TMD and Migraines
TMD often coexists with daily or near-daily headache syndromes but is overlooked by many physicians in the history and physical examination.
Headaches typically begin as episodic disorders but certain causative factors influence the progression from episodic to daily or near-daily head-ache disorders. Over the last five years, multiple epidemiological studies have identified common risk factors for transformation of episodic to chronic migraine. The most common risk factors include: obesity, socioeconomic status, medication overuse, and previous head trauma.
Under-recognized and easily treatable patients are those who have developed myofascial pain syndromes of the head and neck with subsequent dramatic worsening of previously benign headache syndromes. These patients will not typically respond to traditional headache preventatives until the myofascial pain syndrome is addressed. This article discusses such a case and presents an approach to these patients.
A 40 year-old white female with 8 years of menstrual-associated migraine is referred to the author for “worsening migraines” of three months duration which occurred after a “hard fall.” During the fall, she landed on her right arm and shoulder without head injury. She has seen her family physician, dentist, a rheumatologist, and at least one other neurologist for this condition. Her main complaint is one of headaches with a Headache Impact Test-6 (HIT-6) score of 69 (previously 40). The pain was primarily on the right side and was associated with nausea, photophobia, phonophobia, osmophobia, and visual aura on most days. Gabapentin, topiramate, and extended release divalproex prophylaxis were not helpful and she was requiring near-daily short acting narcotics. The initial exam revealed myofascial trigger points in the right masseter and medial pterygoid and an otherwise normal neurological examination. She was given a two-week detailed headache diary and pain location chart. At her two week follow-up visit, the diary and pain charts revealed right jaw and facial pain in addition to her right hemicranial migraines. The jaw and facial pain was dull and aggravated by chewing. The patient’s husband confirmed nocturnal bruxism. The headache met ICDH-II criteria (see Table 1) for medication overuse headache.
Temporomandibular dysfunction (TMD) encompasses problems involving the temporomandibular joint or associated structures, as well as the masticatory musculature. Primary headache disorders have been shown to occur significantly more often in TMD patients and vice-versa. One small trial has demonstrated a significant decrease in headache frequency compared to placebo with TMD treatment.