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11 Articles in Volume 6, Issue #5
Clinical Pearls for Treating Headache Patients
Determining Which Low Level Laser to Use
Guidelines for Opioid Management of Pain
Interventional Therapies in the Continuum of Care
Lessons Learned from a Headache TMD Study
Potential Hazards of Vertebroplasty
Splenius Capitis Muscle Syndrome
The Moral Community of the Clinical Pain Medicine Encounter
Urine Drug Testing and Monitoring in Pain Management
Vitamin D Deficiencies in Pain Patients
Why Electromedicine?

Lessons Learned from a Headache TMD Study

A retrospective study of two groups of patients yields some insight into the relationship of TMD and headaches.

Headaches are among the most common complaints in primary medical practice with a subset of headache complaints from individuals who are experiencing a temporomandibular dysfunction (TMD). Such headaches have been found to be associated with both internal joint pathology and muscle disorders.

TMD is a disorder encompassing a group of signs and symptoms that are usually localized to areas of the head and neck. This disorder can include a number of distinct clinical conditions such as myalgia, myositis, internal derangements of the temporomandibular joint, arthritic disorders, and craniofacial pain and dysfunction of multiple origins. Signs and symptoms can include headache, ear, face, neck, and jaw pain. These individuals often present with a reduced range of jaw motion often accompanied with deviations of jaw motion and unusual temporomandibular joint (TMJ) sounds.

The pathology of this disorder usually involves dysfunction in the TMJ proper. The etiology may originate from problems associated with the TMJ components such as the capsule, the ligaments, or the supporting osseous structures. These TMJ components have demonstrated referral of pain to the head and cervical areas.1-5 Pain can arise from disorders in these structures and can also be directly associated with subsequent protective muscle splinting or bracing. Sustained muscle activity associated with this bracing reaction leads to discomfort in these muscle groups. Rasmussen, et al., showed that a rise in intra-muscular pressure with sustained muscle contraction leads to mechanical compression of blood vessels with a resulting local ischemia.6 Metabolic alterations due to microcirculatory disturbances can result in localized pain.7

Palpation of these jaw and joint parts has demonstrated referral of pain to other areas of the head and neck. As problems in the health of these muscle groups grow, connected neuro-networks manifest pain to remote sites. In his recently published teaching text, Wright suggests “TMD patients tend to hold more tension in their masticatory muscles.” He demonstrates this referral phenomenon of pain in the head and neck area with many other clinical cases cited for study.8 Travell and Simon mapped the surprising extent of muscle referral patterns in their often-cited text of 1983.9 In fact, the symptoms of headache in this study were found in five different sites, namely, the frontal, temporal, occipital, vertex, and retro-orbital areas of the head and the cervical area.

The literature is replete with reports of an association of headaches and TMD. Various researchers have recognized headaches as a common symptom in individuals with TMD10-14 and a number of studies have noted a link between complaints of headache and TMD.14 Dawson noted that many patients with TMD reported incidence of headache. He found that headaches of the temporal muscle region were often related to TMD.2 It was also suggested that occipital headaches might be related to occlusal disharmony—a disruption of the stability of the craniomandibular complex. Farrar found that headache is the most common reported symptom of TMD, especially with patients showing internal derangements or degenerative arthritis. These headaches manifest as pain in the frontal, temporal, retro-orbital, and occipital areas—sometimes even with ear pain.15


Patients were selected using specific criteria in order to be included in this study. First, after presenting for care, a diagnosis had to have been made of having a temporomandibular disorder. Secondly, the patient must have made a concurrent complaint of headache. The charts of 546 consecutive patients originally diagnosed with TMD were examined to determine if headache was listed as a complaint. Sixty-five of the original patients (11.9%) did not have any headache symptoms reported and were removed from this study. The remaining group of 481 (88.1%) patients had their records examined.

These were divided into two groups, those reporting a history of trauma involving the head or neck (TG) and those reporting no such history of a trauma to the head or neck (NTG). The TG consisted of 254 patients and the NTG contained the remaining 227 patients. The records of both groups were inspected retrospectively to establish the locations and frequency of occurrence of headache complaints.

Concurrent Number of Referred Headache Sites from TMD
# Referred Sites 1 2 3 4 5
Trauma Group (TG) 33 55 73 38 57
  13% 19.7% 29.9% 15% 22.4%
Non-Trauma Group (NTG) 89 70 41 24 3
  39.2% 30.8% 18.1% 10.6% 1.3%
Figure 1.

For our discussion, the pain of the cervical area was included and was designated as a cervical headache. A patient could have a headache in one area (ex. temporal) or in all five areas reviewed for this study. Headaches sites evaluated were the cervical, frontal, retro-orbital, temporal and vertex areas. Headache occurrence was charted as having one, two, three, four, or five specific sites per patient. Each patient’s combination of headache sites were noted. Thus, a patient having a headache at two sites (temporal and cervical) was different from another patient exhibiting pain in the retro-orbital and vertex sites. The total number of headache complaints per group, along with gender data, was tabulated and reviewed for trend assessment.


The TG was composed of 254 persons of which 195 were female (76.8%) and 59 were male (23.2%). This group reported a total of 589 headache complaints or 2.32 headaches per patient. In this TG, the temporal area accounted for 213 headache sites (83.9%) followed by 146 headaches of the cervical area (57.5%), then 141 in the frontal area (55.5%), then 104 in the retro-orbital areas (40.9%) and finally, 85 in the vertex area (33.5%).

The NTG consisted of 227 patients of which 182 were female (80.2%) and 45 were male (19.8%). This group had a total of 451 headache complaint sites or 1.99 complaints per patient. In this NTG, the temporal area again had the most frequent site noted at 168 or about (37.3%), followed by 99 in the retro-orbital areas (22.0%), then 82 in the cervical site (18.2%), then 70 in the frontal area (15.5%), and lastly, 34 in the vertex area (7.5%).

A comparison of number of referred sites per patient, as well as a frequency chart of the areas of referred pain for the trauma and non-trauma groups, are presented in Table 1 and Figure 1, respectively.


A retrospective analysis of data collected from TMD patient histories provides some insight in in the diagnosis of patients presenting with headache symptoms. This study suggests that:

  1. The incidence of headache can occur with nearly as much frequency in a non-trauma group of patients as with those sustaining a head or neck trauma. The frequency of patients seen in family practice with some level of dysfunction of the craniomandibular complex may be higher than expected.
  2. Consistent with prior epidemiological reports, the incidence of pathology of the craniomandibular complex, at least in this linear sample, is higher with females than it is with males, (see Figure 2).16 Some research is trying to understand this phenomenon. Miller et al., postulates that females have weaker muscles of mastication than do males, which could lead to more severe symptoms when these muscles become hyperactive in TMD.17
  3. It appears that headache symptoms originating from TMD will refer pain to more than one site. This is especially true with those having suffered a past trauma to the head or neck. This data is consistent with other reports by Romanelli.18
  4. The areas of the temporalis muscles display the highest incidence of headache. Then the location of headache frequency varies by the study groups. A site consistency does not exist between the study groups.

There appears to be more than just a casual correlation between reported headache and a diagnosis of TMD. Correlation between palpation of the craniomandibular complex and referral to headache sites cannot be dismissed, especially since the patterns of referred pain sites and headache sites were found to be consistent and predictable.

Practitioners should consider craniofacial pain’s propensity to refer pain to other sites when evaluating or treating patients for TMD. The results from this study may help the clinician determine areas of high probability for referred patterns of headache or neck pain.

Consider that 88.1% of the TMD starting sample showed signs of pain referred to areas of the head and neck. The temporalis area was most often cited. Further, 87% of the TG and nearly 61% of the NTG reported referral pain to more than one area. Upon a patient’s health history evaluation, a report of headache should be reason for the clinician to further evaluate the health of the patient’s craniomandibular complex. Even without a history of head and neck trauma, signs of headache are seen in a significant number of patients who were diagnosed with a TMD. It is thought that headache or neck pain can be a sequela to disorders of the jaw-joint complex.19 So it is not surprising that a report of headache or neck pain by a patient may lead to an abnormal finding in the health of the mechanics and function of the craniomandibular complex in a significant number of patients presenting for care.20

Figure 2.
Practical Tips in Diagnosing Headaches From TMD
  1. Consider TMD especially when a headache is in the temporal area.
  2. Multiple headache sites including the cervical area may indicate TMD.
  3. Patients with a history of whiplash or above-shoulder trauma frequently have TMD.
  4. Consider referral for a TMD evaluation when first line treatment fails.

While researchers will continue to argue which came first, the chicken or the egg, they can at least agree that where you find an egg there will be a chicken close by.


A charting review of 481 TMD patients who reported for treatment in a private practice setting demonstrates that a significant number of patients diagnosed with a temporomandibular disorder also show, upon examination, consistent referred headache or neck ache in multiple locations. TMD patients having a history of head or neck trauma, as well as those without such a history, both showed a high incidence of head and neck ache with the temporalis areas being the most affected.


Last updated on: May 16, 2011
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