BlueCross BlueShield of Tennessee Medical Policy Manual

Intraoral Devices for the Treatment of Headaches

DESCRIPTION

Intraoral devices are being offered for the treatment of headaches (e.g., migraine, tension-type). There are different types of the intraoral devices. One type is the pericranial muscular suppression device (e.g., Nociceptive Trigeminal Inhibition Tension Suppression System or NTI-tss®). Another similar device is the anterior midpoint stop appliance (AMPSA CS™, Migran-X™). These devices are plastic mouthguards fitted by a dental practitioner and worn during sleep. They are proposed to treat migraine associated tension-type headaches by reducing muscular tension and activity.

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Well-designed studies published in peer-reviewed journals are lacking regarding the use of any intraoral device for the treatment of headaches.

SOURCES

Franco, L., Rompre, P., de Grandmont, P., Abe, S., & Lavigne, G. (2011). A mandibular advancement appliance reduces pain and rhythmic masticatory muscle activity in patients with morning headache. Journal of Orofacial Pain, 25 (3), 240-249. (Level 3 evidence)

Moeler, D. (2013, Spring) Evaluation of a removable intraoral soft stabilization splint for the reduction of headaches and nightmares in military PTSD patients: a large case series. Journal of Specialized Operational Medicine, 13 (1), 49-54. Abstract retrieved December 19, 2017 from PubMed database.

Stapelmann, H., & Turp, J. C. (2008). The NTI-tss® device for the therapy of bruxism, temporomandibular disorders, and headache - where do we stand? A qualitative systematic review of the literature. BMC Oral Health, 8 (22). (Level 2 evidence)

U. S. Food and Drug Administration. (2001, June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K010876 (NTI-tts®). Retrieved February 6, 2012 from: http://www.accessdata.fda.gov. 

ORIGINAL EFFECTIVE DATE:  9/1/2002

MOST RECENT REVIEW DATE:  1/25/2018

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.