Jaw Clenching (not grinding) and Stimulants-- how to balance?
March 14, 2016 10:31 AM   Subscribe

Without stopping stimulant-use, what works for you? Has anyone tried botox to relax jaw muscles? Nightly muscle relaxers?

After finally being diagnosed and prescribed medication for Adult ADHD--Inattentive type, I have no interest in going back to being unmedicated. My work and personal life have greatly improved, and I feel more confident about my future in general. However, my jaw clenching is becoming a big problem.

Before medication, I was known to clench my jaw regularly in reaction to stress. I had a sleep mouth guard made, and it helped somewhat.
Now that I've started taking ADD meds, the jaw clenching is near constant and is causing daily headaches that are not debilitating but still pretty bad.

My first medication was Adderall XR 15mg; it worked great. I loved it.
Yes, my jaw clenched more than normal, but I would stop taking pills on the weekend to give it a break (and to save pills). It was worth the jaw side effect to be on it at all. Unfortunately, my insurance wouldn't cover it, and the out of pocket cost meant I would normally go weeks before refilling the prescription sometimes.

To try and save money, my doctor prescribed Adderall IR 15mg-- hot damn was there a cost difference!
At first, I thought this was a miracle fix. I no longer saved pills and took one every morning. It took about two months, but slowly and surely I started having a reoccurring headache every night around 6pm. I didn't at first associate it with the meds and instead went to see if I needed new eyeglasses, and I also started seeing a massage therapist for a weekly 30min session. Neither produced any results. After skipping two weekends, I eventually stopped the Adderall IR cold turkey mid-February. It took a week and a half, but my headaches eventually ceased, and my massage therapist noticed a considerable difference in muscle tension.

At the end of February, I had another appointment with my psychiatrist. I told her about the headaches, and she prescribed 20mg of Ritalin IR-- hoping it would also cost less and not have unwanted side effects. Well. It ended up being more expensive than the original Adderall XR, but for the sake of science (and hope springing eternal) I filled it to see what would happen. At first things went well, the focusing/calming effect was different than Adderall but still beneficial. However, after a full week of use, the jaw clenching became very pronounced and worse than ever. I would wake up with a stiff/almost-locked jaw and didn't have to wait until 6pm for a headache.

Now I don't know what to do. I'm currently off everything entirely and struggling once again. My house is a mess, and I'm feeling very depressed in general. I don't want to go back to this being my normal. I'm going to ask my psychiatrist to prescribe the Adderall XR again despite the cost, but I'm worried that I've done cumulative damage to my jaw that will respond badly no matter what.

So now, I'm trying to think of other things I can do to supplement the stimulant use. I'm going to start up again with the weekly massage appointments and continue using my mouth guard-- but I'm wondering if looking into botox injections is crazy or not? I've heard of botox being used to treat TMJ and force jaw muscles into paralysis.
Would asking for a small prescription of Flexeril or other muscle relaxer make sense? Is that something others have done? Is there something else I'm not thinking of?
Any help would be appreciated.
posted by elleyebeebeewhy to Health & Fitness (26 answers total) 7 users marked this as a favorite
I am not a doctor but:

Adderall XR 15mg to Adderall IR 15mg is actually a large increase in dose, since the XR only releases half of that 15mg when you take it and the rest over the course of the day (and lasts longer) while IR releases it all in one go (and lasts a much shorter time). Most people I know on IR have to take it a few times a day - so it'd be 5-10mg twice a day, instead of taking the one XR pill in the morning.

Were you only taking one IR dose a day? If so, it seems like your doctor may not have known what he/she was doing and you should consider getting a second opinion.

Also, personally, my insurance out of pocket cost for the same drug is ridiculous and I get a better price by just using GoodRx (though only some pharmacies will take the code - even within the same chain, they differ). YMMV, of course.
posted by R a c h e l at 10:42 AM on March 14, 2016 [2 favorites]

I am getting physical therapy for my TMJ. There are a number of exercises you can do and strategies you can use, ranging from re-evaluating your desk setup (if you have a desk job) to not chewing gum or chewy candy, to getting a hard mouth-guard, rather than the silicone kind that encourages clenching.

My trajectory was to see my dentist first, who referred me to an oral surgeon and finally he sent me to the physical therapist.

Additionally, I had my eyes checked and got a multi-focal contact lens to help stop me from peering into my screen as I work, and leaning forward when I drive, both of which behaviours contribute to tight neck and shoulder muscles which translates into worse TMJ symptoms.
posted by Dragonness at 10:47 AM on March 14, 2016 [2 favorites]

This sounds silly, but as well as using a bite plate at night, I had to train myself to keep the tip of my tongue between my teeth during the day so I wouldn't unconsciously clench my jaw. Sometimes I fall out of it and have to re-train, but it does help. Clenching is no joke; I had a long lapse in self-care and managed to crack some of my fillings and significantly wear down my molars.

I'm curious about Botox, too.
posted by Stonkle at 11:21 AM on March 14, 2016 [4 favorites]

Stonkle, my PT also advised the tongue trick - she says to keep the tongue on the ridge behind my front teeth.
posted by Dragonness at 11:23 AM on March 14, 2016 [1 favorite]

You may want to consider taking a magnesium supplement. It's still largely anecdotal, but there is a growing understanding that at least for some people magnesium helps reduce or eliminate bruxism, suggesting that clenching/grinding may partially be the result of Mg deficiency.

Make sure the magnesium supplement you take is either citrate or glyconate/bisglyconate; magnesium oxide has really poor bio availability. I'd probably take the magnesium in the morning and right before bed, in anticipation of my next Ritalin dose. You should be fine with taking whatever's recommended on the supplement bottle. If you take more than your body wants you'll start to experience softened stool or some nausea. If you get to that point, reduce your dosage. If you get to that point before finding relief from jaw clenching, you know it doesn't work for you. But happily, it's a fairly cheap option with, to my knowledge, a low side-effect profile, so it's not hard to recommend to people as a first line of defense.

You may find it a useful piece of information that I've experienced jaw clenching on some ADD medications at certain doses, and am currently on Focalin, which does not have that effect (on me). There are about a half dozen different stimulants (which make up the dozen plus brands you can choose from) one can take for ADD (of which you've now taken two), and it's possible there's one out there that will have a more positive interaction with your body.
posted by Poppa Bear at 12:01 PM on March 14, 2016 [3 favorites]

For the first year or so I was on Vyvanse I had terrible jaw clenching. Those symptoms have worn off (along with the useful appetite suppression, dammit) but the medication still does its useful thing. What you're experiencing might be temporary.
posted by A Friend of Dug [sock] at 12:12 PM on March 14, 2016

Magnesium (a chelated form like magnesium glycinate or malate - not magnesium oxide, which is poorly absorbed and gives you diarrhea) can help. There are also mouthguards that you can use for daytime, the NTI TSS type is probably the most well-known, it's very small and I believe that the daytime version sits on the bottom front teeth.
posted by quince at 12:33 PM on March 14, 2016

Multi-B vitamins helped me. I don't normally advocate for vitamins, but I stopped clenching and teeth grinding when I took these.
posted by oneirodynia at 1:04 PM on March 14, 2016 [1 favorite]

I had similar side effects when I started medication last summer, exacerbated by an extremely stressful autumn at work. It wasn't quite as bad as yours sound, but I also had jaw tension, TONGUE tension (who knew that was even a thing!), and headaches for several months, as well as a cough that would kick in every evening as the drugs were wearing off.

Thought 1: The main thing that helped me was time. Pretty much all the side effects went away after about six months or so. In the meanwhile, I chomped a lot of gum (figured chewing was marginally better for my teeth than grinding and clenching), scheduled more frequent professional massages, and googled some good self-massage and jaw stretching techniques.

Thought 2: My headaches seemed to be the worst when the medication should've been peaking and the coughing only occurred as it was wearing off in the evenings. You mentioned your headaches were initially only in the evenings. It might be worth giving the extended release versions another shot, and/or trying different ones that kick in and wear off more gradually.

Thought 2a: There are generics available for both classes, including time-release formulations, that might make it cheaper for you to find something that works. However, between "authorized generics" and the FDA downgrading some versions of generic Concerta, the way your doctor writes the prescription can make a surprisingly big difference in what you get from the pharmacy and how you're charged by insurance. It is confusing and obnoxious and even doctors who deal with this stuff regularly may not be aware of all the ins and outs so it is worth doing some reading to make sure you're getting what you're expecting and not paying more when you don't need to.

Thought 2b: Seconding R a c h e l's concerns about the dosages your doctor prescribed. I'd also say consider second opinion, if or when you can swing it.
posted by yeahlikethat at 1:40 PM on March 14, 2016 [1 favorite]

For what it's worth I tried the tongue trick when I was on Adderall and I just chewed through the sides of my tongue. It was gross and awful. I ended up with a mouthguard, and then later I stopped Adderall.
posted by Anticipation Of A New Lover's Arrival, The at 2:01 PM on March 14, 2016

I see a neurologist for chronic headaches, and he has me taking a low dose of bedtime klonopin for clenching. It makes a huge difference. We had to fiddle around with doses to find one that worked without leaving me hungover the next day, but since we did, it's been good.
posted by not that girl at 2:13 PM on March 14, 2016

Have a dentist evaluate exactly what you are doing and recommend the appropriate type of appliance. You may benefit from an inhibitor rather than simply a full coverage guard that still allows you to grind.
Botox does not do what you think it does, and is not indicated for this, and medium to long-term muscle relaxant therapy is not recommended either.
posted by OHenryPacey at 2:18 PM on March 14, 2016

Seconding klonopin. I take it at night for anxiety and I've noticed that it reduces my jaw clenching.
posted by kitcat at 2:22 PM on March 14, 2016 [1 favorite]

400mg of magnesium glycinate before bed helps my jaw clenching. I'm currently using this one from Amazon.
posted by bradf at 5:13 PM on March 14, 2016 [2 favorites]

Although I wasn't taking them for ADD, a while ago I was prescribed Adderall, then Ritalin. I had to stop taking both due to the pretty harsh side effects, including jaw clenching. I finally had success with Dexedrine SR, which is another stimulant medication. I found it to be much more tolerable physically than either Adderall or Ritalin, and I noticed that it did give me greater focus. Maybe you could try that?
posted by impatient0 at 5:48 PM on March 14, 2016

R_a_c_h_e_l and yeahlikethat -- I was also more than a little confused by the 15mg to 15mg conversion. So much so that in spite of the directions on the bottle, I split those 15mg pills and would only take half in the morning and half around 3pm. When I saw my psychiatrist next, she assured me that I should've been taking an entire pill each time... by then I was getting headaches, so I didn't attempt that routine and was instead off to the races with Ritalin.

All of these meds have been the generics as brand name would've bankrupted me.

I have a mouth guard that my dentist made for me; it looks like this. Is this different than an inhibitor?

Would asking about a possible klonopin prescription be normal? I'm afraid to look like a drughound now that I'm taking a class of drugs known for it's heavy abuse.

Relatedly, how long should I really try to wait through negative side effects?
Would a good game plan be to try and wait through a period of bad-- while also medicating the symptoms (klonopin, etc.) until the symptoms stop? I'm not real excited about potentially signing up for a permanent drug-to-treat-another-drug sort of deal. :(

Okay, on my definite to do list:
- use GoodRx
- read up on jaw stretching techniques
- buy some magnesium glyconate
- buy some multi-B vitamins
**question** can someone take too many supplements?
(I'm currently taking a multivitamin, D3, and Omega-3 Fish Oil each morning.)

posted by elleyebeebeewhy at 7:17 PM on March 14, 2016 [1 favorite]

I have a mouth guard that my dentist made for me; it looks like this. Is this different than an inhibitor?

The most common inhibitor is called an NTI and it looks like this.

Maybe a bit bigger to cover more upper teeth, but essentially it puts pressure on the ligament around the lower teeth when you clench, telling you (subconsciously) to stop.
posted by OHenryPacey at 9:04 PM on March 14, 2016

Your doc was nuts to say that about the Adderall. I've taken them both, a lot. You were right to split your Adderall IR. I used to get 30 mg IR pills and split them in half when my insurance wouldn't cover XR. I hope that the Ritalin (IR really?) isn't all one dose. Because it has a 2 hour half life. Less than half as long as Adderall IR. The first version of Ritalin extended release (actually called sustained release) is about the same as taking Adderall IR. Usually dosed about every 4 hours. The Concerta version of methylphenidate is the only one that lasts all day.

As for the jaw clenching, while I never had it as seriously as you, it is still a problem for me too. Like others here I've had to train myself to consciously notice how I'm holding my jaw and to relax it. At this point I manage to keep it open a bit most of the time, just to keep from doing damage to my teeth. When under stress or busy, I usually chew gum. It is a small price to pay for being able to actually leave my house and keep my thoughts under control.

It sounds like you might need something else to help. You might look into guanfacine, it helps with the ADHD and side effects from Adderall. As a regular (non-extended release, generic for Tenex) med it is quite cheap. You do not need the stupid expensive extended release version (Intuniv or generic ER). It is a sensible step to take as a next med to add before trying other things. It is the first thing my prescriber adds. I take guanfacine, have taken both forms and they are both effective. Next step would probably be Ativan or Klonopin. I take Xanax, but only because I have unacceptable side effects to all of the other benzos I've taken. I don't recommend it unless it is the only option, I took years debating even trying Xanax. Sometimes a benzo is the right tool for the job.

Because I take both Adderall and bupropion, and have severe anxiety, I have occasionally been given methocarbamol for muscle tension that has caused crippling spasms in my shoulder. The kind that last for weeks and all you can do is lay somewhere whether you're on meds or not. It is just about the only muscle relaxant that doesn't interact with many medications, and it has a very low abuse potential. It isn't a long term solution, and muscle relaxants are all sedating enough that they basically invalidate the stimulant. I don't think they'd be the right way to go for you. They'd just be masking the problem for a short time, delaying the inevitable process of adjusting.
posted by monopas at 1:28 AM on March 15, 2016

You could try a Pavlok. Basically, shock yourself whenever you clench.

Sounds silly, but I've watched my friend stop pulling her hair after _sixteen years_ of doing that. No more bald spots, no more hats at work. No idea if it'll work for clenching, and I'm vaguely involved with the creation of the device, but I'm curious. The thing is being ludicrously effective for all sorts of weird things.
posted by effugas at 4:31 AM on March 15, 2016

You certainly can take too many supplements, but only insofar as you can overstress a part of your body by elevating its activity too much at one time (liver, heart, etc), but not because you're going to give yourself, say, "supplement toxicity" by exceeding your body's total supplements allowance, because that doesn't exist. In other words, you can consume too much (for example) iron, whether it comes in a pill, a steak, or a salad, but you don't have a generalized "supplement tolerance" that you need to be mindful of.

Check your multivitamin to see how much Mg and B you're already getting so you can keep it in mind while you're adding your new supplements. I've already mentioned the signs of having a surplus of magnesium in your system. The B vitamins affect the body in a few different ways, and their side effects are pretty variable. But from what I've read (which is limited) you're unlikely to exceed your body's tolerance for them even if you take a B supplement with your multivitamin. There's info out there about upper range tolerances for B vitamins if you wanted to look into it further.
posted by Poppa Bear at 6:12 AM on March 15, 2016

I have a mouth guard that my dentist made for me; it looks like this. Is this different than an inhibitor?

The oral surgeon prescribed a hard plastic splint for me that looks exactly like this. He explained the soft kind can encourage clenching.

Regarding chewing gum - the PT absolutely forbade me from ever doing that again. Your case may be different but I am to minimize using the jaw outside of meals.
posted by Dragonness at 7:00 AM on March 15, 2016 [1 favorite]

monopas -- thank you for your detailed experience. that's super helpful. I checked the Adderall bottles and both are as I remembered, but you were right to suspect me on the Ritalin. I'm apparently taking an extended release generic of Focalin not Ritalin. (dexmethylphenidate ER 20mg) I am 100% certain that my psychiatrist said that we were "trying Ritalin" next, but that's not what was written on the prescription pad, I guess. Do you have thoughts on Focalin?

This sounds dumb, but I'm actually really nervous to question my psychiatrist. Do I literally just say, "I've heard _____ could be used to help with jaw clenching/headache side effects. Can I try that?" My initial instinct is that that's stepping on her toes and could be taken poorly. There's a considerable shortage of mental health professionals in my city, and I'd be scared to lose the one I have.

I cannot afford to be as ineffective at work as I've been, so I'm going to do some experimenting today with the half-pills of the 15mg Adderall-IR that I still have. I'm going to try taking one every four hours instead of a general morning & afternoon dose (so 9am, 1pm, and 5pm) to see if maybe I can avoid the evening headache from the come down?

Thanks to everyone who's contributed so far; I really appreciate it.
posted by elleyebeebeewhy at 8:27 AM on March 15, 2016

Well, theoretically the extended release of Focalin could last all day like Adderall XR is supposed to. Also, it should be roughly equivalent to Adderall in dosage amount (Ritalin is half as strong). I have not tried Focalin. When I was getting my meds worked out it was so much more expensive than Ritalin that we didn't bother to try it since Ritalin didn't work well for me.

Focalin XR would be more expensive, it just came off patent. Regular Focalin would be cheaper, and probably dosed every 4-6 hours.

Expiramentation is often part of the process. Good Luck!
posted by monopas at 10:42 AM on March 15, 2016

1) I'm totally biased, but I think Focalin is thebomb dot com. So, congratulations! Regarding your psychiatrist's comment: here's my two cents. Many psychiatrists have never experienced ADD, which means they have never experienced taking medication for ADD. What this often means in practice is that they look at the active chemical and make assumptions about how that chemical may or may not be functionally different from others they're familiar with. You are currently taking dexmethylphenidate, which is...forgive me, organic chemists...one of the two different chemical shapes of methylphenidate, better known as Ritalin. You know how your hands are mirror images of each other? Well, Focalin is just Ritalin with the "left-handed" molecules taken out. Some people find it subtly but significantly different in its effects from Ritalin. I personally know psychiatrists who would consider them functionally the same drug, and I think that assumption (and others like it) has led to many people never finding the stimulant that might work best for their personal manifestation of ADD.

2) I think it's very unlikely that your psychiatrist is going to consider your interest in supplements, to respond to a physical, not a mental/behavioral difficulty, as a move on her territory. She may not even have no idea what you are talking about. To be real with you, I wouldn't ever have considered bringing it up, if only out of respect for the limited time I have with my psychiatrist.

3) I find that headaches are often produced or exacerbated by dehydration. If I were in your shoes, I would try stepping up my water intake and see if that helps at all.
posted by Poppa Bear at 5:29 PM on March 15, 2016

I clench my jaw when the dose is too high usually. But Adderall has strangely almost completely eliminated my frequent migraines. I get tension headaches now, sometimes, and they're nothing compared to the migraines. Light headaches + anxiety when I "crash" off it at the end of the day.

If the adderall was working, go back to IR, and experiment with doses and timing. I have to take 10mg every four hours, and I take it 2-3 times a day. 12 hours of coverage definitely helps me avoid a 6pm crash.

I used to have TMJ actually, years ago. I could barely open my mouth. I was supposed to get a mouth guard but I couldn't afford it. So... every night before I went to bed, I just imagined my jaw muscles relaxing, and envisioned them staying that way through the night. I know it sounds ridiculous, but within two weeks, my TMJ was gone. When I feel it coming back on, I focus on the muscles relaxing for a few days / nights, and it usually just goes away.

But amphetamine-induced jaw clenching is probably a different beast and a sign of too much, imo.
posted by chaos_theory at 6:06 PM on March 25, 2016

How can you be sure there isn't a habit forming element to nightly klonoplin?

I take it as needed for anxiety, and clench and grind a lot all day (but specially at night...I've had a hard mouth guard for years) and my job has been stressing me out so now I have tension headaches from grinding and clenching at work.

Thank you for the tongue tip! I'll try that for sure.
posted by OysterLucy at 8:24 PM on June 15, 2016

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