Headache and orofacial pain are complaints commonly reported in the same patient, particularly in children and adolescents. In patients with migraine, comorbid temporomandibular dysfunction (TMD) can lead to an increase in migraine frequency and use of migraine medications.
For further insight regarding the diagnosis and management of this patient population, we spoke with Paul G. Mathew, MD, a headache, sports neurology and concussion specialist with Brigham and Womens Hospital at Harvard Vanguard Medical Associates and Assistant Professor of Neurology at Harvard Medical School in Boston, MA, as well as Steven D. Bender, DDS, the Director of Facial Pain and Sleep Medicine with the Department of Oral and Maxillofacial Surgery at Texas A&M College of Dentistry in Dallas, TX. Both Dr Mathew and Dr Bender uniquely encounter patients with TMD and migraine in their respective practices, and shared their personal experience and advice for managing this often overlooked comorbidity.
How did you first become interested in TMDpathology?
Dr Mathew: First of all, I ammarried to a dentist, and so I have learned quite a bit about dentistry throughmy wife, which includes some of the nuances of how dental issues can impactmultiple aspects of health and wellbeing. I have also served as faculty for theTufts Headache and Face Pain Symposium, which brings together dentists andphysicians for a highly interactive 2-day program that explores the overlapsbetween craniofacial pain and orofacial pain.
Overmany years of practice, I have treated a growing number of patients who, duringa headache history, mention that they also have jaw pain. Unfortunately, afterseeking help from general dentists, pain clinicians, and even oromaxillaryfacial surgeons who may offer invasive surgical procedures, only a smallpercentage of patients end up being seen by an orofacial pain specialist, adentist with specialized training in the treatment of disorders including TMD.
Dr Bender: I became interestedin TMDs when I was in dental school and then began to study it more earnestlysoon after graduation due to my own jaw pain. Also, my wife developed seriousTMD pain shortly after I graduated from dental school and I couldnt findanyone who had the knowledge to help her.
What arethe primary mechanisms that can cause both TMD and migraine pain?
Dr Bender: A number of papersdescribe the incidence of these 2 disorders occurring together, although themechanisms that may be involved are yet to be fully described. There is thoughtthat convergence of nociceptive information into the trigeminal nucleuscaudalis plays a major role in sensitizing the central nervous system (CNS).So, if one has migraine, which is thought to be a disorder where the CNS ismore easily sensitized, and you add nociceptive input from other parts of thetrigeminal system as seen with TMD, the cascade of events leading to a migrainemay be more easily initiated and the patient will experience more frequent andintense migraine events
How do you identify TMD in a patient withmigraine?
Dr Mathew: The big issue here is making thediagnosis. Most patients either assume there is nothing that can be done,or they are told by doctors or dentists that they do not treat jaw issues. Assuch, many patients abandon hope of getting treatment, and may never even seekadditional care. In my experience, most patients do not mention this complaintwhen they present for a headache evaluation, so part of my examination includesevaluating jaw range of motion and palpating the joint, as well as examiningthe teeth and oral cavity looking for oral pathology. If there are anysignificant findings, I will ask questions about grinding, clenching, andwaking up in the morning with jaw tightness and pain.
Dr Bender: As migraine can sometimes present as a toothache or other facial pains, it is important for the provider to be familiar with the diagnostic ICHD 3 criteria of migraine, (ie, a headache that has at least 2 of the following qualities: primarily unilateral, pulsatile, of moderate to severe intensity and/or is aggravated by activity as well during the attack having one of the following: nausea and or vomiting and/or a sensitivity to light and sound, and a duration of the orofacial pain 4-72 hours which then remits) could be indicative of a migraine presentation.1
The human body does not have systems in isolation, so if you have TMD, it can serve as a trigger for migraine.
How important it is to recognize and diagnoseTMD?
Dr Mathew: It is very important to make the diagnosis of TMD. If a patient has pain with opening and closing the mouth, it can become very difficult to eat and to talk. In addition, the loud popping and clicking that is often associated with TMD can be socially embarrassing. The human body does not have systems in isolation, so if you have TMD, it can serve as a trigger for migraine. Studies have demonstrated that if you have both migraine and TMD, adequate treatment of TMD can lead to the improvement of the frequency and intensity of migraine. In other words, untreated TMD can make it more difficult to adequately treat migraine.
What diagnostic criteria do you use and why? Do you use any tests to confirm?
Dr Bender: While its certainlynot perfect, I use the ICHD 3 diagnostic criteria for headache disorders. A newclassification for orofacial pains was recently published and may prove usefulfor standardizing the diagnosis of orofacial pains.2 Also, theDiagnostic Criteria for Temporomandibular Disorders (DC/TMD) has been used forsome time both in the research arena and clinical practice.3 TheDC/TMD also outlines validated examination techniques of the relevant structuresinvolved in temporomandibular disorders.
Ultimately the confirmation will come from the preclinical interview and examination.
Ultimatelythe confirmation will come from the preclinical interview and examination. Additional testing will be directed by the history andexamination. New onset headaches and neuropathic pains should usually be imagedwith MRI and/or CT, although in most cases, TMDs dont necessarily requireadvanced imaging to establish a diagnosis. Laboratory studies are typically notindicated unless the pain presentation is suspected to be a manifestation of asystemic etiology.
Why is aneurological assessment important when a patient has symptoms indicative of TMD?
Dr Bender: A neurologicscreening, especially a cranial nerve screening, is an important aspect of anevaluation for most non-odontogenic facial pains like TMDs, neuropathies,neuralgias and headache disorders, particularly if a patient has developed arelatively new onset headache. Conversely, in a neurologic practice, theclinician should become familiar with examination techniques to assess thestomatognathic structures (muscles of mastication, cervical muscles andtemporomandibular joints).
Whatinterventions are used to manage these 2 conditions?
Dr Mathew: My first recommendation is that patients see a dentist, preferably an orofacial pain specialist. If they are clenching or grinding, a night guard can be useful. A night guard is a custom-made appliance that can accomplish a few things: 1) Protection of tooth enamel from wear associated with nocturnal clenching/grinding, 2) Prevention of migration of the teeth within the gums and the development of gaps, and 3) Reduction at times of the forces generated from clenching and grinding, which may help reduce tension/pain within the muscles of mastication and the temporomandibular joint.
Second,I advise patients to avoid activities that can exacerbate symptoms, such aschewing very tough things like steak or sticky candy, which can serve astriggers.
Third,a physical therapy referral can be very useful, especially if thetherapist is well versed in the management of migraine and TMD. By treating TMD, neighboring muscle groupsmay benefit. If TMD/neck pain and tightness improve, there is a tendency formigraine frequency and intensity to also improve, so a physical therapist canbe very helpful in addressing coexisting posture and ergonomic issues. Mostorofacial pain specialists can recommend a local/regional physical therapistwho specializes in the management of TMD.
Lastly,I often recommend the use of pharmacological treatments including medicationslike muscle relaxants and Botox [onabotulinumtoxinA] injections to manage painfrom both migraine and TMD.
Dr Bender: Many patients I see have previously consulted with multiple providers for their headaches and TMDs who did not consider the comorbidity of these disorders. I explain to the patient that in most cases, if we can decrease nociceptive information entering the trigeminal system from the stomatognathic structures we will be better able to successfully treat both disorders. With TMDs, we try to start with very conservative measures such as self-care therapies (resting the jaw, ice/heat, limiting certain foods, jaw mobilization techniques and in some cases over the counter analgesics). We may also refer to a physical therapist trained in caring for TMD patients.
Many patients I see have previously consulted with multiple providers for their headaches and TMDs who did not consider the comorbidity of these disorders.
In selected cases of refractorymasticatory muscle pain, the judicial use of low doses of botulinum toxin maybe helpful. The potential benefits of this therapy must be weighed against therisk of osteopenic changes to the involved bony structures.4 Selectivenerve blocks and muscle trigger point injections may also be of benefit forsome patients.
Pharmacotherapy (muscle relaxers,anti-inflammatories/analgesics) can be beneficial for some patients but in mostcases, it is not needed for most TMDs. A custom fabricated intra oral deviceworn on the teeth (commonly termed an oral splint, night guard or oralorthotic) will benefit many TMD presentations if well designed and constructedspecifically for the individual patients presentation. More invasive andirreversible therapies such as orthodontics, jaw repositioning procedures, jawsurgeries or bite adjustments should be avoided as these therapies lackevidence and can potentially create even more significant pain. The well-managedTMD patient with a concomitant headache disorder will often find that theyrequire less prophylactic and abortive medications.
Arethere other types of therapies (drugs, surgical techniques, patient-appliedtherapies) that may also help?
Dr Bender: Along with the above therapies, we give the patient self-care instructions to try to decrease sympathetic tone. We will talk to them about behavior modification techniques to stop the habit of awake teeth clenching or bracing. Even light nonfunctional tooth contact has been shown to elicit muscle activity which can add to nociceptive signaling. We also instruct our patients in physical self-regulation based on the work of Carlson et al5 in which patients follow a somewhat structured program designed to decrease sympathetic tone. This will include proper hydration and nutrition, diaphragmatic breathing, posture awareness, adequate sleep, and focused relaxation.
Manypain patients have previously undiagnosed sleep disorders. In our practice, a part of our initial evaluation willinclude screening for these disorders with questionnaires and the use of homepulse oximetry to screen for sleep related breathing disorders. In many cases,treating the underlying sleep disorder has significantly reduced our patientsheadache and TMD complaints.
A clinical psychologist trained inpain management can also help patients better manage thoughts and behaviorsoften associated with chronic pain.
How well dopharmacological treatments like Botox work?
Dr Mathew: Oral medications (like muscle relaxants) can be effective, but many patients have difficulty tolerating them. In other cases, patients would prefer not to take a daily oral medications. As such, patients are often quite happy with receiving Botox injections every 3 months, given the convenience and a favorable side effect profile.
Although I have been injecting Botox since 2009, itwas FDA approved for the treatment of chronic migraine in 2010. Botox does nothave an FDA indication for the treatment of TMD, but I have been injecting forthe treatment of this diagnosis since 2013. Securing a Botox priorauthorization specifically for the treatment of TMD can be challenging. Nearly all of my Botox patients have a priorauthorization for the diagnosis of chronic migraine, and a portion of the Botoxunits are used for the treatment of TMD.
Botoxhas an established action of reducing transmission at the neuromuscularjunction, which makes it a good option for the treatment of overactive muscles thatmay play a role in TMD. It also haseffects on pain signaling. I was pretty amazed at how, for some patients,injecting 20 units in each temporalis and as little as 5 units in each massetercould significantly improve TMD symptoms. With other patients, I have togradually increase the dose by 5 units every visit to doses as high as 40 unitsper side to achieve a benefit. My hypothesis is that lower dose requirementsfor some patients may reflect the responderswho benefit primarily from the effects of Botox on pain signaling, while thoserequiring higher doses may also need the neuromuscular effect of Botox in orderto reduce masticatory hyperactivity. This may explain why patients who aretreated in orofacial pain clinics in general tend to need higher doses, asthese more refractory cases may have a larger motor component to theirTMD.
How often do youtreat TMD in patients with migraine?
Dr Bender: As an orofacial pain specialist, the majority of my practice consists of diagnosing and managing people with TMDs. So, I probably see 6-8 patients per day with some form of a TMD.
If clinicians are overlooking TMD signs and symptoms, the diagnosis will not be made, and an opportunity to treat will be lost.
Dr Mathew: I encounter patients with TMD every single day in clinic, multiple times a day. I would say that if I am performing Botox injections on 15 patients for the treatment of chronic migraine in a day, at least 5 of them are receiving masseter injections for treatment of TMD. TMD is extremely common in my headache medicine practice because I am actively looking for it through my history-taking and examination. If clinicians are overlooking TMD signs and symptoms, the diagnosis will not be made, and an opportunity to treat will be lost.
Whatoutcomes can be expected for comorbid TMD/migraine?
Dr Bender: While every individual will have a unique presentation, if the clinician engages in a comprehensive examination process beyond the traditional neurologic examination and employs evidenced-based therapies for both disorders, outcomes can be very predictable and successful. These therapies are often more comprehensive than the pharmacotherapeutic-based approaches employed by most headache practitioners. Many of our patients with TMDs note a significant improvement in their headache intensity and frequency when their TMD is well-treated.
Dr Mathew: I find the best results occur when patients are on combination treatment with an oral appliance, trigger avoidance, physical therapy with continued self-guided home stretching/exercises, and pharmacological treatment. This is where interdisciplinary collaboration between the neurologist/headache specialist, dentist/orofacial pain specialist, and physical therapist can lead to the best outcomes.
References
1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalagia. dio: 10.1177/0333102417738202
2. The Orofacial Pain Classification Committee. International Classification of Orofacial Pain. Cephalagia. doi: 10.1177/0333102419893823
3. Schiffman E, Ohrbach R, Truelove E, etal. DiagnosticCriteria for Temporomandibular Disorders (DC/TMD) for Clinical and ResearchApplications: recommendations of the International RDC/TMD Consortium Networkand Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. doi:10.11607/jop.1151
4. Kahn A, Kn-Darbois JD, Bertin H, Corre P, Chappard D. Mandibular bone effects of botulinum toxin injections in masticatory muscles in adult. Oral Surg Oral Med Oral Pathol Oral Radiol. 2020;129:100-108. doi: 10.1016/j.oooo.2019.03.007. Abstract.
5. Carlson CR, Bertrand PM, Ehrlich AD, Maxwell AW, Burton RG. Physical self-regulation training for the management of temporomandibular disorders. J Orofac Pain. 2001 Winter;15:47-55. Abstract.