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Is It TMD Or Is It Migraine? Two Case Studies

Author: John E. Dinan, DMD MS

Date: September 27, 2023

 

As an Orofacial Pain Specialist, I frequently encounter patients presenting with various forms of temporomandibular disorder (TMD) – a condition characterized by pain and dysfunction stemming from the temporomandibular joints or the associated chewing muscles. However, there are instances when patients arrive at our practice with a misdiagnosis of TMD, only to discover that they are grappling with an entirely different issue.

Let me share two recent cases where patients’ conditions were initially misdiagnosed as TMD, leading to years of ineffective treatments:

Case 1 “Nora”

Nora, a 36-year-old woman, had been living with pain for over two decades. Every month, coinciding with her menstrual cycle, she experienced excruciating throbbing pain in her right temple and jaw. These episodes brought with them heightened sensitivity to light and sound. In her own words, she described it as, “It hurts so badly that I get nauseous!”

Nora’s agony persisted for 48 to 72 hours before subsiding, only to return in the following month. She also noticed a clicking sound in her right temporomandibular joint (TMJ) when she opened her mouth wide, though it was more of an annoyance than pain. Apart from this non-painful TMJ noise, Nora’s clinical and radiographic exams revealed no remarkable findings.

Nora had been previously diagnosed with TMD (she referred to it as TMJ) many years ago. Her treatment primarily involved various oral appliances, which provided no relief. She resorted to taking Ibuprofen during her pain episodes, which merely offered partial respite.

Case 2 “Veronica”

Veronica, a 24-year-old woman, had endured pain for five years. Approximately two to three times each month, she experienced severe throbbing pain in the region in front of her right ear and under her right eye. These episodes typically lasted between 24 to 48 hours and were accompanied by heightened sensitivity to light and sound, occasionally leading to nausea. Interestingly, her masticatory function remained unaffected and did not trigger these attacks.

Between these painful episodes, Veronica was entirely pain-free. Her clinical and radiographic examinations showed no discernible issues. Like Nora, Veronica’s condition had initially been misdiagnosed as TMD. Consequently, she had undergone ineffective treatment with an oral appliance for years and relied on Ibuprofen for partial relief.

Diagnosis

In our practice, the diagnostic process involves a comprehensive assessment, encompassing a patient’s medical and dental history, physical examination, imaging, and, crucially, attentive listening. In the cases of both Nora and Veronica, it became evident that their conditions had been erroneously diagnosed as TMD. The actual culprit? Migraine.

While migraine is conventionally thought of as a “headache” condition, it’s common for sufferers to experience facial and jaw pain alongside head pain, as seen in Nora’s case. Less frequently, patients can endure facial pain exclusively, with no associated head pain, as observed in Veronica’s situation.

Migraine is remarkably prevalent, affecting approximately 12% of the American population. It manifests through recurrent headache episodes, characterized by a combination of the following features:

  • Unilateral location
  • Moderate-to-severe intensity
  • Pulsating quality
  • Aggravation with physical activity
  • Nausea and/or vomiting
  • Sensitivity to light and sound
  • Duration ranging from 4 to 72 hours
  • Aura (about one-third of migraine sufferers experience visual, auditory, sensory, etc., changes preceding the headache attack)

When we compared these migraine characteristics to the symptoms described by Nora and Veronica, it became evident that their primary issue was, in fact, migraine. Nora’s condition could be more specifically identified as “menstrual migraine” since her episodes coincided with her menstrual cycle. The presence of her TMJ noise was a misleading factor that had contributed to the misdiagnosis of TMD.

Treatment 

The treatment approach for both Nora and Veronica was quite similar. Firstly, we explained to each patient that they were experiencing migraine attacks and did not have significant temporomandibular disorders. Secondly, they were prescribed sumatriptan, a commonly used medication for aborting migraine attacks.

According to the Mayo Clinic, many individuals find that their headaches completely vanish after taking sumatriptan. Others discover that while their headaches may not entirely disappear, they become significantly less intense, allowing them to resume their normal activities despite some residual discomfort. Sumatriptan often alleviates other symptoms accompanying migraine headaches, such as nausea, vomiting, light sensitivity, and sound sensitivity. It’s important to note that it isn’t a general pain reliever like Ibuprofen or acetaminophen.

Nora and Veronica experienced consistent relief from their pain attacks with the use of sumatriptan, further confirming the diagnosis of migraine. They were subsequently referred to their primary care physicians for long-term management and maintenance of their sumatriptan prescriptions.

Identifying Non-TMD Jaw Pain

In my experience, around 5% to 10% of patients referred to our practice for pain aren’t suffering from TMD-related pain but rather conditions like facial migraine. Several key points in a patient’s history may suggest non-TMD jaw pain:

  • The Pain Is Not Influenced by Jaw Function: Musculoskeletal pains typically worsen when the affected joint or muscle is engaged. In the realm of jaw pain, conditions related to TMD tend to worsen during activities like chewing or wide-mouth opening. If jaw pain remains unaffected by these functions, it’s less likely to be associated with TMD.
  • The Pain Occurs in Cycles: Musculoskeletal pains typically don’t spontaneously turn on and off without any intervening symptoms. The presence of recurrent episodes or attacks suggests certain headache or nerve pain conditions.
  • The Pain Is Accompanied by Other Symptoms: While TMD often coincides with symptoms like TMJ noises, limited jaw range of motion, jaw locking, occlusal changes, or ear issues, non-TMD pains may present with a different set of symptoms. In the cases mentioned above, classic migraine symptoms – heightened light and sound sensitivity and nausea – were indicative of a migraine diagnosis.

Conclusion

Although the majority of jaw pain cases are linked to various musculoskeletal temporomandibular disorders (TMD), it’s crucial to remain vigilant for other potential pain sources. The two cases discussed here involve patients who endured migraine attacks for years, misdiagnosed as TMD and thus treated ineffectively. While we couldn’t turn back the clock for them, our expertise in diagnosis allowed them to look forward to a brighter future.

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