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Year : 2014  |  Volume : 25  |  Issue : 1  |  Page : 119-121
The coexistence of paroxysmal hemicrania and temporomandibular disorder: Importance of multidisciplinary approach

1 Department of Prosthodontics, Bauru School of Dentistry, University of Sao Paulo, Bauru, Brazil
2 Private Clinician from Franca, Sao Paulo, Brazil

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Date of Submission18-Feb-2013
Date of Decision12-Apr-2013
Date of Acceptance21-Sep-2013
Date of Web Publication21-Apr-2014


Paroxysmal hemicrania (PH) is a trigeminal autonomic cephalalgia, a rare primary headache characterized by unilateral periorbital and/or temporal attacks of severe intensity and short duration. In this situation, the determination of a correct diagnosis is crucial for the establishment of a proper management strategy. In the case of head and facial pain, this step is usually a big challenge since many conditions share the same features, as some primary headaches and temporomandibular disorders (TMD). The relationship between PH and TMD has not been determined. This paper describes a case of a female patient diagnosed with TMD and presenting concomitant headache attacks fulfilling the International Headache Society's criteria for PH. It is also emphasized the importance of dentist in this scenario, for many times responsible for the initial diagnosis of facial/head pain. Moreover, it is presented an integrated and simultaneously approach of both conditions, PH and TMD.

Keywords: Differential diagnosis, facial pain, headache, paroxysmal hemicranias, temporomandibular joint disorders

How to cite this article:
Porporatti AL, Costa YM, Bonjardim LR, Stuginski-Barbosa J, Conti PR, Martori AH. The coexistence of paroxysmal hemicrania and temporomandibular disorder: Importance of multidisciplinary approach. Indian J Dent Res 2014;25:119-21

How to cite this URL:
Porporatti AL, Costa YM, Bonjardim LR, Stuginski-Barbosa J, Conti PR, Martori AH. The coexistence of paroxysmal hemicrania and temporomandibular disorder: Importance of multidisciplinary approach. Indian J Dent Res [serial online] 2014 [cited 2023 Sep 23];25:119-21. Available from:
The differential diagnosis of facial pain is complex due to many closely related anatomical areas, which may lead to pain and therefore a careful pain history and clinical examination are essential in aiding diagnosis. [1]

Temporomandibular disorder (TMD) is a collective term embracing a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ) and associated structures or both. [2] TMD is a common situation of facial pain and may be associated to other pain conditions as headaches. [3]

Paroxysmal hemicrania (PH) is a trigeminal autonomic cephalalgia (TAC), which relationship with TMD has not been determined. PH is a rare primary headache characterized by unilateral attacks of severe intensity and short duration [Table 1]. [4]
Table 1: Diagnostic criteria for hemicrania paroxysmal according to International Headache Society

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This paper describes a case of a female patient who complained of head and facial pain for 6 years, which was diagnosed of TMD and simultaneously presented headache attacks compatible with PH.

   Case Report Top

A 35-year-old Caucasian female presented for treatment with the complaint of bilateral facial and left head pain. Pain was daily and severe (10 in the visual analog scale) and first appeared 6 years ago.

According to patient's report, 4 years ago, she was misdiagnosed with migraine without aura by another professional and underwent treatment with several drugs, including fluoxetine, naproxen, propranolol, divalproex sodium, ergotamine tartrate, maleate chlorphenamine and tricyclic antidepressants. No triptans use was reported by the patient.

2 years ago, she was diagnosed with TMD by a dentist and had an intraoral soft appliance inserted. Sleep bruxism was also reported by the patient. No significant pain improvement with both treatments, for migraine or for TMD was however achieved.

After taking the history of patient, physical examination revealed bilateral moderate pain upon palpation of temporal and masseter muscles as well as of the TMJ. Trigger points were found in left masseter, eliciting a pattern of pain referral to the ipsilateral maxillary and mandibular first molars. Patient reported that pain was familiar, i.e. that this sensation was her usual pain. Patient opened her mouth up to 52 mm, which was accompanied by pain. Protrusive and lateral movements were within normal limits and without pain. Wear facets were found in anterior and posterior teeth and no other significant signs were detected.

Masticatory myofascial pain and arthralgia were the initial diagnosis and treatment consisted of counseling, physical therapy and the nocturnal use of a rigid acrylic occlusal stabilization splint in the upper jaw.

Coincidently, after this appointment, patient returned in the same day with left orbital and supraorbital severe headache, lasting 27 min with ipsilateral ptosis, eyelid edema, nasal congestion and lacrimation. She reported daily episodic attacks like that. Hypotheses diagnosis was PH. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is a pretty similar condition; however, it was not considered because of the mean duration of paroxysms about 1 min, with a usual range of 10-120 s. [5] The patient was referred to a neurologist who confirmed PH diagnosis and prescribed indomethacin 150 mg/day.

After 1 month, patient returned with no sign of myofascial pain and arthralgia and with reduction in PH attacks. Indomethacin dose was kept (150 mg/day). After 3 months, patient remained asymptomatic for TMD and PH attacks reduced to 4 per month.

   Discussion Top

Diagnosis of orofacial pain is a challenge for dentists and physicians', becoming even more complicated when patient's signs and symptoms are due to rare etiologies such PH. This case reported a patient with concomitant TMD and PH, treated for both painful conditions.

The proper TMD diagnosis process includes detailed anamnesis and physical examination and is crucial for the establishment of a correct management strategy. However, although muscle and TMJ tenderness to palpation are typical signs of musculoskeletal pain, caution is necessary because such findings are common in the asymptomatic population.

PH is a rare primary headache, marked by short attacks of severe pain, lasting 2-30 min, accompanied by trigeminal autonomic signals and prevented completely by therapeutic doses of indomethacin. [4],[6] Women are the most affected by a ratio of 3:1 and onset age is between second and third decade of life, with a mean age of 34 years, similar to the age of the patient presented in this case. [7]

Literature suggest that TMD and PH are quite distinct entities although have common features such as temporal and maxillary pain. Moreover, PH patients may exhibit ipsilateral muscle tenderness, which contributes to the misdiagnosis. [1],[3]

The dental profession has a significant role in this scenario because in many times, the dentist is the first professional sought by patients with orofacial pain. Because of that, the presence of some important features as severe unilateral pain, presence of neurological symptoms, photophobia, phonophobia or osmophobia, nausea, vomiting, numbness, myasthenia, autonomic symptoms, sudden onset of a new type of pain and progressive worsening in short periods are not common clinical features found in TMD patients and when present, require attention. [8]

In these cases, an accurate diagnosis is necessary to avoid the worsening and even death of patient. On the other hand, iatrogenic complications and unnecessary dental interventions must be avoided, because they are not indicated to treat primary headaches. A cochrane study has already shown there is no evidence that occlusal adjustments treat or prevents TMD. [9] Furthermore, dental occlusal adjustment might not be recommended for TMD or even primary headache management.

It has been reported that, in a 230 cluster headache patients, 45% came to the dentist as the first professional and 18% of them were mistakenly treated with dental interventions. [10] Moreover, in some cases, the "headache" may present only as pain in the facial region. Cases of migraine, cluster headache, SUNCT, PH and continuous hemicrania have been previously described as pain conditions presented in the face, [11] teeth, TMJ [12] or rhinological region. [13]

Comorbidity refers to the greater than coincidental association of two conditions in the same individual. TMD has been noted to be comorbid with a number of other illnesses in specialty care and in population samples, including migraine and tension type headache. [3] Comorbidities have been suggested to play a role in facial pain and headache onset and progression. In the present case report, patient presented both conditions, TAC and TMD, at the same time. Even the exact association between PH and TMD is currently unknown; it could be possible that nociceptive impulses from masticatory muscles or from PH attacks could induce sensitization mechanisms in the subnucleus caudalis of the trigeminal nerve system. This mechanism could explain the fact that the presence of TMD could worse headache and vice versa and that treatment for both painful conditions brought pain relief to the patient, [1] as reported here.

   Conclusion Top

Based on the role of the dental profession in recognition of primary headaches and the establishment of a multidisciplinary approach when necessary seem to be essential to the achievement of successful results in patients presenting with comorbid conditions.

   References Top

1.Gonçalves DA, Speciali JG, Jales LC, Camparis CM, Bigal ME. Temporomandibular symptoms, migraine and chronic daily headaches in the population. Neurology 2009;73:645-6.  Back to cited text no. 1
2.Okeson JP. Bell`s Orofacial Pains. 6 th ed. Chicago: Quintessence; 2005.  Back to cited text no. 2
3.Ballegaard V, Thede-Schmidt-Hansen P, Svensson P, Jensen R. Are headache and temporomandibular disorders related? A blinded study. Cephalalgia 2008;28:832-41.  Back to cited text no. 3
4.Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2 nd edition. Cephalalgia 2004;24 Suppl 1:9-160.  Back to cited text no. 4
5.Pareja JA, Caminero AB, Sjaastad O. SUNCT syndrome: Diagnosis and treatment. CNS Drugs 2002;16:373-83.  Back to cited text no. 5 Leeuw RA. Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. American Academy of Orofacial Pain. 4 th ed. Chicago: Quintessence; 2008.  Back to cited text no. 6
7.Benoliel R, Sharav Y. Paroxysmal hemicrania. Case studies and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:285-92.  Back to cited text no. 7
8.Riman T, Dickman PW, Nilsson S, Nordlinder H, Magnusson CM, Persson IR. Some life-style factors and the risk of invasive epithelial ovarian cancer in Swedish women. Eur J Epidemiol 2004;19:1011-9.  Back to cited text no. 8
9.Koh H, Robinson PG. Occlusal adjustment for treating and preventing temporomandibular joint disorders. J Oral Rehabil 2004;31:287-92.  Back to cited text no. 9
10.Bahra A, Goadsby PJ. Diagnostic delays and mis-management in cluster headache. Acta Neurol Scand 2004;109:175-9.  Back to cited text no. 10
11.Gaul C, Gantenbein AR, Buettner UW, Ettlin DA, Sándor PS. Orofacial cluster headache. Cephalalgia 2008;28:903-5.  Back to cited text no. 11
12.Taub D, Stiles A, Tucke AG. Hemicrania continua presenting as temporomandibular joint pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e35-7.  Back to cited text no. 12
13.Daudia AT, Jones NS. Facial migraine in a rhinological setting. Clin Otolaryngol Allied Sci 2002;27:521-5.  Back to cited text no. 13

Correspondence Address:
André Luís Porporatti
Department of Prosthodontics, Bauru School of Dentistry, University of Sao Paulo, Bauru
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.131163

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2 Symptomatic Trigeminal Autonomic Cephalalgias
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