What are the treatment options for headaches caused by Temporomandibular Joint (TMJ) disorder?

Treatment Options for Headaches Caused by TMJ Disorder

For headaches caused by temporomandibular joint (TMJ) disorder, strongly recommended first-line treatments include cognitive behavioral therapy, therapist-assisted jaw mobilization, manual trigger point therapy, supervised jaw exercises and stretching, and supervised postural exercise. 1

First-Line Treatment Options (Strong Recommendations)

The most recent and comprehensive clinical practice guideline from BMJ (2023) provides clear direction for managing TMJ-related pain, including headaches:

1. Cognitive Behavioral Therapy (CBT)

   • With or without biofeedback or relaxation therapy
   • Can be delivered remotely to reduce costs
   • Addresses psychological components that often accompany TMJ disorders

2. Physical Therapy Interventions

   • Therapist-assisted jaw mobilization: Gentle manipulation of the jaw to improve range of motion
   • Manual trigger point therapy: Targeting specific painful areas in the muscles of mastication
   • Supervised jaw exercises and stretching: Structured program to improve function
   • Supervised postural exercise: Addressing contributing factors from neck and upper back

3. Usual Care Package

   • Home exercises
   • Stretching techniques
   • Reassurance and education about the condition
   • Self-management strategies

Second-Line Treatment Options (Conditional Recommendations)

If first-line treatments are insufficient, consider these conditionally recommended options:

1. Manipulation techniques
2. Acupuncture
3. Combined approaches:
   • Jaw exercise with jaw mobilization
   • Manipulation with postural exercise
   • CBT with NSAIDs (non-steroidal anti-inflammatory drugs)

Not Recommended or Use with Caution

The guideline specifically recommends against several commonly used treatments:

1. Conditionally Against (benefits uncertain, potential harms):

   • Removable occlusal splints (night guards)
   • Arthrocentesis procedures
   • Botulinum toxin injections
   • Medications including gabapentin, benzodiazepines, and beta-blockers
   • Trigger point injections
   • Acetaminophen (with or without muscle relaxants)

2. Strongly Against (clear evidence of harm outweighing benefits):

   • Irreversible oral splints
   • Discectomy (surgical procedures)
   • NSAIDs combined with opioids

Special Considerations for TMJ-Related Headaches

TMJ disorders can present with headaches as a primary symptom 2, often misdiagnosed as migraines. Key considerations:

• Headaches from TMJ disorders may be accompanied by other symptoms like dizziness and tinnitus
• The relationship between TMJ dysfunction and headaches involves both myogenous (muscle-related) and arthrogenous (joint-related) components 3
• TMJ-related headaches typically present with:
  • Pain in temples, forehead, or behind the eyes
  • Pain that worsens with jaw movement
  • Associated jaw clicking, popping, or limited opening

Treatment Algorithm for TMJ-Related Headaches

1. Begin with strongly recommended conservative approaches:

   • CBT to address pain perception and management
   • Physical therapy focusing on jaw mobilization and trigger point therapy
   • Home exercise program with proper education

2. If inadequate relief after 4-6 weeks, add conditionally recommended treatments:

   • Acupuncture
   • Combined approaches (e.g., CBT with NSAIDs)

3. Avoid treatments with unfavorable risk-benefit profiles:

   • Splints (unless specifically indicated for bruxism)
   • Invasive procedures like arthrocentesis or surgery
   • Medications with significant side effects or addiction potential

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure TMJ disorder is correctly diagnosed as the cause of headaches rather than primary headache disorders
2. Overtreatment: Avoid jumping to invasive or irreversible treatments before trying conservative approaches
3. Underappreciation of psychological factors: TMJ disorders often have psychological components that need addressing
4. Reliance on splints alone: Evidence does not support splints as a primary treatment
5. Ignoring contributing factors: Poor posture, stress, and sleep disorders can perpetuate TMJ-related headaches

By following this evidence-based approach, most patients with TMJ-related headaches can achieve significant improvement without resorting to invasive or potentially harmful treatments.