What is the differential diagnosis for a patient presenting with tooth pain and migraine symptoms?

Differential Diagnosis for Tooth Pain and Migraine Symptoms

When a patient presents with both tooth pain and migraine symptoms, the primary differential includes: dental pathology (pulpitis, periodontitis, cracked tooth), temporomandibular disorders (TMD), atypical odontalgia/persistent dentoalveolar pain, migraine with referred orofacial pain, post-traumatic trigeminal neuropathy, and trigeminal neuralgia. 1, 2, 3

Critical Diagnostic Framework

The key challenge is that dental pain and migraine frequently coexist and can mimic each other, making diagnosis complex. 4, 3 The anatomical overlap of trigeminal innervation means that migraine can present as tooth pain, and conversely, dental pathology can trigger or worsen migraine attacks. 1, 3

Primary Considerations

Dental Pathology (Most Common)

• Pulpitis/periapical disease: Localized to specific tooth, sharp pain with hot/cold/sweet stimuli, percussion tenderness, visible decay or restoration on examination 1
• Cracked tooth syndrome: Sharp pain on biting/chewing, difficult to localize, requires direct microscopic examination 5
• Periodontal disease: May share inflammatory mediators with migraine and potentially contribute to chronification 6
• Requires intraoral examination with good lighting, percussion testing, cold testing for pulpal vitality, and periapical radiographs 1, 5

Temporomandibular Disorders (5-12% of population)

• Bilateral or unilateral dull, aching pain in jaw/temple/ear region, aggravated by chewing or jaw movement 1
• Associated with jaw clicking, locking, muscle tenderness on palpation, limited mouth opening 1
• Highly comorbid with migraine and tension-type headache 1, 3
• Peak age 20-40 years, more common in women, linked to depression and catastrophizing 1

Migraine Presenting as Orofacial Pain

• Episodic throbbing pain that can be felt in teeth/jaw, lasting 4-72 hours 1, 7
• Must have nausea/vomiting OR photophobia AND phonophobia 2, 7
• Pain worsens with routine physical activity 7
• May have visual aura (scintillating lights, zigzag lines, scotomas lasting 5-60 minutes) 2
• Requires ≥5 lifetime attacks meeting these criteria 2, 7

Atypical Odontalgia/Persistent Dentoalveolar Pain (Neuropathic)

• Continuous burning, aching, or throbbing pain localized to tooth or tooth-bearing area without identifiable dental pathology 1, 5
• Predominantly affects women over age 30 in posterior teeth 5
• Pain persists despite appropriate dental treatment (root canal, extraction) 5, 3
• May have hyperesthesia in the affected area 1
• Critical pitfall: Leads to multiple inappropriate dental procedures that worsen the condition 8, 5, 3

Post-Traumatic Trigeminal Neuropathy

• Develops within 3-6 months of dental procedure or facial trauma 1
• Continuous burning, tingling, sharp pain in trigeminal distribution 1
• May have allodynia (pain from light touch) or other sensory changes 1
• History of poor analgesia during the inciting procedure is common 1

Trigeminal Neuralgia (Less Common)

• Unilateral, severe electric shock-like pain lasting seconds to minutes 1
• Triggered by light touch, washing face, cold wind, eating, brushing teeth 1
• Refractory period between attacks 1
• Responds to carbamazepine 1
• Requires MRI to exclude secondary causes 1

Diagnostic Algorithm

Step 1: Rule Out Dental Pathology First

• Perform intraoral examination with adequate lighting 1
• Cold testing of involved teeth for pulpal vitality 5
• Percussion testing for periapical inflammation 1
• Periapical radiographs of symptomatic teeth 5
• Dental panoramic tomograph if bony lesions suspected 1
• If dental pathology identified: Refer to dentist immediately 1

Step 2: Assess for Migraine Criteria

• Document attack frequency, duration (4-72 hours), and characteristics 1, 7
• Ask directly: "Do you feel like you have a headache of some type on 15 or more days per month?" to identify chronic migraine 1
• Implement headache diary to track attacks, associated symptoms, and medication use 1, 2, 7
• Look for unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine activity 7
• Document nausea/vomiting, photophobia, phonophobia 7
• Screen for aura symptoms (visual, sensory, speech disturbances lasting 5-60 minutes) 2, 7

Step 3: Evaluate for TMD

• Palpate muscles of mastication for tenderness and trigger points 1
• Assess temporomandibular joint for clicking, crepitus, limited opening 1
• Note if pain worsens with prolonged chewing or jaw movement 1
• Check for bruxism (tooth wear facets) 1

Step 4: Consider Neuropathic Pain if Dental Pathology Excluded

• Perform cranial nerve examination including sensory testing 1, 5
• Qualitative sensory testing for allodynia, hyperalgesia, or hypoesthesia 1
• Document history of dental procedures or trauma in the preceding 3-6 months 1
• Consider diagnostic nerve block to confirm neuropathic origin 8
• MRI brain if atypical features, progressive symptoms, or to exclude secondary causes 7, 5

Step 5: Screen for Red Flags Requiring Urgent Evaluation

• Giant cell arteritis: New-onset headache in patients >50 years with scalp tenderness, jaw claudication (check ESR/CRP, though ESR normal in 10-36% of cases) 1, 7
• Progressive pain: May indicate malignancy or space-occupying lesion 1
• Thunderclap headache: Subarachnoid hemorrhage (requires immediate CT) 7
• Focal neurological deficits: Stroke/TIA (requires urgent neuroimaging) 2, 7
• Fever with neck stiffness: Meningitis 7

Common Diagnostic Pitfalls

Performing irreversible dental procedures without confirming dental pathology is the most serious error—up to one-third of chronic facial pain patients have undergone prior unsuccessful dental procedures. 5, 3 Once dental treatment fails and pain persists, long-term complete pain relief occurs in <25% of patients. 5

Failing to recognize migraine-tooth pain overlap: Migraine can present as episodic throbbing tooth pain, and dentists remain largely unfamiliar with headache disorders. 4, 3 Conversely, physicians often miss dental causes of facial pain. 1

Misdiagnosing atypical odontalgia as dental disease: This neuropathic condition mimics toothache but has normal dental examination and radiographs. 1, 8, 5 Diagnostic nerve block is often the only way to confirm the diagnosis. 8

Overlooking medication overuse headache: If patient uses non-opioid analgesics ≥15 days/month or triptans/combination medications ≥10 days/month for ≥3 months, this represents medication overuse headache requiring different management. 7

Missing chronic migraine: Headache on ≥15 days/month for >3 months with ≥8 days meeting migraine criteria represents chronic migraine, which has substantially greater burden and requires prophylactic treatment. 1, 7

Management Approach

If dental pathology confirmed: Urgent dental referral for definitive treatment 1

If migraine diagnosed:

• Acute treatment with NSAIDs/acetaminophen for mild-moderate attacks, triptans for moderate-severe attacks 7
• Prophylactic treatment if chronic migraine (topiramate is the only agent proven effective in randomized controlled trials for chronic migraine) 1

If TMD diagnosed: Early reassurance, simple physiotherapy, and splints for nocturnal bruxism 1

If neuropathic pain (atypical odontalgia, post-traumatic trigeminal neuropathy): Neuropathic pain medications (gabapentin, tricyclics, topical anesthetics), cognitive behavioral therapy, avoid further dental procedures 1, 5

If diagnosis uncertain or treatment fails: Refer to multidisciplinary team including neurology, oral medicine, and pain medicine 1