Temporal Tendinitis Migraine Mimic
This article describes a very common headache disorder called temporal tendinitis1-7 which is often initiated by auto accident trauma and is complicated diagnostically by the intrinsic and extrinsic components of the temporomandibular joint (TMJ) and dental occlusion.
In pain management, diagnosis is key. Goethe’s maxim says “What ones knows, one sees.” Conversely, what one does not know, one does not see. When diagnosing, physicians look through a mental filter when viewing the patient. Appropriate and effective diagnosis and treatment of neck and head injuries requires both dental and medical knowledge in the areas of teeth, soft tissue, and TM joint function. If the patient has jaw joint pain and soft tissue pain, the clinician must determine which is primary and which is secondary in the diagnostic stream. In particular, it is crucial to first assess the condition of the jaw joint and its muscles and tendons before proceeding to equilibrate the teeth.
|Pain Reference Sites of Temporal Tendinitis
Intense, chronic head pain of questionable origin has been a dilemma for patients and doctors alike. The patient may often complain of pain and an aching sensation over the eye, behind the eye, radiating into the lateral temple over the ear, and into the occiput, or the rear of the head. The pain may radiate from the rear of the head into the neck, shoulder, back, as well as the arm and hand. The cheek and cheek-bone areas may be reported to be swollen along with aching and throbbing. The eye may feel sore and feel as if the eye ball is trying to pop out of the socket. With many patients suffering from temporal tendonitis,8-12 the ear, jaw joint, insertion of the stylomandibular ligament, and the upper and lower molar teeth may ache and throb. The range of vertical opening of the mouth may also be restricted due to the contracture of the injured temporal tendon. Another feature of temporal tendinitis is seen in some patients who do not seem to be able to close the back teeth together.1 This problem isapparently related to the inability of the injured tendon (splinting effect) to properly contract due to pain and inflammation.
When the headache is intense, the patient will often seek the help of analgesics and or sedatives to try to sleep off the headache. Often, the patient will go to a hospital emergency room in the evening hours seeking relief from the pain. When the exam is inconclusive, the patient is often treated as a classic migraine case. It is not unusual for the examining doctor, when confronted with temporal tendonitis, to suspect migraine headache since the history taken will often include a prodromal experience, severe headache, photophobia, nausea, and vomiting when the pain is at its worst. The pain may be hemicranial or bicranial depending on the degree of injury or degree of degenerative change at the tendon insertion zone. However, the E.R. doctor will not likely know about temporal tendinitis, nor will he know that it is known in the Craniofacial pain field as “the Migraine Mimic" (coined by the author in 1983).
Materials and Methods
The temporal muscle (see Figure 1) is fan-shaped at its origin on the temporal bone of the skull and occupies most of the lateral surface. The muscle is divided into anterior, middle, and posterior fibers; and is typically composed of two tendon insertions. The short tendon, or lateral head, inserts on the coronoid process, while the long tendon, or medial head, inserts at the base of the ascending ramus of the mandible. Though both tendons are clinical pain entities, this paper’s focus is the short tendon and its attachment on the coronoid process and its tip (see Figure 2) where insertion tendinosis occurs. The standard or protocol to determine whether the patient actually exhibits temporal tendinitis is to palpate (see Figure 3) the insertion of the tendon at the coronoid process of the mandible. Pressure should increase the intensity of pain suffered by the patient (see Figure 4), and should exacerbate the reference sites in pain intensity as well. If the provocation of the headache pain with digital pressure is successful, then local anesthetic infiltration at the medial surface is accomplished with a very slow rate of injection, about ½ cc per minute (see Figure 5). If the pain is remitted while anesthetized, then the slow injection rate may help to mediate what will likely be a painful post-injection flare experience, if insertion tendinosis is present. Insertion tendinosis13 means that there is cellular focal necrosis and the tendinitis will not have the capacity to heal with non-surgical management.
If the injection of local anesthetic temporarily eliminates the painful complex of symptoms, then a cortisone preparation or sarapin injectible is infiltrated medial to the tendon. Avoid actually inserting the needle into the tendon sheath, as this will be a very painful experience for the patient and will exacerbate any post-injection flare that may result from the injection. If the TMJ pain and/or stylomandibular ligament pain is present prior to the injection but is at least temporarily remitted with the block, then the contracted temporal tendon has loaded the TM joint and the stylomandibular ligament. The loading effect has created pain in these areas and may simply be secondary reactive sites, rather than primary sites of injury.
Do not attempt to equilibrate at this point until the painful symptoms have abated, and you have proved that the dentition is the primary etiology. The proving of this may be difficult as there may be a primary TM joint problem, a primary temporal tendon problem, etc; sorting out the symptoms may prove a challenge even to the most experienced diagnostician. If one equilibrates a primary temporal tendon problem created by auto accident trauma or some other trauma incident, then one will have removed enamel that the patient may well need when the pain of temporal tendinitis is solved.