Trigeminal Trifecta

Deborah Heath, DO Professor & Co-Chair OMM

Mindy Hansen, MS, OMS IV

ATSU SOMA

A.T. Still

“I want men and women to study

Osteopathy who reason and think for

themselves. It is never a question as to

what the remedy or the treatment will do to

the body, but what the body will do with

the remedy or treatment.”

Introduction

Part I:

• Trigeminal/Occipital anatomy and physiology

• Neuromodulation – summary of evidence

based studies

Part II:

• Lab – integration of palpation, evidence and

observation

• Summary and conclusion

Trigeminal Nerve “The 3 Twins”

V1 = ophthalmic

Sensory for: scalp&forehead; frontal&ethmoidal sinus; upper eyelid &conjuntiva; cornea; dura/meninges

V2 = maxillary

Sensory for: lower eyelid & conjunctiva; maxillary sinus; nasal cavity; upper lip; upper molar, incisor, & canine; superior palate; dura/meninges

V3 = mandibular

Sensory for: mucous membranes; external ear; lower lip; anterior 2/3tongue pain/temp (not taste); lower molars, incisor & caninesl dura/meninges

Motor for: medial and lateral pterygoids, masseter, temporalis;digastric anterior belly; tensor veli palatini &tympani

Anterior/Middle

fossa:

Trigeminal nerve

Posterior fossa:

Upper 3 cervical

branches

Sympathetic

branches

Vagus

Hypoglossal

Trigeminocervical Complex

Trigeminal Nucleus

Main sensory nucleus:

posterior pons (touch &

pressure)

Spinal nucleus: extends to

the 2nd – 3rd cervical seg.

(pain & temp)

Mesencephalic nucleus:

around cerebral aqueduct

Motor nucleus: pons

(muscles of mastication,

tensor tympani, tensor veli

palatini, mylohyoid, ant

bellydigastric)

Occipital

nerve

• Originates from

C2, C3

• Pierces fascia,

trapezius and

ascends the scalp

• Innervates scalp at

the top of the head,

the top of the ear

and over the

parotid glands.

TRIGEMINAL REFLEXES

Trigeminal Reflexes

Trigeminovascular system

Trigeminocardiac reflex

Trigeminocervical reflex

Trigeminomandibular reflex

Nociceptive Blink Reflex

Trigeminocervical complex C1-C3

“Hit your nose + eyes water” Reflex

“Sneeze in the sun” Reflex

Occipital reflexes

• Influence on nociceptive blink reflex of trigem

NEUROMODULATION

How to affect change?

Pharmacology

Neuromodulation: peripheral (nerve blocks,

implantables or noninvasive)

Jurgens, T., Leone, M. Pearls and pitfalls: Neurostimulation in headache. Cephalgia. 33(8):512-525, 2013

Neuromodulation

MOA

• Initially thought to be based on Gates Theory

• Evidence is suggesting PNS alters pain perception in central mechanisms

• There is a modulation of nerve activity within CNS pain processing and integration centers in the brain

Low freq = incite HA

High freq = inhibit HA

Noninvasive Brain Stim

Transcranial magnetic stimulation (TCs)

• Uses weak magnetic field to alter the global currents

in the brain

• Repetitive pulses used for neuromodulation (rTMS)

• High frequency = excites cortex

• Low frequency = depresses cortex

Transcranial current stimulation (tCS)

• Direct or alternating current delivered to scalp via

electrodes

Mechanical Stimulation

Mechanical pressure on trigeminal nerve endings can

elicit pain reduction and motor relaxation

• Uses mechantransduction mechanisms – mechanical

stimulation is translated into electrical, chemical, and

mechanical signals

Q’s on Anatomy/Physiology?

Let’s put it all together

Lab

A.T. Still – to a student

“I could not wish you any better luck

than when you start practicing you may

come up against hard problems that

you have to solve. Go to a small

town...but sleep with your anatomy

under your pillow, and don’t forget you

are supposed to have a brain inside

your skull.”

FIRST and FOREMOST– No Agenda

1. History – any recent: HA, head injury, sacral

injury, dental work, eye strain?

2. General Scan: assess head, OA, cervical,

thoracic, lumbar, sacrum

3. MONITORING!!

Sub-occipital

Triangle

“The HA

Triangle”

Pay attention to

what attaches

where!

Let’s get started

OA Junction – what do you assess?

• Tenderness when comparing sides

Any changes with an OAD?

What doesn’t change might be related to the trigeminal and occipital influences – or a restriction downstream.

How do you monitor?

This is a major key in knowing when tissues

change!

It’s different and more comprehensive than just

checking for motion.

Being able to know that the area of restriction is

changing is invaluable!

Occipital Nerves

Don’t forget – these innervate the posterior fossa

of the head

Trigeminal and Occipital

interaction

Find the Occipital notches

• Greater is 1 cm lateral to inion

• Lesser is halfway b/t inion and mastoid

Any tenderness? Any response where you are

monitoring?

Now check V1, V2, V3 for tenderness and

reciprocal change in the OAD where you’re

monitoring

Trigeminal Foramen

Auriculotemporal

Trigeminal

V1, V2, V3 – if you find tenderness and

reciprocal changes at the OA

• Find a pulse frequency and pressure that

allows the changes of TART at the OA

where you are monitoring

Trigeminal

Next in the progression is checking C2

(this is where the TCC lives, remember?)

• The association may be ipsilateral or

contralateral – you have to pay attention to

the monitoring hand

Trigeminal

RECHECK

Do you have any autonomic changes like heat and moisture?

Recheck the spine, has anything changed?

See if the inhibitory signals have influenced the rest of the system.

No one technique is everything

• Like any art, no one technique or tool will be

the answer for every patient.

• If something doesn’t change – it means

something else is holding it.

• Ask the question: “What does this person need

at this moment.”

• This tool can be extremely effective in the

right context.

Thank you from ATSU SOMA

Deborah Heath, DO

Mindy Hansen MS, OMS IV

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