Temporomandibular Disorders and Tension-type Headache Franco Mongini, MD
Corresponding author Franco Mongini, MD Department of Clinical Pathophysiology, Headache and Facial Pain Unit, University of Turin, Corso Dogliotti 14, I-10126 Torino, Italy. E-mail:
[email protected] Current Pain and Headache Reports 2007, 11:465–470 Current Medicine Group LLC ISSN 1531-3433 Copyright © 2007 by Current Medicine Group LLC
Pathologies currently defined as temporomandibular disorders may be different in nature. Temporomandibular joint (TMJ) disorders and craniofacial and cervical myogenous pain (MP) are distinct pathologies but may be superimposed and share some etiologic factors. Tension-type headache (TTH) may often be associated with craniofacial and cervical pain, and the same pharmacologic and nonpharmacologic treatment may be efficacious for both. Psychiatric comorbidity (depression and/or anxiety disorder) is less frequent in sheer TMJ disorders, compared with MP and TTH. A screening for the presence of an underlying psychiatric disorder should be part of the clinical evaluation in patients suffering from headache and facial pain.
Introduction In several types of headache and facial pain, different etiologic factors may be combined. Moreover, problems arising from the craniofacial structures may be complicated by the superimposition of systemic or mood disorders. This may lead to controversial opinions about the relevance of some factors in the different head pain pathologies. This, in particular, is true in facial pain conditions frequently referred to as temporomandibular disorders (TMDs). This term has been used to define conditions characterized by chronic or recurrent craniofacial pain that also extends to the preauricular and/or the auricular area. Other symptoms include tenderness of the jaw; limited, deviated, or irregular jaw movements; clicking or popping noises when opening the mouth; and even headaches and neck aches. However, a localized masticatory muscle pain is the only finding in most patients diagnosed with TMD [1]. Previously used terms were craniomandibular disorders, temporomandibular joint (TMJ) pain dysfunction syndrome, myofascial pain
dysfunction syndrome, and oromandibular dysfunction. The latter term was introduced in the 1988 Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias, and Facial Pain of the International Headache Society as an important pathogenetic factor of tension-type headache (TTH). However, in the second edition (2004) [2], this term was removed. TMJ disorders are mentioned in section 11.7 of the classification as “Headache or facial pain attributable to temporomandibular joint disorders.” The use of the term TMD without better specification seems unjustified and misleading. Pathologies currently defined as TMD may be very different, even though they may be frequently superimposed on the same patient. For example, it is obviously preposterous to diagnose as TMD a patient with depression and/or anxiety disorder, chronic headache of tension type, and a joint clicking noise. When assessing pathologies leading to pain in the preauricular and cheek areas, it is reasonable to make a distinction between a pain condition consequent only or mainly to a TMJ disorder, a second condition due to a muscle disorder leading to myogenous pain, and a third condition in which both disorders are present [3–6]. Moreover, the possible presence of other pathologies should be considered, as should a facial pain disorder (FPD) as a somatoform disorder and neuropathic pain (NP) [7•]. TTH is a very frequent condition, with a considerable overall human and financial cost [8]. In an extensive population-based study [9], the overall prevalence of episodic TTH (ETTH) was 38.3%, whereas the prevalence of chronic TTH (CTTH) was 2.2%. Of patients with ETTH, 8.3% reported lost workdays because of their headaches, whereas 43.6% reported decreased effectiveness at work, home, or school. Patients with CTTH reported more lost workdays and reduced-effectiveness days, compared with patients with ETTH. TTH is frequently associated with myogenous pain in the craniofacial and neck area [10,11]. The possible presence of psychiatric comorbidity is a further factor to consider when dealing with the aforementioned conditions. This is a potentially important factor in several head pain conditions [12–17]. A high degree of comorbidity was also found between chronic facial pain and depression [1,7•,18–20], and a significant overlap was established between both depression and chronic facial pain with other stress-related pain disorders, such as fibromyalgia and
466 Tension-type Headache
1.6
Without psychiatric disorders With psychiatric disorders
Score
1.2 0.8 0.4 0 EM
CM
ETTH
CTTH
EM ETTH
Figure 1. Muscle tenderness scores in patients with different headache types with or without psychiatric comorbidity. A remarkCurrent Pain and Headache Reports PA 11-6-2-04 Fig. 1 ably significant score difference is observed in patients with episodic 240 pts. W/ 168 pts. D (20 x 14) migraine (EM). CM—chronic Author: Monginimigraine; Editor: CTTH—chronic Chris Artist: TEtension-type headache; ETTH—episodic tension-type headache. (Adapted from Mongini et al. [41•].)
widespread pain [21,22]. Myogenous pain in the craniofacial and neck area may be combined with low back pain and pain in other body areas. However, in this case it also must be distinguished from fibromyalgia. The most important distinctive criterion is the presence of generalized muscle pain accounting for a generalized disturbance of pain modulation in fibromyalgia, whereas in the case of myogenous pain the distribution of pain sites and trigger points is regional. Therefore, the main issues to consider can be summarized as follows: 1. What is the relationship between TMJ disorders, myogenous craniofacial pain (MP), and TTH? 2. To what extent does psychiatric comorbidity impact such conditions? 3. What are the clinical implications?
Discussion Patients suffering from intracapsular TMJ disorder show clinical signs such as joint noises, pain at joint palpation, and jerky jaw movements. Imaging techniques may reveal disc displacement with or without reduction. Bony change in shape might also be present in some cases. The TMJ is the sole or main source of pain in these patients, and mastication is always an aggravating factor. In patients with MP, pain is localized in the projection areas of one or more facial or masticatory muscles; pain is spontaneous but may be exacerbated by muscle palpation. Location of pain differs with the muscles mainly involved—preauricular and cheek areas for the lateral pterygoid and masseter muscles; parietal, temporal, and periorbital areas for the temporal muscle. Pain may be aggravated by meteorological changes or certain weather conditions (cold, damp, windy), or sports
involving prolonged isometric contractions, whereas mastication is not an overt aggravating factor. Muscle disorder, also defined as muscle parafunction, is a frequent condition in the craniofacial, neck, and shoulder areas and is considered a potential etiologic factor in some types of head pain. It includes tooth clenching, bruxism, tongue thrust, nail or lip biting, sustained contraction of the craniofacial and cervical muscles, and so on. Muscle disorder may increase muscle tenderness at palpation and may be of importance in TTH [23–28], and, to some extent, in migraine [29–31]. Moreover, muscle disorder can lead to spontaneous myogenous pain in the craniofacial-cervical area [32,33]. A significant association was found between emotional status, tooth grinding, and facial myogenous pain [34,35]. Therefore, it is not surprising that TTH and MP are frequently associated conditions [36–38]. Pain in the cheek and the neck is frequently observed to spread to the temple and parietal areas, and vice versa. On the other hand, muscle parafunction may cause or facilitate TMJ disc displacement. Several authors maintain that bruxism and the consequent dental attrition are etiologic factors of TMJ dysfunction [34,39,40]. Different mechanisms may be hypothesized as to how muscle parafunction may induce TMJ dysfunction. Prolonged daily and nightly tooth grinding, with excessive anteroposterior and/or lateral mandibular and condylar movement, may lead to stretching and tearing of the joint capsule and ligaments, and eventually, to consequent disc displacement. Psychiatric comorbidity is a frequent finding in headache and craniofacial pain and may have a relevant impact on the level of tenderness of the craniofacial cervical muscles in different head pain conditions. A recent study [41•] of patients with different headache types investigated the tenderness of pericranial and cervical muscles and its relation to anxiety and depression. The data showed a significantly lower muscle tenderness in migraine patients with respect to those with TTH. Anxiety and depression were frequent comorbid disorders, and their prevalence was highest in patients suffering from chronic migraine. The main finding of this study was a positive relationship between muscle tenderness and psychiatric disorders in patients with episodic migraine alone or combined with TTH (Fig. 1). More recently, the association between muscle tenderness and psychiatric comorbidity was evaluated in patients with MP, TMJ disorder, NP, and FPD [7•]. The arthrogenous TMJ was more common among the younger women. This is in accordance with the widely accepted notion that symptoms of TMJ derangement are more frequent in women [40,42,43] and may positively evolve with time [44,45]. The prevalence of depression was highest in FPD patients (44.9%). Unsurprisingly, muscle tenderness was greater in patients with myogenous pain than in patients with TMJ or NP. Also, patients with FPD had higher muscle tenderness scores. The prevalence of anxiety and depression disorders was equally higher in patients suffering from MP and FPD than from other
74 (16%)
43 (±15)
155 (33.5%)
103 (22.3%)
Male gender, n (%)
Mean age, years (± SD)
Anxiety disorder, n (%)
Major depression, n (%)
1.31 (±0.97)
2.56 (±1.64)
Mean CTS (± SD)
Mean CUM (± SD)
1.29 (±1.61)
0.68 (±0.95)
0.61 (±0.76)
11 (15.7%)
11 (15.7%)
38 (±17)
10 (14.3%)
1.64 (±1.74)
0.82 (±0.99)
0.82 (±0.84)
7 (10.3%)
11 (16.2%)
50 (±14)
24 (35.3%)
NP (n = 68)
Diagnostic group TMJ (n = 70)
2.02 (±1.84)
1.11 (±1.12)
0.91 (±0.86)
22 (44.9%)
15 (30.6%)
46 (±13)
11 (22.5%)
FPD (n = 49)
< 0.001
< 0.001
< 0.001
< 0.001
0.001
< 0.001
0.001
Overall P value
MP vs TMJ; MP vs NP
MP vs TMJ; MP vs NP
MP vs TMJ; MP vs NP
MP vs NP; MP vs FPD; TMJ vs FPD; NP vs FPD
MP vs TMJ; MP vs NP
MP vs NP; TMJ vs NP; TMJ vs FPD
MP vs NP; TMJ vs NP
Comparisons, P value < 0.05
2
*Differences among groups tested by one-way analysis of variance or x test. Bonferroni adjustment for multiple comparisons. CTS—cervical tenderness score; CUM—cumulative; FPD—facial pain disorder; MP—myogenous pain; NP—neuropathic pain; PTS—pericranial tenderness score; SD—standard deviation; TMJ—temporomandibular joint intracapsular disorder. (From Mongini et al. [7•]; with permission.)
1.25 (±0.86)
Mean PTS (± SD)
Muscle tenderness scores
MP (n = 462)
Patients’ characteristics
Table 1. Distribution of patients’ characteristics in groups with different types of facial pain*
Temporomandibular Disorders and TTH Mongini 467
468 Tension-type Headache
Table 2. Associations between patients’ characteristics and cumulative muscle tenderness score in groups with different types of facial pain* Cumulative tenderness score Patients’ characteristics
OR
(95% CI)
P value
Male gender
0.4
(0.27–0.58)
< 0.001
Age, years
0.99
(0.98–1)
0.029
Anxiety disorder
1.55
(1.13–2.12)
0.006
Major depression
1.56
(1.1–2.21)
0.012
TMJ
0.18
(0.11–0.3)
< 0.001
NP
0.46
(0.29–0.75)
0.002
FPD
0.47
(0.26–0.84)
0.01
Diagnostic group†
*ORs and 95% CIs estimated with ordered logit regression are adjusted for all variables listed in the table. Both anxiety and depression increase the likelihood of having a higher muscle tenderness score. † Reference group: MP. FPD—facial pain disorder; MP—myogenous pain; NP—neuropathic pain; TMJ—temporomandibular joint intracapsular disorder. (From Mongini et al. [7•]; with permission.)
Muscle disorder
TMJ disorders
Myogenous pain
Psychiatric disorders
Tension-type headache Migraine
facial pain types (Table 1).and These dataReports suggest PA that these Current Pain Headache 11-6-2-04 pts. W/ 108 D (27 x 9) two groups, diagnostically324 different on pts. presence/absence Mongini Editor: Chris Artist: TE of objective findings Author: and presumed involvement of psychologic factors, may be more similar than is generally recognized. However, regardless of the diagnostic group, anxiety and depression independently increased the likelihood of having a higher muscle tenderness score (Table 2). This result seems of particular interest because it suggests the presence of an additional mechanism linking these disorders to facial pain and the possibility of a more integrated treatment approach. A longitudinal study of migraine patients has shown that the presence of psychiatric disorders does not influence the results of short-term treatment but appears to influence headache history in the long-term [17]. A similar hypothesis may be put forward for patients suffering from different types of facial pain. The factor intersection between the different pain conditions is expressed in Figure 2. From a clinical point of view, a careful screening for an underlying psychiatric disorder (anxiety or depression) should be part of the clinical evaluation in TTH and/or craniofacial pain of any type, and such disorders should be appropriately treated if present. The treatment of TTH and MP is substantially similar. Pharmacologic treatment includes NSAIDs
Pain in somatoform disorders
Figure 2. Facial pain disorder as a somatoform disorder is a psychiatric disorder. Furthermore, psychiatric disorders may negatively influence the headache history either directly or by increasing muscle disorder. The latter is a potential etiologic factor of temporomandibular joint (TMJ) disorders, myogenous pain, tension-type headache, and, to some extent, migraine.
and Fig. 2 tricyclic antidepressants. Furthermore, there is a general agreement that nonpharmacologic treatment should also be considered. Several studies have assessed the efficacy of noninvasive physical management in reducing the frequency of different types of headache and neck pain. However, the results of recent studies were conflicting [46– 48]. We recently performed a controlled trial designed to evaluate the effectiveness of a cognitive and physical program in reducing the frequency of head and neck pain in an extensive working community divided into two groups (study group and controls; submitted paper). All patients were given a diary for the daily recording of pain episodes in the craniofacial and cervical area. After 6 months of intervention, a substantial reduction of the monthly frequency of head, neck, and shoulder pain, as well as drug intake, was observed in the study group. Most of the patients suffered from concomitant headache, as well as neck and shoulder pain spreading to the face in some cases. About 30% of the patients also showed signs of mild TMJ internal derangement, generally in the form of a TMJ clicking noise. The treatment program applied led to a symptom improvement in about 50% of the cases. This datum points out the possibility that MP and TMJ intracapsular disorders share a common etiology in a number of cases. Moreover, a cascade effect may also
Temporomandibular Disorders and TTH Mongini 469
be envisaged; treatment eases up MP, which secondarily reduces the stress on the TMJ.
11.
12.
Conclusions Pathologies currently defined as TMD may be different in nature. TMJ disorders and craniofacial and cervical MP are distinct pathologies, and it is more appropriate to assess them separately. However, they may share some etiologic factors and be superimposed on the same patient. TTH often may be associated with craniofacial and cervical pain, and the same pharmacologic and nonpharmacologic treatment may be efficacious for both. Nonpharmacologic treatment may include cognitive strategies and exercise programs. Psychiatric comorbidity (depression and/or anxiety disorder) is less frequent in sheer TMJ disorders, compared with MP and TTH. A screening for the presence of an underlying psychiatric disorder should be part of the clinical evaluation in patients suffering from facial pain. If present, such disorders should be adequately treated as part of treatment of the pain pathology.
13. 14.
15. 16. 17. 18.
19. 20.
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