What is the workup for a patient presenting with headache and temporomandibular (TMJ) pain?

From the Guidelines

A comprehensive workup for headache and jaw pain should begin with a detailed medical history and physical examination, focusing on the characteristics of the pain, including location, intensity, duration, and triggering factors, as recommended by the most recent guidelines 1. The healthcare provider will assess the characteristics of the pain, including location, intensity, duration, and triggering factors. For headaches, they may classify it as primary (like tension, migraine, or cluster headaches) or secondary (resulting from another condition). For jaw pain, they'll evaluate for temporomandibular joint disorder (TMJ), dental issues, or referred pain. Diagnostic tests may include blood work to check for inflammation or infection, imaging studies such as X-rays, CT scans, or MRIs to visualize structures, and possibly a dental examination. Treatment depends on the underlying cause but might include pain relievers like acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-600mg every 6-8 hours), muscle relaxants, stress management techniques, physical therapy, or dental interventions such as night guards for teeth grinding, with a strong recommendation in favor of cognitive behavioral therapy (CBT) with or without biofeedback or relaxation therapy, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise, supervised jaw exercise and stretching with or without manual trigger point therapy, and usual care 1. Some key points to consider in the workup and management include:

• The importance of a detailed medical history and physical examination
• The classification of headaches and jaw pain into primary and secondary causes
• The use of diagnostic tests such as blood work and imaging studies
• The consideration of treatment options including pain relievers, muscle relaxants, and dental interventions
• The strong recommendation for cognitive behavioral therapy (CBT) and other non-pharmacological interventions Patients should seek immediate medical attention if headache or jaw pain is severe, sudden, accompanied by neurological symptoms, follows head trauma, or occurs with fever, as these could indicate serious conditions requiring urgent care, as highlighted in the clinical question 1. Understanding the connection between these symptoms is important as they often share common mechanisms like muscle tension, nerve pathways, or referred pain patterns, and current clinical practice guidelines are largely consensus-based and provide inconsistent recommendations 1. The guideline panel issued strong recommendations in favor of several interventions, including CBT, therapist-assisted mobilisation, and supervised jaw exercise and stretching, and conditional recommendations in favor of others, such as manipulation and acupuncture 1. Overall, the workup and management of headache and jaw pain require a comprehensive and multidisciplinary approach, taking into account the latest evidence and guidelines, as emphasized in the BMJ Rapid Recommendation article 1.

From the Research

Workup for Headache and TMJ Pain

• The workup for a patient presenting with headache and temporomandibular (TMJ) pain should include a comprehensive assessment of both conditions, as they are often related 2.
• Imaging of the TMJ may be necessary if there is marked limitation of opening, and treatment should include education on limiting jaw function, appliance therapy, instruction in jaw posture, and stretching exercises, as well as medications to reduce inflammation and relax the muscles 2.
• Conservative therapeutic modalities, such as occlusal splints, laser, and photobiomodulation therapy, have been shown to be effective in reducing TMD pain 3.
• Imaging modalities, including MRI, CT, cone beam CT, ultrasonography, and conventional radiography, can be used to diagnose and manage TMD, with MRI being the gold standard for imaging soft tissue components of the TMJ 4.

Treatment Options

• Treatment options for TMJ pain and headache may include:
  • Appliance therapy, such as a nocturnal bite splint 5
  • Intra-articular injections of substances with anti-inflammatory properties, such as betamethasone, sodium hyaluronate, or platelet-rich plasma 5
  • Physical therapies, such as spray and stretch and trigger point injections 2
  • Medications, such as tricyclic antidepressants and new-generation antiepileptic drugs, to reduce inflammation and relax the muscles 2
  • Manual therapy, such as Mulligan manual therapy, to address cervical spine impairments and craniocervical muscle control and endurance 6

Diagnostic Considerations

• The diagnosis of TMD and headache should be based on a comprehensive assessment of the patient's symptoms and medical history, as well as imaging and other diagnostic tests 4.
• The International Headache Society guidelines can be used to diagnose and classify headache disorders, including migraine and cervicogenic headache 6.
• The Research Diagnostic Criteria for TMD and the Diagnostic Criteria for TMD can be used to diagnose and classify TMD 3.