What are the differential diagnoses and appropriate work‑up and management for concurrent jaw and neck pain?

Concurrent Jaw and Neck Pain: Differential Diagnosis and Management

Exclude Life-Threatening Conditions First

In any patient over 50 years old presenting with jaw and neck pain, giant cell arteritis must be immediately excluded with ESR and CRP testing, as this is a vision-threatening emergency requiring high-dose corticosteroids within 2 weeks to prevent blindness. 1, 2

• The American College of Rheumatology mandates distinguishing giant cell arteritis from temporomandibular disorders in all patients over 50 with temporal or jaw pain 1
• The British Society for Rheumatology requires immediate temporal artery biopsy for suspected cases 1
• Cancer (primary oral malignancy or metastatic disease) must be considered in patients with progressive neuropathic jaw pain, particularly in older adults 1

Most Common Diagnoses by Likelihood

Temporomandibular Disorders (TMD) - Most Common Non-Dental Cause

TMD is the most common non-dental cause of chronic jaw pain and frequently causes referred neck pain due to pathophysiological links between the cervical spine and masticatory system. 3, 1

• The American Academy of Orofacial Pain identifies TMD as the primary non-dental etiology, typically involving muscles of mastication unilaterally or bilaterally 1
• Suspect TMD strongly if the patient has at least 2 of the following: history of treated/untreated TMD, unilateral temporomandibular joint pain with clicking, lateral deviation during mouth opening, or mouth opening limited to less than three fingerbreadths 4
• Pain patterns suggestive of TMD include nocturnal arousals, triggering by temporomandibular movements, and suboccipital pain refractory to conventional treatment 4
• Occlusal disorders have an estimated prevalence of 45% and may cause neck pain that responds to dental treatment 4

Acute Dental Pathology

• The American Dental Association states acute dental pain is the most common overall cause of jaw pain, typically presenting unilaterally 1
• Intraoral X-rays are required to exclude dental problems before diagnosing atypical odontalgia or persistent dentoalveolar pain 3

Cervical Spine Disorders with Referred Pain

• Chronic non-specific neck pain affects a large population, with jaw opening naturally associated with neck extension and jaw closing with neck flexion 5
• Minor repeated masticatory dysfunction with craniocervical asymmetry commonly presents as suboccipital pain refractory to conventional treatment 4
• Nearly 50% of individuals with acute neck pain will continue experiencing some degree of pain or frequent occurrences 6

Diagnostic Work-Up Algorithm

History Red Flags to Identify

• Age over 50 with new-onset pain: Check ESR/CRP immediately for giant cell arteritis 1, 2
• Progressive neuropathic pain: Consider cancer 1
• Sharp, electric shock-like pain triggered by light touch (brushing teeth, washing face): Trigeminal neuralgia requiring MRI to exclude MS, tumors, or neurovascular compression 3, 7
• Continuous burning pain with allodynia: Post-herpetic neuralgia or post-traumatic trigeminal neuropathy 3
• Neurological symptoms (diplopia, vision loss, weakness): Myelopathy, stroke, or MS 7, 6

Physical Examination Specifics

• Assess mouth opening (should be ≥3 fingerbreadths); limitation suggests TMD 4
• Check for lateral deviation during mouth opening 4
• Palpate temporomandibular joints for clicking, tenderness, or crepitus 3
• Test for light touch-evoked pain in trigeminal distribution (suggests trigeminal neuralgia) 3
• Examine temporal arteries for tenderness, absent pulse, or nodularity (giant cell arteritis) 3
• Assess neck range of motion and cervical spine tenderness 6

Imaging Strategy

• MRI of TMJ: Gold standard for disc and ligament assessment in TMD 1
• CT or CBCT: Gold standard for bony TMJ pathology 1
• MRI brain: Required for trigeminal neuralgia to exclude MS, tumors, or neurovascular compression 7
• MRI cervical spine: Consider for radiculopathy, myelopathy, or pain refractory to conventional treatment 6

Pain Assessment Tools

• Use Brief Pain Inventory, McGill Pain Questionnaire, or Beck Depression Inventory for comprehensive evaluation, as psychological comorbidities are common in chronic TMD 3

Management Based on Diagnosis

TMD Management (Most Relevant for Concurrent Jaw-Neck Pain)

For chronic TMD pain, the BMJ strongly recommends conservative treatments and advises against irreversible interventions like discectomy or irreversible oral splints. 3

• NSAIDs are recommended for initial management 3
• Cognitive behavioral therapy is effective for persistent dentoalveolar pain and burning mouth syndrome 3
• Integrating jaw opening/closing movements with active neck exercises is significantly more effective than neck exercises alone, showing 73% improvement in pain, 57% improvement in disability, and 152% improvement in neck flexion endurance 5
• Avoid: Discectomy, irreversible oral splints, and NSAIDs combined with opioids due to important harms 3

Trigeminal Neuralgia

• Carbamazepine is first-line treatment 2, 7
• Oxcarbazepine or lamotrigine (for SUNA/SUNCT variants) are alternatives 3, 7
• Critical: Pain is unresponsive to standard analgesics; anticonvulsants are required 7
• Neurosurgery for refractory cases 2

Neuropathic Pain Syndromes

• Post-herpetic neuralgia and post-traumatic trigeminal pain require neuropathic pain medications (gabapentin, pregabalin, tricyclic antidepressants) 3
• Burning mouth syndrome: Reassurance, education, CBT, and possibly neuropathic pain medications 3

Cervical Spine-Related Pain

• Exercise treatment is beneficial for neck pain 6
• Muscle relaxants for acute neck pain with muscle spasm 6
• Physical therapy and short-term corticosteroid therapy for musculoskeletal origins 8

Common Pitfalls to Avoid

• Do not diagnose "sinus headache": 68-95% of self-diagnosed sinus headaches are actually migraine or tension-type headache 2
• Do not delay giant cell arteritis work-up: Vision loss is irreversible if treatment is delayed beyond 2 weeks 1
• Do not perform irreversible TMD treatments: Discectomy and irreversible oral splints cause important harms without proven benefit 3
• Do not use standard analgesics for trigeminal neuralgia: These are ineffective; anticonvulsants are required 7
• Do not overlook masticatory dysfunction: Rheumatologists should consider MD in patients with abnormal craniocervical posture and signs linking neck pain to mastication 4