Published August 5, 2019 By Adam Lowenstein

Adam Lowenstein: Hi and welcome to the Headache 360 Podcast. I’m your host, Dr. Adam Lowenstein, and today I have a great guest who is arguably overqualified to be talking to me. Dr. Prabu Raman is a physiologic neuromuscular dentist, and I have to admit that I did not know such a specialized specialty existed before I got into to doing headache surgery myself. Dr. Raman came from India in 1972 and went to William Jewell College and got his DDS, his doctorate in dentistry from the University of Missouri in Kansas City, and he has done extensive postgraduate education after that.

Adam Lowenstein: He does a lot of teaching and a lot of speaking around the country and around the world and mentorships. He is a fellow of the International College of Craniomandibular Orthopedics and has a mastership status there. And then there’s another prestigious institution in Las Vegas called the Las Vegas Institute of Advanced Dental Studies and he has a mastership there. He’s the only dentist with these two masterships and a lot of initials after his name. MICCMO and LVIMM as well as DDS. Dr. Raman, thank you very, very much for being here with us today. And please feel free to fill in the blanks wherever I might have have missed out on some things here. Your education is quite impressive.

Prabu Raman: Well thank you so much, Dr. Lowenstein. It’s very kind of you. This is just my passion, so you end up collecting a few initials after your name.

Adam Lowenstein: Well said. We’ve talked in the past a little bit about what you do and as I said, I’m not historically familiar with particularly all of these letters, and we know that a lot of patients’ headaches are coming from their jaw and their joints in their jaw. And commonly I think we hear the letters TMJ, but there’s also a TMD and CCMD and I’m hoping that, let’s start off by, maybe you can tell us a little bit about what all of these different letters mean.

Prabu Raman: I’ll be happy to. TMJ is commonly used to denote the problems related to the jaw joint. TM stands for temporal mandibular. Temporal is part of the temporal bone and the mandible would be the lower jaw. Where they connect would be a temporal mandibular joint. The problems related to the TMJ often are called TMJ disorder or just for short, TMJ. That’s like saying you have knee, meaning really you have knee problems.

Adam Lowenstein: I’ve always wondered about that because it doesn’t sound right, but okay.

Prabu Raman: Yeah, but that is colloquially used. But really TMD, sometimes is used for temporomandibular disorders and temporomandibular dysfunction is a better term, meaning the lower jaw connecting to the upper upper head, if you would, as part of the temporal bone to be part of the head. If there’s a misalignment, it’s not functioning correctly, then it is a little bit more than a joint alone.

Prabu Raman: The analogy that I often use is, if a door doesn’t quite fit right in a hotel room, for example, most people just shove it really hard and close the door so they can lock the door, but perfectly fitting door’s been shoved in. If you keep doing it long enough, eventually something will happen to the hinges. This analogy, I print it off like a door frame. It’s inmobile, the lower jaw is mobile part, and if that doesn’t quite fit right, meaning it takes some effort for the jaw muscles, the muscles that are controlled by the trigeminal nerve, the mast icular muscles, to get them into place so they can close, meaning the teeth can come together, then that effort over time can have an impact. So a lot of problems are related to muscle related problem because they’re working hard all the time, and sometimes that precedes, or many times it precedes joint problem.

Prabu Raman: Just like a door doesn’t fit long before the door hinge goes bad. That make sense?

Adam Lowenstein: Yeah, it makes sense to me.

Prabu Raman: And the CCMD part, whatever happened to the jaw affects the neck. As a matter of fact, it is normal for somebody to open their mouth really wide ,for the neck to go up and go back. The head tilts back if you opened really wide.

Adam Lowenstein: Yeah, I’m doing it right now. I bet a lot of our listeners are, too, but yeah, go ahead.

Prabu Raman: So the lower jaw or connects to the head, the temporomandibular joint, that condile it’s called, a little bumpy part. The ball of it, if you would consider this socket depth and the bottom part of the skull, the occipital condile, they work together in unison. Functionally the upper part of the neck and jaw are connected meaning whatever happens to one affects the other and vice versa.

Prabu Raman: So the term that I have preferred to use for some years, it’s not well known yet, hope it becomes, is craniocervical mandibular dysfunction. That temporomandibular [inaudible 00:05:54] talks about just the head and the jaw, but this one goes one step further because in reality, neck is affected. They can’t take it out of the equation. So the cranial cervical of course, head, neck and then the mandibular, lower jaw dysfunction. If they don’t function right… Because this includes symptoms that are primarily related to the neck. In other words, it may not feel like a jaw related problem. Somebody has vertigo as an example. But that could be from a misalignment of the upper part of the cervicals, atlas and axis. So the CCMB is a little better term in terms of a true description of the problems because then you can see why that can have a global symptomatology more than just the jaw and head.

Adam Lowenstein: So it’s instead of the ankle bone connected to the leg bone connected to the knee bone, it’s kind of like the jaw bone’s connected to the neck bones and the neck muscles and what causes problems in one thing can be cascading to the others as well.

Prabu Raman: I love it. A highly qualified surgeon using a children’s analogy. It makes sense, it makes sense.

Adam Lowenstein: Can you, just for our listeners, I know a little bit about this, but the anatomy of the temporomandibular joint is somewhat unique in the body as a translational joint as opposed to a kind of hinge joint, if I’m not mistaken. Is that something that is worthy of a little discussion?

Prabu Raman: Sure. It is the most unique joint in the whole body. Bar none. One time I was in a… I take yoga and I took a yoga workshop by a surgeon from Florida named Ray Long, and he said something about how the shoulder joint is the most complicated. Anyway, she had to stop for a second and said, of the ones that I operate, they are the most complicated. Obviously in the TM joint, the jaw joint, it can act like a hinge, just like an elbow in one plane. It can also act like a rotating part, just almost like a hip or a shoulder. It can actually come slightly out of the socket, translate out of there. So it can have all these complex motions. No other joint house that.

Prabu Raman: And the funny part also, we can call it that is, whatever happens to one joint affects the other because connected by that that jaw bone, the horseshoe bone.

Adam Lowenstein: Yeah.

Prabu Raman: The most interesting part is, when we close the joint, lower jaw, what stops it is out back teeth. In other words, depending on how tall the back teeth are is how far the joint closes. So if somebody were to loose the back teeth or they’re restored but they’re little shorter than otherwise, now the joint is closing further than it should. That would then lead to this getting out of place and all kinds of problems.

Adam Lowenstein: Got It. Okay, so when a patient… I guess let’s start off, who usually comes to to your office? When you see a new patient, what are their symptoms and where do they come from?

Prabu Raman: It varies quite a bit. About half of my patients are referred by other doctors, dentists and physicians. Some are from ENTs because one of the common symptoms is ear pain, so it makes sense for them to think, I must have an infection. They go there and say, no, no, your ears are fine. I think it’s your jaw. That’s common. About half of them are. The other half find me on the Internet, even from overseas and so on. What I have noticed is, of the half that find me through a physician or dentist referral, doctor referral, they primarily come to me thinking some kind of a jaw problem because the way they think is, well, he’s a person that takes care of the jaw problem.

Prabu Raman: But the other half oftentimes may have other issues. I mentioned vertigo. I have seen several patients that have intractable vertigo. Nothing could be done. Well known institutions have done everything they know how. Nothing can be done. And yet it turned out their upper jaw, I mean upper part of the cervical, I mentioned about atlas and axis, that was misaligned because the jaw doesn’t fit right. So if you get the jaw, neck, all of them together at the same time, properly aligned, then it corrected those problems. So sometimes the people that find me on the Internet may be looking for solutions for other symptoms that were considered to be incurable.

Adam Lowenstein: Got it. Right. And sometimes they think it’s unrelated, but it’s actually quite related.

Prabu Raman: Yes. Again, they’re looking at symptoms, vertigo, immediately think in terms of a balance organs in the ear. That makes sense, but it can also be, if the head is not screwed on straight. Basically. If the atlas is off, one set of balance organs is at a different level than the other.

Adam Lowenstein: Just for listeners who are not anatomy oriented, the atlas and… These are bones. They’re a couple of specific cervical vertebrae or bones in a cervical spine that have their own names.

Prabu Raman: Yeah. They’re so special. Special names. C1 is atlas, C2 is axis.

Adam Lowenstein: Right, so that’s what Dr. Raman is referring to. So what kind of interventions would you be offering for your… A specialized practice like yours, I don’t think there’s any average patient because usually, at least in my practice, by the time they get to meet, they’ve been through the average things.

Prabu Raman: Kind of similar. Kind of similar.

Adam Lowenstein: What kind of things do you have as interventions?

Prabu Raman: Good question. Oftentimes people think I treat a lot of, oh, you treat migraines, you treat trigeminal neuralgia, you treat fibromyalgia, whatever. And I usually tell them, actually, no. I’m going to do one thing and I hopefully do it very well. It’s getting the jaw and neck lined up right. So it starts off as a very thorough diagnostic workup and that includes, we have a [inaudible 00:12:14] of CT scan, the office, we have for 13 years. We just canceled that. Lots of measurements of the muscles and so on. Bottom line is, because that affects, the jaw isn’t lined up right, it doesn’t have tongue room, the tongue doesn’t have enough room in order to compensate for the airway, the head comes forward, that leads to neck problems and so on and so forth. So my job is to see, what if I can get all of them, jaw, neck, vertebrae, all of them as optimally aligned as possible.

Prabu Raman: We’re not talking days, we’re talking about an hour and a half to get that all correctly diagnosed. The discrepancy between where the jaw is coming together now compared to where it ought to be. That gap, if you will. And that varies, whatever that [inaudible 00:12:59]

Prabu Raman: It’s not always equal, some more than the other, whatnot. And once that is diagnosed, the first step is do it reversibly because it’s really important to me. We don’t do anything to make people worse than they already are. Above all else, do no harm. So the first step is make up the difference in what’s called a fixed orthotic. Basically bond, tooth-colored composite material onto the lower jaw teeth so that it’s on top of them. They look like teeth, so that’s when the jaw comes together, these fake teeth, if we can call it, they come together rather than your natural teeth. Natural teeth are at a lower position if you would.

Prabu Raman: And that’s done for no more than 90 days. And that’s a trial time. And large extent, it’s because chronic pain, as you know, is considered incurable. That’s why they have pain management doctors. Because once you have, chronic pain sets in, the neuroplasticity view, the memory of the pain. No matter what you do, nothing will get better. I’m not saying they’re wrong, but what I do know is, if I do this much of a whole body outlet, getting the jaw and neck lined up… But I keep talking about neck. About 2006, 13 years ago, I came up with a technique to relax the neck muscles. Somebody named it my name and all that, but that is basically going through the number 11 spinal accessory nerve, the cranial nerve number 11, to get all those muscles that are controlled by that nerve to loosen them up as well.

Prabu Raman: Then I also do some physical therapy in the neck, get them all aligned properly.

Adam Lowenstein: What do you do to the spinal accessory nerve?

Prabu Raman: Stimulate them from the outside. There’s a cervical triangle, posterior cervical triangle. The border would be sternocleidomastoid muscle and the clavicle and the trapezius. That triangle. And about two thirds of the way up, that was my research, to figure out where to put it. So somebody named after me. But anyway, that idea is if you can stimulate from the surface [inaudible 00:15:06] low frequency TENS machine. It’s every one and a half second, a pulse. It’s not a usual TENS machine. There’s a pain control. This is much, much slower and it is critical about where we place it so that we stimulate the motor nerve. So all the nerves, all the muscles that are controlled by that, are contract and let go, contract, let go, every one and a half seconds.

Prabu Raman: Honestly, when I first did it, 2006 or so, I didn’t even know all those little muscles, including the little known muscles like posterior… Let me see. I’m drawing a blank. The [inaudible 00:15:53] bridge, the little muscle that controls, connects to the [inaudible 00:15:56] to the C1. Even that gets used in that.

Adam Lowenstein: Wow, okay.

Prabu Raman: So it’s cool to be able to do that. And then, back to your question about how to fix them, make sure that actually helps them. Over 90% of the people helped by this. I know they seem like farfetched statistics, but that’s what it is. But it’s not 100%. There are some people, no matter what I do, they just not feeling better. At least I haven’t gotten them any worse. Take them off. But if they are helped, which most of them are, then we have some three different options.

Prabu Raman: One is, I can just replace a fixed orthotic. I do the fixed orthotic because I want them to be 24/7. Just like doing a cast on a broken leg instead of something that comes on and off. During the healing period or during the period, we want to erase the memory of the pain, if you would. Once that is done, I can actually move the teeth to where they should be. Then we do orthopedic and orthodontic braces and other appliances, change the jaw shape itself, and move the teeth to where they should have been so that once it’s all done, their natural teeth are coming together where they should have been. Replacing the orthotic, the [inaudible 00:17:04] to begin with. That’s one option. Other times people don’t have the patience to go two, three years.

Prabu Raman: They want it done much quicker. Then I can get the orthopedic change and move the teeth, straightened out, and then add porcelain to all the teeth, top and bottom. At one visit. So that gets done quicker, less than 12 months. It costs more. Then the third option would be somebody that said, I know you’ve just had an upper jaw [inaudible 00:17:27] you just made the change on the bottom, but I’m feeling 90% better, 95% better. I don’t need to get any better than this.

Prabu Raman: I want to do it economically. Then we will remove that fixed orthotic in stages so that we can record that defined alignment if you would, and make something… It’s a computer assisted milling process, so it goes on top of the teeth, but they can take it out and brush and floss, compared to a fixed orthotic that is attached to it full time. So it is a management option. And a lot of people do that as an economical way of doing it. I’m not really invested on which one they choose. My job was know how to do it. Give them all the options, give them the plus and minuses, and I step aside and you decide what makes sense to you.

Adam Lowenstein: Right. Okay. So, in short, you’re basically changing their occlusion, right?

Prabu Raman: Correct.

Adam Lowenstein: Okay. So and just again for listeners, occlusion means where the upper teeth and the bottom teeth, how they meet when you’re in your bite.

Prabu Raman: Yeah. Where they come together. Yeah.

Adam Lowenstein: Right. I got so many questions for you. It sounds like what you’re starting is, you’re starting with an occlusion change test, but the stimulation of the spinal accessory nerve resets things to relax those muscles and mimic what a longer term change in the occlusion would be. Is that fair?

Prabu Raman: Well, it’s fair, but actually I didn’t speak enough about the trigeminal nerve. Trigeminal nerve is the one that moves the jaw. That has been done for a lot longer than I have. That is the virginal method of neuromuscular dentistry, where they put the similar technique, where they put the, right by the mandibular notch on the side, put a pad and then pulse the number five trigeminal nerve and number seven facial nerve. That is the classic neuromuscular dentistry. That has been done lots longer than I have. But I’ve been doing this only about 25 years and I came up with this technique about 13 years ago. To add to that same idea, but the neck as well. That’s when the CCMD part, that’s when I suggested the CCMD part because now you’re looking at the jaw and neck, not just the jaw.

Adam Lowenstein: But the muscular relaxation is kind of like a resetting with the appliances, even temporary appliances in place?

Prabu Raman: Well, resetting may not be… Basically, as you know, a muscle that is tight, it now doesn’t have the normal venous flow or lymphatic flow because everything except… Lactic acid builds up and all this stuff. So when we do this pulsing, it essentially loosens up those muscles. Think of it like a massage, electronic massage through the nerves, so even the muscles I can’t reach are all in, contract, let go for an hour. And in addition, one of the other things that’s cool about that is, because it is just a motor nerve that I’m pulsing further down from the brain, the message or the pulse doesn’t just go downstream. It also goes upstream.

Prabu Raman: Because the nerves don’t have a valve, they can go either way. So it also is useful during the time I’m pulsing, it basically blocks the messages from the central nervous system, so the idea of muscle memory, idea of muscle spindles being tight because you’re stressed, any of those are temporarily blocked. So it’s basically blocking that message while I’m loosening up the muscles. When we’re done, what we’re really looking for is if the muscles are unstrained, they’re not tight, they’re loosened.

Prabu Raman: Again, if you go back to the actin myosin filaments, the muscle physiology or muscle down to the cellular level, the actin myosin filaments, they slide across when they contract. Now they are at an optimal overlap. They’re not stretched too far. They’re not tight, they’re just idling. How do we know they’re idling? In real time, we can measure the electromyography output, if you would. A calm muscle would be idling like a nicely well-tuned car. A muscle that is hypertonic, that’s working a lot, would be higher, just like a car that’s idling at, say, 3000 RPM. That’s not normal. So we can actually measure that in real time so we know how it was before, how it is after that is relaxed. When all the muscles are nice and calm, how does everything line up? Because lower jaw can infinite…

Adam Lowenstein: Ah, so you’re doing that… So your first… I’m trying to just figure out when you’re doing this, the muscular part. So you relax the muscles first and that’s how you evaluate the proper occlusion?

Prabu Raman: Exactly. Yep. Proper alignment.

Adam Lowenstein: Alignment. Okay.

Prabu Raman: The reason I keep using the alignment word on purpose is this: Occlusion, to dentists, mean where the teeth meet.

Adam Lowenstein: Yeah.

Prabu Raman: Right? So back to the door analogy. Once a door is shoved into place, yeah, it’s fitting fine. No, it’s been shoved in.

Adam Lowenstein: Yeah.

Prabu Raman: So back to the occlusion [crosstalk 00:22:39] yeah, it’s been pushed into place, so if in your mind, if you can delete the teeth for a minute, upper jaw’s there, lower jaw’s there. They’re controlled by. The muscles let them go where they want to go and then see if the teeth are also fitting there, life is wonderful. Most times they’re not. To the extent they are off, we have an adaptive capacity. Not everybody needs help. We have adaptive capacity to the extent we exceed the adaptive capacity, then we have problems. Then my job is to see how much can I reduce it because many, many factors go into this. Pain perception is different. Men and women are different. Athletes, non athletes are different. Young people, old people are different. Pain is a subject that’s, it’s more of a perception, So when somebody feels pain, basically their body is saying, hey, I need help.

Adam Lowenstein: What you’re talking about is really interesting for me, from a personal standpoint as well as from a professional standpoint. We do very similar things in very different ways because what I’m doing is releasing the muscles that are squeezing on the nerves themselves and you’re releasing, you’re relaxing the muscles and then going to see if there’s a jaw related reason that the muscles are tight in the first place. But in either way, we’re addressing the neurologic aspects of this from different standpoints. Yesterday I woke up with a migraine and as the day progressed, I ended up with pretty severe left ear pain and malocclusion. I couldn’t close my jaw completely and my ear hurt. I understand what’s going on. But if you were my neighbor with all of your machines there, I would have loved to… This is exactly the kind of thing that would be helped, I think, by somebody with your expertise.

Prabu Raman: Yeah. You mentioned migraine. If I could talk for a second. The most common symptom of poorly aligned jaw, it’s not jaw problem. It’s really headaches. Number two is neck pain, number three is ear pain. Way down the line is jaw pain. A jaw can have lot more adaptability, if you would. It can put up with a lot more than something else causing pain. The migraine is considered to be… I’m sure as a physician, you know lots of theories about why, whatnot. But one thing a lot of people have come to a certain level of consensus is, CGRP, calcitonin gene related peptide. So that’s where these new injections come, like [inaudible 00:25:28] and others, where they go block it, once a month, injections and so on. But if you do some research, one of the largest sources of CGRP, calcitonin gene related peptide is [inaudible 00:25:40] roots.

Prabu Raman: So why are they doing this? Why would a [inaudible 00:25:46] root be inflamed enough to give all this CGRP release? Well, what if all day long the jaw doesn’t quite fit right? Because of that, those muscles, as you know, [inaudible 00:25:58] more sensory nerve as well as the motor nerve. It has more than half of the proprioceptive input into the brain. Comes from that one nerve so that nerve is constantly busy because it is working to keep the jaw lined up better.

Adam Lowenstein: Yup. What you’re talking about is basically, lessen the production of CGRP by preventing the triggering happening in the first place.

Prabu Raman: You got it.

Adam Lowenstein: And that’s exactly what I’m doing as well in the forehead and in the occipital region by addressing it in the super orbital nerves, the occipital nerves. Further fascination for me is, there are some recent studies that have tied some commonality in nerves, particularly from the occipital region to the dura. And so it completely makes sense for what I do for the occipital irritation to be potentially literally inflaming the dura and having a direct line for CGRP release and pain around the brain. And again, the dura is the lining of the brain. But also postulated with all of this is, because some of that dura is the dura that’s around the cerebellum, that that irritation is what is contributing to some patients’ balance issues.

Adam Lowenstein: The other patient that I would love to… We’ll see how long I can talk to you about this, but I operated on a patient yesterday. This was her second operation. The first operation, I did some occipital work on her. And she had really bad vertigo that was cured by the occipital nerve release, which I thought was fantastic. And now I think with these recent studies that all makes sense. But she also had ear pain and the occipital pain all got better, but the ear pain did not. I don’t think she was evaluated. I’m sure she wasn’t evaluated by somebody with your expertise, but I’m wondering whether or not that was the kind of patient that would be perfect for you to see. What I ended up doing is releasing and then actually cutting her greater auricular nerve.

Adam Lowenstein: She was just begging for improvement and I gave her a shot at that nerve and numbed the nerve up and her pain went away. So that kind of showed me that I could do that. I’m wondering, would your techniques and your workup have shown a different way to go about dealing with that patient?

Prabu Raman: You’re talking about ear pain or vertigo?

Adam Lowenstein: The ear pain.

Prabu Raman: Ear pain. Okay. Before I forget, I mentioned earlier, I got drawn a blank on the [inaudible 00:29:14] connection came back to me. Rectus capitis posterior minor.

Adam Lowenstein: Yeah, okay. Because everybody knows that muscle, it just rolls off the tongue. I actually, I got honors in my craniofacial anatomy class back at the University of North Carolina 35 years ago. I’m relatively certain nobody ever mentioned that muscle.

Prabu Raman: I think it was not even discovered until about 20 years ago.

Adam Lowenstein: Oh, okay. There you go. That dates us both, but okay.

Prabu Raman: Anyway, back to your question. Ear pain. This is one thing that’s confusing to patients as well as physicians because we are used to having something causing something. Meaning if somebody has an ear infection, pretty good bet they have ear pain. They’re not going to have something else. But in this case, ear pain can also be from poorly aligned jaw because when the lower jaw is set backwards because upper jaw may be narrow, upper jaw is further back than it should have been, then lower jaw has to go further back. And then if you can put a little finger inside the ear of a patient and have them close, something you can do when you’re evaluating, when they bite down together, if you feel pressure against your finger, that means it’s really getting shoved backwards. That is a big source of pain in the ear pain.

Prabu Raman: So when we let the jaw go over [inaudible 00:30:35] because nothing is making it go backwards [inaudible 00:30:40] teeth that has to fit within, give it freedom, then oftentimes the jaw will come quite a bit down, away from the posterior part of that TM joint. That’s where the, oh, synovial fluid being produced, that’s where the nerve tissue is. It’s a sensitive area. So that sensitive area is no longer compressed, so the pain goes away.

Prabu Raman: So somebody has ear pain like that. Having the jaw just come forward some more, even temporarily, see if that helps. And earlier you mentioned about dentists. Unfortunately dental school, the school that I’ve mentioned, my alma mater, from Kansas City, UMKC. It’s a great school, but even that school, to a large extent, hasn’t changed a whole lot when it comes to this one subject, TMJ, TMD. It really hasn’t evolved much. That’s a bit unfortunate, but it is what it is. So when you just say it happens many times, EMT might say, no, I don’t think it’s ear pain, but go to your dentist. Well, they let us look at occlusion, get them a bite guard. They’re done. Not much more left.

Adam Lowenstein: But the ear pain that you’re talking about is actually, is coming from the proximity of the actual joint to the ear.

Prabu Raman: Correct.

Adam Lowenstein: As opposed to this patient that I had. Once I addressed her greater auricular nerve, her pain went away. And so I saw her, actually operated on her two days ago. I saw her yesterday and she’s cured and her pain is better. I was thinking that perhaps the issues that you were talking about with the muscles of the neck getting tight and secondarily causing dysfunction to the sensory nerves, like the lesser occipital nerve, which I commonly deal with and the greater auricular nerve. This is actually not… I have one colleague who’s done a similar patient once before, so this kind of situation that I was dealing with was quite unique, but I found it very interesting and I’m wondering whether I should also, in follow up, have her see somebody like you who… Because perhaps her alignment is causing some anterior as opposed to occipital, but lower neck dysfunction that that was causing her to have that nerve [crosstalk 00:33:07]

Prabu Raman: The greater, lesser occipital neuralgia, [inaudible 00:33:10] if you would, is what you’re feeling a lot, sounding like. The compression can many times be used to the forward neck posture because look at somebody, and that foreign neck posture, like okay, why did they have that? A lot of times it’s because if the upper jaw is too far back, lower jaw is too close, any of those issues, not have enough tongue room. So I know you do anesthesia. So look at the [inaudible 00:33:34] one, two, three and four.

Prabu Raman: If somebody has [inaudible 00:33:37] three or four, tongue doesn’t have enough room. So rather than the tongue going back to the throat, what the body does is to compensate for it, bring that neck forward. So you have better air, but if you’re looking forward without changing the head position, you’re looking down on the feet. So the head, neck forward and prostrate rotation of the skull. That is a compensating mechanism. So now we have, vision is pretty horizontal and the airway’s a little better. They’re functioning yet they’re compressing that area, the nuchal line, quite a bit. Oftentimes that’s one of the reasons.

Adam Lowenstein: And that’s actually what I think is in the news a lot about, what do they call it? Phone neck or phone head.

Prabu Raman: I saw that.

Adam Lowenstein: It should be tongue and airway head or airway neck.

Prabu Raman: Well, that’s funny I saw that because I think there was a Australian study first, it was all over everywhere.

Adam Lowenstein: Yeah.

Prabu Raman: They had, teenagers have, what is it? They have horns in the back or something.

Adam Lowenstein: Yeah, something like they’re finding bony protrusions cervical spine, right?

Prabu Raman: Yeah. It’s fairly common really in the population that I see. We take CT scans. It’s fairly common. I was laughing because they acted like it is something new, just happened to teenagers that are looking at the smartphones all day. It’s not new. And you see it in people with that neck dysfunction quite commonly. And they come up with a cute thing, horns on teenagers, so they can call them horny teenagers. Something to get their people’s attention.

Adam Lowenstein: Yeah, I hadn’t heard that, that extreme of it. I’m glad to hear that Steve Jobs did not cause horny teenagers.

Prabu Raman: Nope. They predate that.

Adam Lowenstein: Horny teenagers were around, yeah [crosstalk 00:35:25]

Prabu Raman: Long before that.

Adam Lowenstein: Well, Dr. Raman, I can’t thank you enough. This has been very educational for me and hopefully as well as our listeners. I really do appreciate your explanations and it’s a really interesting aspect of our field, of caring for headache patients that I think is often overlooked. Correct me if I’m wrong, but your website is Is that right?

Prabu Raman: Correct. Yeah. As I mentioned, headache is the number one symptom, so people don’t know why they have it, but they know what they’re having, so that’s where the name came from. there’s a blog there and all sorts of information.

Adam Lowenstein: And you’re on Facebook as well. Is that right?

Prabu Raman: Yes, Facebook.

Adam Lowenstein: People can find… What? PR Work?

Prabu Raman: PR Work, yeah.

Adam Lowenstein: At PR Work. Great.

Prabu Raman: And YouTube, there’s a YouTube channel. Bunch of stuff. But you can come to our website, you can find them all you want. If you have time to spend, you can spend a lot of time on there.

Adam Lowenstein: Well that’s great. I really encourage our patients to be educated about all of these different things. There are so many hopeless people out there, and unfortunately I think a large part of the problem is a lack of understanding of all of the things that are potentially available to them. I commend you on your vast years of research and education and helping all of these patients. Really fantastic. Thank you so much.

Prabu Raman: I have really enjoyed speaking with you, Dr. Lowenstein, and I particularly commend you for your open mind and commend you for having the curiosity to look beyond your training, look beyond the medical training. There are other things going on and I can tell you it’s not common. And so I truly appreciate your curiosity and your efforts to get this information out to people. I appreciate that.

Adam Lowenstein: That’s nice of you to say. We’re always trying to do the right thing and whether it’s doing the right thing here in our office or doing the right thing getting other patients hooked up with other providers that can help them. That’s always the right thing to do. Great. Well, thank you all for listening. I hope you’ve enjoyed the the podcast and stay tuned. I’m actually headed off for a couple of weeks of, I don’t know, I hope to say well deserved vacation with my family. But in a few weeks we’ll start back up and we’ve got some exciting episodes coming up. Talking with some headache specialists, particularly about medications and what are appropriate versus unappropriate, or inappropriate, excuse me, medications, which I think can potentially help a lot of migraine and chronic headache patients out there. So again, thank you very much, Dr. Raman, and best wishes to everybody for a great couple of weeks while I’m on vacation.

Prabu Raman: It was my pleasure. Thank you, sir. Bye Bye.

Adam Lowenstein: You Bet. Bye Bye. Hey, everybody. This is Dr. Lowenstein once again and I have two last things to ask of you. Firstly, the thing you can do for fellow headache sufferers is to please remember to subscribe and rate our podcast. The more ratings and subscriptions that we get, the more visibility that we’ll get and the more listeners will be able to find us and the more helping information we’ll be able to provide the huge population of people who suffer from headache pain. Secondly, please remember that the treatment of headaches of all types is very individualized.

Adam Lowenstein: The purpose of this podcast is not to give medical advice, so please use the information here on this podcast and elsewhere that you hear on the internet to broaden your knowledge, but consult with your physician before acting on any information that you hear on podcasts or see on YouTube or read anywhere on the internet. I as a physician don’t necessarily endorse the opinions or practices of my guests and if you have particular questions that you’d like to consult with me directly about, please call our headache surgery center. Our phone number is (805) 969-9004 or you can email us and my staff will set up a consultation, and we can discuss your specific case over the phone or in person. Our website is filled with information as well and that his Thanks and best wishes from all of us here at the Headache 360 Podcast.

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