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CCJ-and-headache

The Craniocervical Junction and Headache Disorders

CCJ-and-headache

 

  • Chronic headaches come in different types
  • The neck and headache disorders
  • The craniocervical junction, NUCCA, and migraines

Headaches disorders are among the most common conditions that people seek treatment from a doctor. While most people will experience a headache of some form,  there are those who develop chronic and repetitive bouts with headaches of different types.

Each headache has unique characteristics that help to make an effective diagnosis for effective treatment. However, when we look at the reality of a daily patient interaction, we see that people with these headache disorders can have traits that overlap. (Remember this point because this is something I’ll come back to later)

That makes these headaches  extremely burdensome on the patient, but it can also be challenging for a doctor or therapist to find effective solutions. The chronic use of medications has led to the emergence of medication overuse headaches as the third leading cause of chronic headaches in the United States.

Medication overuse headaches were once classified as rebound headaches because of the way headaches could come back with a vengeance after the pain-relieving effects of a medication wore off. It became re-classified in part due to the alarming number of patients showing a regression in their headache symptoms after prolonged and frequent use of medication. While the physiology of this disorder is widely unknown, it does show characteristics of physical dependency as seen with drug withdrawals.

As drug therapies become less effective for this subset of headache patients, there has become a growing need to identify non-pharmacologic strategies to help patients with headache disorders. For many of these patients, a possible solution might lie in the neck.

The Neck and Headache Disorders

Headaches caused by a neck problem are usually classified as a subtype known as cervicogenic headaches. People with cervicogenic headaches are usually those with chronic headache along that is associated with neck pain, whiplash, or a resistance to most medications.  Studies on chiropractic and cervicogenic headaches are mixed, but it is mostly accepted that these types of headaches can be responsive to traditional spinal manipulation [1].

The study of these headaches has helped us understand the neurology behind head and neck pain in general. There’s a lot of really sensitive anatomy in your neck. Structures ranging from the muscles, ligaments, joints, nerves, arteries, and nerves. Things like whiplash, concussion, and even sub-concussive head injuries can damage some of these structures causing pain receptors to fire into your brain stem.

The muscles in the deep part of the neck have been implicated in headache disorderrs

The muscles in the deep part of the neck have been implicated in headache disorders

That’s where things can get a little bit screwy. The area in the brain stem that gets pain signals from the neck also receives pain signals from the head and face too! When nerve fibers from different parts of the body converge onto one location called the trigeminocervical nucleus (TVN), it allows for 2 things:

  1. It allows dysfunction in what part of the body to be felt in other parts of the body. It’s like when you have a pinched nerve in your back but you feel it in your leg, or when someone has a heart attack, they may feel it in their left arm.
  2. It allows the opportunity for treatments in one part of the body to have the ability to reduce pain in other areas. i.e – targeting TMJ and the neck to help with head pain

But What About Neurovascular Headaches Like Migraine?

Neurovascular headaches are those attributed to problems in the blood vessels in the head or brain. Migraine and cluster headaches are the main classes of chronic neurovascular headaches.

From a basic science standpoint, the neck still seems to be a problem area for migraine patients. We also know that patients with migraine also tend to have overlapping pain in parts of their neck too. However, from a clinical research standpoint, most studies on treating the neck in migraine patients have been underwhelming.

Findings like these challenge my beliefs because while I know the research says that treating the neck is not likely going to get you far, the results in my practice seem to dispute that.

The Cranialcervical Junction and Headaches

As an office focused on upper cervical chiropractic, we often see headache patients who have chronic and treatment resistant headaches. They’ve usually been through multiple rounds of different medications and have bounced around through various specialists from renowned neurologists, to local chiropractors.

Despite seeing these patients with significant challenges, our success rate in chronic migraine headache is pretty high. About 85% of our patients with a primary complaint of migraine headache reported a favorable outcome after 8 weeks on a progress exam.

 

How I imagine Brad Pitt would react if he had chronic migraines and didn't anymore

How I imagine Brad Pitt would react if he had chronic migraines and didn’t anymore

Of course I wish everyone got better, and I spend a lot of time reading and going to seminars trying to get answers for the other 15%. We just have a high degree of confidence that even some of the most challenging headache cases seem to do well when we address the upper neck.

If so many people get relief in our office, but clinical trials on chiropractic show limited effect, then what gives?

The big thing is that I don’t practice the same way that most chiropractors practice. Our office uses precise x-rays of the top of the neck called the craniocervical junction and we use very low-force techniques like the NUCCA procedure to address the neck. We also take pre and post x-rays to verify that we’ve changed the way the head sits on top of the neck.

  • Maybe previous chiropractic studies didn’t use techniques that accurately identified the problem area in the spine?
  • Maybe the way the spine was manipulated was not well suited to the specific patients?
  • Maybe the adjustments used didn’t actually show a structural change in the craniocervical region? It’s hard to say.

However,  a small 2015 study on patients suffering from chronic migraine headaches showed that the correction of the atlas vertebra using precise upper cervical methods showed a reduction in headache days and high patient satisfaction.

Obviously we can’t generalize these findings to every migraine patient because there was no control group and migraine studies have a high rate of placebo, but this is clearly something worth studying more.

Is It Worth It?

So I can’t tell someone if getting their atlas corrected is going to be worth it. For many people, the prospect of having far fewer headaches is worth any price. For others, you may have become so used to having headaches that you have learned to live with it and don’t mind the pain.

What I can say is that getting the atlas corrected through the NUCCA procedure is a really safe way to address some of the real anatomical and physiologic causes of many headaches.

The only things I can say for sure are this:

  1. If your atlas is a major cause or contributor to your headache syndrome, we’ll know it pretty quickly as you will likely respond to this within a few weeks.
  2. We will do everything in our power to help you find solutions to this disabling secondary condition, even if it means we have to refer you to another provider that is better equipped to help.

 

Talk to Dr. Chung

 

 

Medication Overuse Headaches

Combating Medication Overuse Headaches

Medication Overuse Headaches

Medication overuse headache (MOH) is a very common manifestation of chronic headache patients. It is one of the unique instances where a once effective way of controlling an illness will actually perpetuate the illness further as the body adapts to a chemical intervention. This condition is unique to patients with chronic daily headache disorders and various chronic pain syndromes like fibromyalgia.

The most frustrating part about MOH is that you may do better for a long period of time because of a medication, but as the effectiveness of the medication wanes over time you may actually experience the headache worse than before.

It’s a situation that can cause despair as medications are generally the treatment of choice for all headache conditions. If your body has become resistant to all of the available medications, what can you do next?

Why Is Your Medicine Making Your Head Hurt?

People with chronic headaches will generally have 7-10  headache days per month. For better or for worse, there are a wide variety of medications that can help knock a headache out or prevent them from occurring. It’s not unusual for a chronic headache patient to have  a cocktail of drugs that they have to take on a daily basis.

The problem with a frequent medication regiment in chronic pain conditions is that the cells of your body almost always have an adaptation to to make itself more resistant to the medications’ effects. This can happen even if you’re taking your medications correctly as prescribed by your doctor.

The headache that results from MOH is often called a rebound headache. As the effect of the medication wears off, the headache returns rapidly which can create a need for another dose of medication. In this way it becomes a cycle of struggle as the effects of the medication start to decline faster and the rebound headaches become more persistent. When this occurs, the chronic headache patient can become the chronic daily headache as the headaches will begin to occur greater than 15 days per month. Because of the reliance on these medications, medication overuse headache has become the 3rd most common headache disorder, and the most common cause of migraine-like symptoms.

Research has shown that this can occur regardless of the type of medication you take. It’smost frequently associated with prescription migraine medications, but it has been documented to occur in people taking over-the-counter drugs like ibuprofen. Hard pain meds like oxycontin may be used by headache patients without a doctor’s prescription, and these can tend to accelerate the process to MOH because of the way that opiods sensitize your brain.

You can read more about how pain pills can make your pain worse in this article I wrote last year:

Research: Can Pain Pills Cause More Pain Over Time?

How to Beat Medication Overuse Headaches

The easy answer is to stop taking your medications for a while because….

you can't if you dont

If you don’t understand this meme, then ask someone who is younger than 30. I promise it’s funny.

Unfortunately, biology isn’t that simple, especially if you have chronic pain.  Are there side effects to stopping a daily medication? Will you experience worse pain when you stop taking the drugs? How will you cope with the pain if you can’t take any meds? How long will this take before you can make the meds work again?

Chronic headache patients need effective non-pharmacological methods to deal with the pain of headache physiology.

One specific target for drug-less treatment of headaches is by correcting dysfunctions in the neck.

In many cases, headaches syndromes can be a result of a secondary effect of a shift in at the top of the neck. This is why chronic headache patients are some of my favorite people to see in practice because a gentle correction of the neck  has allowed us to have a very high success rate with chronic headache syndromes.

While addressing the cervical spine may not address the cause of  a medication overuse headache, it may help fix the primary source of a patient’s headache condition so that taking the medication becomes less necessary. The most common comment I get from headache patients is when they tell me that they’re taking less ibuprofen since they started getting their neck better.

A shift in the atlas can disrupt fluid in the spine and cause neuroinflammation in the brain. In some cases, this may be tied to MS.

A shift in the atlas can disrupt fluid in the spine and cause neuroinflammation in the brain. In some cases, this may be tied to MS.

Within 2 weeks of neck corrections with the NUCCA procedure, the vast majority of our headache patients experience relief in either the frequency or intensity of their daily headaches.

Not All Neck Adjustments Involve Cracking

A lot of people are scared about having their neck worked on by a chiropractor. The general portrayal of a neck adjustment by viral Youtube videos can make it seem scary.

While chiropractic adjustments have a tremendous track record for safety, the bottom line is that a lot of people just don’t want their neck cracked because the sound and the motion make them really uneasy. This leads to patients tightening up their neck and bracing which can make a neck manipulation hurt in the hands of a chiropractor that is not skilled.

That’s one of the big reasons why I’ve used the NUCCA procedure throughout my career. The NUCCA procedure involves a very light pressure to correct the neck as opposed to a high velocity manipulation. By using the NUCCA procedure, the doctor is able to measure and control how much force goes into the neck, and if we have corrected the underlying dysfunction. All of this happens without the popping, twisting, or cracking of the spine.

Not all patients with headaches are good candidates for the NUCCA procedure. Only patients with a subtle shift in the top vertebra called the Atlas will benefit from the NUCCA correction. A thorough history and examination will help us determine if the Atlas is causing a problem and if it’s something that can be fixed.

 

Request a Consultation with Dr. Chung

Migraines and Concussions

Why Concussions Hit Migraine Patients Harder

Migraines and Concussions

 

The vast majority of people who suffer concussive injuries will recover without any chronic symptoms. However, about 15% of people who suffer concussions will go on to have post-concussion syndrome, where they will experience headaches, dizziness, and cognitive problems beyond 30 days after an injury. These symptoms can be debilitating, and some people can experience the effects of these head injuries for years later.

A lot of research has been done to identify people who are at higher risk of developing post-concussion syndrome. The most significant risk factor for this is having multiple concussions, but that’s a rather obvious one. The more concussions you’re exposed to, the greater the opportunity to have chronic symptoms. However, research has pointed to one specific risk factor that seems to contribute heavily to post-concussion syndrome in the athletic population. That risk factor? A history of migraine headaches.

Migraines and Concussion: a terrible duet

Post-traumatic headache is one of the hallmark symptoms of post-concussion syndrome. These headaches look a lot like migraines because of the wide range of neurological symptoms that concussions can cause.

It’s no secret that concussions can cause terrible headaches in people, but many people don’t know that having a history of migraine headache is a risk factor for worse outcomes in post-concussion syndrome. ¹ ² ³

This is important for a couple of reasons:

  1. If you know someone with migraines is at a higher risk for post-concussion symptoms we can be better prepared to see appropriate specialists in the event of a concussion.
  2. We have a better understanding for why sports like girls’ soccer are more susceptible to concussive injuries and can be more prone to chronic post-concussion syndrome.
  3. Because understanding the common physiology in migraines and concussion can help us identify effective treatments for one of its most debilitating symptoms.

Migraines, Post-Concussion Syndrome, and the Neck

Treatment for headache symptoms in migraine and post-concussion syndrome are pretty similar. Amitriptyline, propanolol, and topirimate. These medications target receptors in the brain that can become overactive and underactive during a migraine attack.

Most research is focused on finding effective drugs to treat headaches, but this treatment philosophy ignores the fact that the headaches from a migraine or concussion can often stem from dysfunction of the cervical spine.

When the neck is compromised the muscles and nerves that surround the upper neck can become areas of concern for the headache patient. The muscles at the top of the neck transmit information to the brain about where the head is in space.  Studies have shown that these muscles can be tied to chronic headache symptoms. ¹ Some studies have even shown that cutting these muscles can lead to headache relief.¹

You can read more about these troublesome little muscles on a previous article I wrote here:

Is This Small Neck Muscle Driving You Mad?

 

The muscles in the deep part of the neck have been implicated in headache disorderrs

The muscles in the deep part of the neck have been implicated in headache disorderrs

 

Additionally, the nerves in the top of the neck are important transmitters of pain. The C1, C2, and C3 nerve roots in the neck are linked to the trigeminal cervical nucleus which is an important relay center for pain in the head. Branches off the C1 nerve like the suboccipital nerve have been targets for nerve blocks in migraine patients with good success.¹

 

The nerves in the upper neck play a major role in headache physiology

The nerves in the upper neck play a major role in headache physiology

 

These mechanisms are important because research has shown that whiplash and concussions can have a significant impact on these anatomical structures. ¹ ² ³

Concussions Worsen Cervical Spine Problems

So here’s the main issue. Many (but not all) migraine issues can be tied to the neck. More than 80% of the migraine patients that come into our office get a tremendous improvement in the frequency of their migraine attacks just by fixing biomechanical issues in the neck, and there is some research that supports it. ¹

When someone has a biomechanical issue in their neck, then a major blow to the head like a concussion can make these neck problems worse. Several studies are starting to show that there are some interesting similarities with what happens in a whiplash and what happens in a concussion. The fact is that the amount of force that it takes to cause a concussion FAR exceeds the amount of force it takes to create a mild whiplash injury.

Whiplash and Concussion

The force required to sustain a concussion far exceeds the forces necessary to cause a whiplash

Obviously not every force over 5 g’s causes a whiplash and not every force over 100 g’s causes a concussion. Otherwise we’d all be walking around with with severe neck injuries every time we got off a roller coaster. There are factors involved like neck strength, timing of muscle bracing, and previous injuries that affect our susceptibility to these forces.

My point is that if you have sustained a concussion, then the probability of you also suffering an injury to the neck is really really high.

If you were a migraine patient before the concussion and the migraine was stemming from your neck, then the odds of that neck injury becoming worse and making the healing process after a concussion is much higher for you than most others.

If you had a small biomechanical issue in your neck that was contributing to your migraine headache symptoms, then the force of a concussion is going to injure the ligaments and muscles that were already compromised! This is addition to the way that concussions knock out your vestibular and ocular systems which are also known contributors to headache physiology.

Addressing the Neck

So what does this mean for you?

  1. If you are an athlete and have a migraine headache problem, you should get your neck checked and rule out any biomechanical problems in the upper cervical spine. Fixing these issues will likely address your migraines, and may provide some protection from head contact.This is even more true for female athletes than male athletes. Women suffer from migraine headache issues at a much higher rate than men, and this can be a contributing factor to the increased rates of concussion we see in girls’ soccer.
  2. If you play contact sports, getting your neck stronger may provide protection from concussive injury. Again, this applies even more so to female athletes because women will tend to have smaller neck muscles than men. Weight training and specific neck exercises is a safe and easy way to possibly mitigate this risk.
  3. If you have a history of neck injury from whiplash and concussion, make sure you’re seeing someone with expertise in addressing the cervical spine. People with traumatic neck injuries may not respond well with vigorous treatment methods and may regress with too much force applied to injured tissue.

 

E-Mail us a question

 

 

Anatomy

The Anatomy of a Headache

Anatomy

 

Outline: [5-10 minute read time]

  • Headaches come in different shapes and sizes and may have different anatomical triggers
  • The brain cannot generate pain. Head pain must come from a source outside the brain
  • Common sources of head pain
  • How head and neck positioning can help

Not all headaches are created equal. Part of being a doctor that sees patients of all shapes and sizes, we have to become familiar with the different types. Here’s a short list of the most common types:

  • Tension headache
  • Migraine headache
  • Sinus headache
  • Hypertensive headache
  • Cluster headache
  • Post-traumatic headache
  • Cervicogenic headache

It can be a challenge for a doctor to identify the type of headache you have because while these headaches have distinct characteristics, most of them overlap and make the clinical picture very gray. In some part, the type of headache you are having is determined by the anatomy that is generating the pain signal.

Although the pain of a headache can make it feel like your brain is going to explode,  there are actually zero pain generating tissues within the brain itself. That means that something outside of the brain is transmitting a signal to the brain that something has gone wrong. I won’t go into some some of the more serious secondary causes of headache like tumors, strokes, etc, this will be more focused on primary headache.

Headache Anatomy

1. Arteries in the brain -

For decades, scientists have studied arteries in the brain and their role in headaches. While we don’t know everything about migraines, we do know that migraine attacks tend to happen when the arteries of the brain swell and lead to inflammation of the nerves that are connected to the artery. These nerve endings are transmitted to the trigeminal ganglion causing the pain portion of the headache.

It’s for this reason that many of the drugs used to treat migraine are those that reduce the swelling of brain arteries. In fact, the target of new drug therapies are using antibodies to target the molecules that cause the arteries to open, and hopefully prevent the attacks from occurring to begin with.

2. C1, C2, C3 Nerve Roots

The top 3 nerves in your spine are highly linked to headaches following a head and neck injury. When someone suffers a whiplash injury or concussion, these upper cervical nerves can become irritated and generate pain across the back and top of the head. In some cases, this leads to a condition called occipital neuralgia where the nerves are chronically disturbed leading to unrelenting pain or numbness in the skull.

c1 c2 c3 nerves

The nerves coming from the top of the neck

 

3. The Meninges

The meninges is a layer of tissue that wraps around the brain, spinal cord, and nerves. When you hear people talking about meningitis, we are referring to this outer covering becoming enflamed. One of the symptoms of meningitis can be a bad headache, and the meninges can be a cause of headache pain even without a meningitis infection.

Some anatomical studies show that small muscles in the neck can connect into the meninges which may be the problem with certain types of headaches.

Brain Meninges

A cross-section of the skull showing the brain and the meninges

4. Head and Neck Muscles

Muscles of the head and neck have been long associated with tension type headaches. While the influence of these muscles in headache were exaggerated over the years, certain muscles do play a role in head pain. Neck pain generated by muscles like the  splenius capitus can generate pain that refers into the head.

With TMJ patients, the jaw muscles like the masseter, pterygoids, and temporalis muscles can become highly contracted and become potent pain generators which is one of the reasons why jaw problems are highly associated with headache.

Neck Muscles

Muscles commonly associated with headache

5. Dysfunctional Neck Joints

The joints of the neck play a large role in postural feedback to the brain. These joints are also sensitive to irritation through injury and chronic malpositioning. Headaches resulting from dysfunctional neck joints are known as cervicogenic headache. These types of headaches are hard to diagnose because they are generally classified by whether a neck treatment helps, but we do know that this is more commonly seen with whiplash and head injuries.

What Do They All Have In Common?

So here’s the fun part. What is it about all of these different pieces of anatomy have in common besides the fact that they all cause headaches? Neurologically it comes down to a bundle of nerves that make up the trigeminal complex.

The Trigeminal Complex

The Trigeminal Complex

This particular piece of anatomy is important because it is the hub for almost all pain signals in the head and neck. Everything from the C1-C3 spinal nerves, meninges, jaw muscles, and skin of the face gets transmitted and processed by these nerves. In some cases, a chronic headache problem might possibly be a less severe form of trigeminal neuralgia.

That means if we can can change the way the trigeminal complex is working, then we can have a meaningful effect on the status of someone’s headache disorder.

How Structural Correction of the Neck Can Help

In our Wellington office, we work heavily on correcting the positioning of the top part of the neck. We talked about how C1, C2, and C3 nerves can transmit pain in regards to a headache, but they also transmit valuable information about your posture and positioning in space.

When the head and neck are in a normal position, then this information gets to the brain without a problem and all seems well. However, a structural shift like Atlas Displacement Complex creates a scrambled signal into the brain and allows pain to be the dominant message. That’s why those nerves at the top of your neck are so important. They can dampen pain signals going into the trigeminal complex and stop the headache process from starting!

 

Image credit to Dan Murphy, DC thechiropracticimpactreport.com

Diagram showing how the nerves from the neck meet with the trigeminal nerves Image credit to Dan Murphy, DC thechiropracticimpactreport.com

 

Our success rate with headaches is so high, not because we’re treating each headache we see differently, but we are finding the neurological element that seems to tie them all together. In many cases, it can be as simple as the Atlas Displacement Complex.

 

 

Could your problems be the result of ADC?

Could your problems be the result of ADC?

TMJ Ruining

TMJ Pain is Ruining My Life

TMJ Ruining

Outline:

  • When treating TMJ pain seems hopeless
  • Surgery may not be your best solution
  • TMJ pain may not be a jaw problem

I’ve seen a lot of patients with TMJ in my Wellington office in the past couple of months.

Patients with TMJ often see a large drop in the quality of their life:

  • “I feel like a baby because I can’t eat solid foods anymore”
  • “There are times where I just have to stop talking because all I can think about is the pain”
  • “That popping sound creeps me out and drives me nuts”

A lot of people will experience jaw pain for a day or two if they bite into a hard/chewy piece of food, but imagine if your life was plagued with jaw pain every single day. We underestimate the importance of our jaw, but it’s the piece of anatomy that allows you to enjoy some of the finest pleasures in life. Everything from kissing, to chewing, to a casual conversation with friends becomes a burden when your jaw fails to function.

Desperate Times and Desperate Measures

Severe cases of TMD can make people reach their breaking point quickly. Many of the patients that come to see me are usually looking at surgery as their next and final option because they don’t know what to do.

Even worse is when a patient spends tens of thousands of dollars for surgery but the pain doesn’t go away. Procedures that help to remove or replace a degenerated disc in the joint is sometimes performed to eliminate this pain sensitive piece of anatomy. The problem is that a degenerated disc can show up on imaging, but it isn’t necessarily the cause of the pain.

Unfortunately this happens more often than you might think, and it’s something that can make a patient with TMD hopeless if even surgery couldn’t get the job done.

This isn’t to say that surgery is not the answer, or that surgery can’t help, but we have to remember that TMD is a problem that science has yet to reveal all of the answers, and dental surgery is still working on figuring out what works and when it’s appropriate. Source

TMJ Pain May Not Be A Jaw Problem

There are many different causes for TMJ pain. They can range from abnormal jaw movement, tight jaw muscles, and degenerated discs. These can all be problem areas for a TMJ patient, but  they all have something in common.

In fact, their commonality goes back to some of the same neurological mechanisms that contribute to neck pain and headaches. That’s why people with TMJ don’t just have jaw pain, they often have neck pain and headaches at the same time. It’s because almost all pain signals from the head and neck go through a small piece of spinal cord called the trigemino-cervical nucleus.

…..Trigemino what????

Sometimes Pain is a Computer Problem

So if you don’t have a medical background, some of that terminology might jump over your head.

Instead of thinking anatomy, let’s talk about it like a computer.

garbage in garbage out

Your brain and spinal cord are like a computer chip. The part of your computer chip that feels head and neck pain is the trigemino-cevical nucleus.

Just like all computer chips, the quality of information that comes out is dependent on the quality of information that comes in. If you put junk information in, you get junk information out.

The computer chip of your body relies heavily on information from the muscles and joints. These signals are like computer programs. Whenever these joints move poorly from bad positioning, then it’s like a bad program that gives faulty information about what’s happening inside the body. This can occur from malpositioning of the jaw, faulty jaw movement, neck positioning errors, and faulty neck movement.

It’s like a computer virus going into your system and scrambling important signals into the brain.

This tells the body to produce a junk signals including:

  • Tight and tense jaw muscles
  • Inappropriate inflammation
  • Central pain sensitivity

Can This Program Get Shut Off?

Fortunately your body’s program for pain can be re-written by changing the way these joints move.

A specialist like a neuromuscular dentist can use non-invasive methods to change the way your jaw moves and alter your bite with an orthotic.

Chiropractors that can correct the craniocervical region can create a dramatic impact on the pain programming in the brain.

That’s why both of these doctors frequently see similar patients, and will actually co-manage them between each other. Neck pain patients may get better relief from a dentist changing their bite, while some TMJ patients will get better relief from correcting their neck.

While we can’t say for certain which takes priority, but many patients can benefit from an interdisciplinary approach to care. Take the time to get a Complimentary Consultation to find out what method fits with you. You may even find that getting the entire jaw/neck complex fixed may be the key to solving your TMD.