lasting for weeks. While having the pain, the patient reports dizziness and throbbing.
Patient received a thorough examination of the jaw, head, and neck. Patient had many muscles of the head, neck, and jaw that were determined to be hypertrophic, painful, and referring. After reviewing symptoms and diagnosis with the patient, a plan was made for treatment. Patient scheduled a return to the clinic for treatment.
Patient returned to the clinic for her first scheduled treatment. An impression was made for an oral appliance for the patient to optimize the musculature of her jaw, both at rest and while she attempts to clench and grind. Patient received the first session of prolotherapy. Patient felt immediate reduction of her chronic pain.
Patient returned to the clinic for delivery of her orthotic appliance and second session of prolotherapy two weeks following initial treatment. Orthotic appliance was delivered and fine tuned during the appointment and the patient received her second session of prolotherapy. Patient feels further reduction of pain levels.
Patient returns to the office for a follow-up on her appliance and third session of prolotherapy three weeks following last treatment. Adjustments were necessary and made to the patient’s appliance. Patient received a third session of injections and reported almost complete elimination of all pain.
Patient called to cancel and reschedule her follow-up appointment and reports that she has been migraine-free and pain-free since her last treatment. She also reports that she has not taken any medication since her last appointment.
Patient returns to the clinic six weeks following the last treatment. Patient reports she is still migraine and pain-free since her last treatment. Adjustments were made to the patient’s orthotic. Patient was released to PRN status and informed to call us if any of her pains or migraines return.
In 5 weeks the patient has become pain-free and off all prescribed pain medications.