Non-Odontogenic Sources of Tooth Pain: Demystifying the Mystery of Phantom Tooth Pain

4/23/21

SEENA PATEL DMD, MPH ASSOCIATE PROFESSOR, ASSOCIATE DIRECTOR OF ORAL MEDICINE ARIZONA SCHOOL OF DENTISTRY & ORAL HEALTH, A.T. STILL UNIVERSITY, MESA, AZ SOUTHWEST OROFACIAL GROUP, PHOENIX, AZ DIPLOMATE, AMERICAN BOARD OF ORAL MEDICINE DIPLOMATE, AMERICAN BOARD OF OROFACIAL PAIN

Financial Disclosure

u I have no financial conflicts of interest to disclose.

Objectives

u Describe the non-odontogenic sources of tooth pain u Implement diagnostic techniques in the evaluation of non-odontogenic tooth pain u Successfully manage each type of non- odontogenic tooth pain

1 4/23/21

Why is it important?

Courtesy of Dr. Brad Gettleman 5

Mr. Jones, 80 yo male: “I feel like I have a headache in my tooth.”

Pain History u Step 1: Rule out dental causes Onset A few weeks prior to this consultation Location Lower right jaw, #30 area Quality Dull ache, throbbing Intensity 4/10 Frequency/duration Daily, constant May 28th, 2020 6/4/2020 Modifying factors Chewing worsens pain, Vicodin helps

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Exam Findings

u MSK palpations: all 0 pain level EXCEPT the right superficial masseter which radiates downward u TMJ noises: crepitus on right

u CBCT: mild osteoarthritis of the right TMJ

Patient report complete pain relief.

Dx: myofascial pain-induced toothache Diagnostic trigger point injection

Pain Mechanisms: Terminology

u Afferent nerve fibers: u Nociception u A-beta u Pain

u A-delta u Suffering u C fibers u Pain behavior

u Silent nociceptors

Pain Mechanisms: Nociception

u Trigeminal nerve: sensory input to the anterior head and intraoral structures

u Trigeminal nucleus: sensory processing center in the CNS

u Trigeminal spinal tract nucleus: u Subnucleus oralis, interpolaris, and caudalis

u Subnucleus caudalis: nociceptive specific, wide dynamic range neurons, and low-threshold mechanoreceptors

u Wide Dynamic Range Neurons u Receive convergent sensory input from primary afferent nociceptors and low-threshold mechanoreceptors u Can lead to expansion of receptive fields and cause radiation of pain

Merrill RL. Central mechanisms of orofacial pain. Dent Clin North Am. 2007;51(1):45-59. ! 9

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Nociceptive Pain

1) Why does pain become chronic?

! Hargreaves et al. Orofacial pain: Peripheral mechanisms. In Fricton JR and Dubner RB (eds): Orofacial Pain and Temporomandibular Disorders. New 2) Why can pain York: Raven Press, 1995: 36. occur without a local cause?

First-order neurons

Merrill RL. Central mechanisms of orofacial pain. Dent Clin North Am. 2007;51(1):45-59. Second-order neurons 11

Peripheral and Central Sensitization

-Expansion of receptive fields -Activation of NMDA receptors -Decreased inhibition

Allodynia Hyperalgesia Chronic Pain 12

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Sensitization and Convergence

https://pocketdentistry.com/introduction-to-orofacial-pain/ 13

The Challenges of Non-Odontogenic Toothache

u How do we deal with these challenges?

u ALWAYS ensure an accurate diagnosis

u Know the different types of pain:

u Nociceptive Protective pain u Inflammatory

u Neuropathic Chronic pain u Dysfunctional

International Classification of Orofacial Pain, 1st edition (ICOP)

u 1) Orofacial pain attributed to disorders of dentoalveolar and anatomically related structures

u 2) Myofascial Orofacial Pain u 3) Temporomandibular joint pain u 4) Orofacial pain attributed to lesion or disease of the cranial nerves u 5) Orofacial pains resembling presentations of primary headaches u 6) Idiopathic Orofacial Pain

International Classification of Orofacial Pain, 1st edition (ICOP). (2020). Cephalalgia, 40(2), 129–221. https://doi.org/10.1177/0333102419893823 15

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Odontogenic

Cardiac pain referral Musculoskeletal

Sinus pain referral Neuropathic

Neurovascular

Step 1: Rule out local causes

Pulpal, Periodontal, Gingival Oral mucosal, salivary gland, alveolar

Step 2: Check for other sources of infection in the surrounding region

Sinus infection Ear infection

Step 3: Check for myofascial sources of pain

Trigger points Joint pain

Step 4: Check for neuropathic sources

Neuralgia PTTN

Step 5: Check for neurovascular sources Orofacial migraine Trigeminal autonomic orofacial pain 17

Case 1: 35 yo female with pain on #10

u Subjective: “pressure-like pain around #10” Trauma to the • Describes face, a mild subsequent tenderness observation to #10

•Pain Endo #1 persists

Endo #2 •Pain persists

Extraction and implant

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Pain History

Onset 18 years ago Location #10 u Medical History: Quality Severe pressure unremarkable Frequency Began episodically, now daily u ROS: unremarkable Attack duration Constant u Sleep Hx Severity 9/10 u Family Hx Ameliorating factors Ibuprofen u Social Hx Exacerbating factors Bruxism u Habits Associated symptoms L TMJ clicking, day- and night-time parafunctional habits Wakes with her jaw clenched

Diagnostic Process

Exam

Imaging

Diagnostic tests

Accurate Diagnosis 20

Musculoskeletal examination

Anterior and MedialUpper and and Lateral TemporalisSternocleidomastoidSuperficialPosterior Tendon shoulderDeepPterygoids Masseter trapezius TemporalisMasseter

4 lbs of pressure

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TMJ examination

u Examination of the TMJs

u A) Palpation: 2 lbs of pressure

u Lateral side u Dorsal side

u B) Range of motion u Pain-free, active, passive

u Lateral movements

u C) Joint sounds

u Single vs. reciprocal click 2 lbs of pressure u Crepitus

Case R L Lateral 3 3 Report: Condyle (TMJ) Exam Dorsal 2 3 Findings Condyle Superficial 3 3 (referred Masseter down the jaw) Anterior 3 3 (referred temporalis down the head, into her anterior teeth; replicated her CC) SCM 3 3 Upper trap 3 3 Shoulder trap 3 3 23

Case Report: Exam Findings

Range of motion Pain-free 27 mm Passive 40 mm, pain on left superficial masseter, soft-end feel Protrusive 8 mm R Lateral 11 mm L Lateral 12 mm

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Musculoskeletal Sources

u Myofascial Pain: u Regional pain disorder characterized by localized muscle tenderness and limited range of motion

u Defined by the presence of myofascial trigger points u Masticatory muscle involvement can be a source of tooth pain

u Described as dull, achy, tiring, deep, pressure-like

Kim ST. Myofascial pain and toothaches. Aust Endod J 2005;31(3):106-110. 25

Myofascial Pain

u Clinical Features:

u Spontaneous dull, aching pain and localized tenderness u Muscle stiffness

u Sustained muscle function causes fatigue easily u Upon palpation: hyperirritable spot within a taut band that exhibits referral u Trigger point (TP): motor endplate with spontaneous firing

u Decreased ROM u Weakness w/o atrophy or neurological deficit

Fricton J. Myofascial Pain: Mechanisms to Management. Oral Maxillofac Surg Clin North Am. 2016;28(3):289-311. 26

Muscle referral patterns: Masseter

Simons DG, Travell JG, Simons LS. Travell & Simons’ myofascial pain and dysfunction: the trigger point manual: upper half of body (Vol. 1). Philadelphia: Lippincott Williams & Wilkins, 1999. 27

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Muscle referral patterns: Temporalis

Muscle referral patterns: medial pterygoid

Muscle referral patterns: lateral pterygoid

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Muscle referral patterns: digastric

Myofascial Pain

u Causation: u Direct muscle trauma

u Adverse effect of medication u Secondary pathology-induced trismus

u Parafunctional habits u Stress-induced hypoperfusion

u Secondary neurogenic effects

Fricton J. Myofascial Pain: Mechanisms to Management. Oral Maxillofac Surg Clin North Am. 2016;28(3):289-311. Graff-Radford SB & Bassiur JP. Temporomandibular disorders and headaches. Neurol Clin. 2014;32(2):525-537. 32

Diagnostic Tests

u A trigger point is a hyperirritable within a taut band of skeletal muscle that is not only painful upon palpation but can cause referred pain and autonomic phenomena

Kim ST. Myofascial pain and toothaches. Aust Endod J 2005;31(3):106-110. 33

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Trigger Point Injection: Superficial Masseter

Orthotics Treatment • Flat, hard acrylic stabilization splint • May consider a day-time splint if needed Plan Pharmacologic • Muscle relaxant: cyclobenzaprine, methocarbamol, metaxalone, baclofen, chlorzoxazone, tizanidine *Often involves a • Adjuvant analgesics: serotonin modulators (TCAs, SNRIs) multidisciplinary Interventional approach • Series of trigger point injections

Physical medicine, Lifestyle Education • Home-based myofascial and avoidance protocols • Physical therapy

Kreiner M, Betancor E, Clark GT. Occlusal stabilization appliances. Evidence of their efficacy. J Am Dent Assoc. 2001;132(6):770-777. De Rossi SS, Greenberg MS, Liu F et al. Temporomandibular disorders evaluation and management. Med Clin NM 2014;98(6):1353-1384. 35

Case 2: 57 yo male with an electric, shock- like pain on #30

Pain History Onset May 2013 Location LR, #30 Quality Sharp, stabbing, electric-shock

Frequency Daily, several attacks in a day

Duration 1-2 seconds (bursts, jolts) Severity 10/10 Ameliorating factors Not moving the jaw

Exacerbating factors Chewing, talking, brushing

Associated Symptoms Pain radiates into the tongue, chin, sinus

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Exam findings

Musculoskeletal exam

TMJ exam Dental exam

Cranial nerve exam Imaging

Shintaku W, Enciso R, Broussard J, Clark GT. Diagnostic imaging for chronic orofacial pain, maxillofacial osseous and soft tissue pathology and temporomandibular disorders. Calif Dent Assoc. 2006;34(8):633-44. 37

Trigeminal Neuralgia (TN)

u IASP defines TN: u “Sudden, usually unilateral, severe, brief, stabbing, recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve” u Annual incidence: 4-5/100,000 people u Classical vs. Symptomatic vs. Idiopathic

Gronseth G, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008;71(15):1183-1190. 38

Diagnostic criteria: Trigeminal Neuralgia

u A. Recurrent paroxysms of unilateral facial pain in the distribution(s) of one or more divisions of the trigeminal nerve, with no radiation beyond, and fulfilling criteria B and C u B. The pain has all the following characteristics:

u Lasting from a fraction of a second to 2 minutes

u Severe intensity

u Electric shock-like, shooting, stabbing or sharp in quality

u C. Precipitated by innocuous stimuli within the affected trigeminal distribution u D. Not better accounted for by another ICOP or ICHD-3 diagnosis.

International Classification of Orofacial Pain, 1st edition (ICOP). (2020). Cephalalgia, 40(2), 129–221. https://doi.org/10.1177/0333102419893823 39

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Clinical features

u Pain can also occur spontaneously 20%

u May have a perioral or intraoral 45% trigger

u May be accompanied by 35% hypoesthesia, hypoalgesia, or hyperalgesia

u Presence of a refractory period Zakrzewska 2014 40

• MRI of the brain Diagnosis • American Academy of Neurology + European Federation of Neurological Societies 2008 guideline

• Up to 15% of patients with TN may have a Imaging: MRI structural cause

• Trial of anti-convulsant: carbamazepine Clinical Medication • Differentials: cracked tooth, other cranial neuralgias, painful, post-traumatic trigeminal neuropathy, trigeminal neuropathy due to herpes zoster, TN persistent idiopathic facial pain, trigeminal autonomic cephalgia

u Usually affects individuals in their 5th decade or higher. Maarbjerg S, Di Stefano G, Bendtsen L et al. Trigeminal neuralgia- diagnosis and treatment. Cephalalgia. 2017; 37(7):648-57. 41

Etiology & Mechanisms

u Primary (Classical) vs. Secondary Spontaneous action Partial nerve Axonal potentials and injury demyelination u 1) Intracranial vascular ephaptic compression/abrasion of the CN V nerve cross-talk root

u Usually the superior cerebellar artery

u 2) Neural damage due to multiple sclerosis

u 3) Neural compression due to an intracranial tumor

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Secondary Trigeminal Neuralgia due to Acoustic Neuroma

Primary Trigeminal Neuralgia: Natural History

u The good news? u There may be periods of unpredictable, complete remission (months to years)

u The bad news? u Over time, the disorder may become progressive and potentially refractory to treatments

Management

u 1) Order appropriate diagnostic tests: imaging, lab evaluation, ECG

u 2) Medical treatment u 1st line: sodium channel blockers (carbamazepine, oxcarbazepine)

u May consider add-on treatment: lamotrigine, baclofen, pregabalin, gabapentin, zonisamide, levetiracetam

u 3) Surgical treatment u 4) Botox?

Maarbjerg S, Di Stefano G, Bendtsen L et al. Trigeminal neuralgia-diagnosis and treatment. Cephalalgia. 2017; 37(7):648-57. 45

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Surgical treatment

Botox

u Affects the release of neurotransmitters and neuromodulators

u Acetylcholine u Botox type A is the most studied type

u Indications:

u 1970s: strabismus, blepharospasm, focal dystonia

u Today: Chronic Migraine, overactive bladder, urinary incontinence, cervical dystonia, spasticity, and severe axillary hyperhidrosis

u Full recovery: 90 days

Moreau N, Dieb W, Descroix V et al. Topical Review: Potential Use of Botulinum Toxin in the Management of Painful Posttraumatic Trigeminal Neuropathy. J Oral Facial Pain Headache. 2017;31(1):7-18. 47

Botox for Trigeminal Neuralgia

Wu C, Lian Y, Zheng Y et al. Botulinum toxin type A for the treatment of trigeminal neuralgia: results from a randomized, double- blind, placebo-controlled trial. 2012. Cephalalgia;32(6):443-50.

Treatment group: Botox type A, 75 U/1.5 mL (21 patients)

Control group: Saline, 1.5 mL (19 patients)

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u Trigeminal neuropathic pain attributed to herpes zoster u Trigeminal postherpetic Trigeminal neuralgia u Post-traumatic trigeminal Neuropathic neuropathic pain Pain u Trigeminal neuropathic pain attributed to other disorder u Idiopathic trigeminal neuropathic pain

Case 3: 69 yo Caucasian female presents with persistent pain on #18

Pain History Dental History Onset 1 year ago 1 year prior: diagnosed with irreversible pulpitis #18 Quality Primarily achy, sometimes Endodontic treatment initiated. throbbing Pain persisted. Frequency Daily Retreat performed 2 months later. Duration Constant Pain persisted. Slightly worsened. Intensity 2-3/10; can increase to 7-8/10 Extraction performed. Pain worsened. Ameliorating factors None #19 was then endodontically treated. No change in symptoms. Exacerbating factors Chewing, touching the site Referral to orofacial pain.

Post-Traumatic Trigeminal Neuropathic Pain

1974: 2000: 1932: Atypical Facial 1947: Atypical Idiopathic 1977: Atypical Trigeminal Neuralgia Facial Pain Odontalgia periodontalgia Neuropathy

2005: Persistent 2011: Chronic ~2016: Painful 2020: Post- dentoalveolar pain, continuous post-traumatic traumatic persistent idiopathic facial dentoalveolar trigeminal trigeminal pain pain neuropathy neuropathic pain

IASP definition: Pain caused by a primary lesion or dysfunction in the nervous system • Absence of a noxious stimulus • Does not serve any biological function • Can be intense and out of proportion to the degree of stimulation • Quality: bright, stimulating, burning, tingling • Pain is unresponsive to NSAIDs and opioids (relatively)

Clark GT. Persistent orodental pain, atypical odontalgia, and phantom tooth pain: when are they neuropathic disorders? J Calif Dent Assoc; 2006;34(8):599-609. International Classification of Orofacial Pain, 1st edition (ICOP). (2020). Cephalalgia, 40(2), 129–221. https://doi.org/10.1177/0333102419893823 51

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Episodic Continuous

Sudden bursts of electric-like, sharp, Continuous or almost continuous shooting pains pain in tooth or tooth site

Unilateral distribution No obvious local cause and a negative clinical examination

Short duration Constant pain of moderate intensity

Pain cannot be triggered during Associated with hyperesthesia refractory period (tender to finger pressure)

Usually not associated with referred Nonresponsive to analgesics, pain or autonomic effects surgery, and dental procedures

No history of evidence of significant psychopathology

Normal radiographs 52

Neuropathy/Sensory Disorders

u BMS

u Chronic trigeminal neuropathy

u IAN Injury (implants)

u Auriculotemporal neuropathy (non- inflammatory TMJ pain)

u Myofascial Pain

u Occlusal Dysesthesia

u Atypical trigeminal neuralgia

u Persistent idiopathic facial pain

u Numb chin syndrome

u CDH (Cmig, MOH, CTTH) ! u PHN, DN, Sinus Neuropathic Pain

Post-traumatic trigeminal neuropathic pain

Description: Unilateral or bilateral facial or oral pain following and caused by trauma to the trigeminal nerve(s), with other symptoms and/or clinical signs of trigeminal nerve dysfunction and persisting or recurring for more than 3 months. -Pain in in the trigeminal nerve distribution persisting or recurring >3 months -Hx of mechanical, thermal, radiation or chemical injury to the peripheral trigeminal nerve -Diagnostic confirmation of a lesion of the peripheral trigeminal nerve explaining the pain -Onset within 3-6 months after the injury -Associated with somatosensory symptoms and/or signs in the same distribution 54

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Who does it affect?

u Primarily women between 45-50 years or older u Posterior teeth u Risk factors: u Persistence and duration of pain before endodontic/surgical treatment u Percussion sensitivity before treatment u Hx of chronic pain problems u Type of treatment rendered u Fear/Catastrophic attitude

Case Report:

u 69 yo female Clark 2006, Polycarpou et al. 2005, Baad-Hansen u Hx of Chronic Pain: fibromyalgia, irritable bowel syndrome, interstitial cystitis & Benoliel 2017 55

Causes?

u Traumatic peripheral nerve damage u Deafferentation

u Systemic abnormalities Case Report: u Metabolic disease Endodontic therapy? Extraction? *Traumatic nerve injury u Neurotropic viral disease u Neurotoxicity

u Autoimmune diseases u Idiopathic

Clark GT. Persistent orodental pain, atypical odontalgia, and phantom tooth pain: when are they neuropathic disorders? J Calif Dent Assoc; 2006;34(8):599-609. 56

Pathophysiology

u Nociceptive impulse àsecond-order neuron in the trigeminal subnucleus caudalis u Pain perception leads to a protective response: u Allodynia Wide Dynamic Range Neurons u Hyperalgesia Nociceptive Specific Neurons Low-Threshold Mechanoreceptors

u Peripheral and Central Sensitization !

Merrill RL. Central mechanisms of orofacial pain. Dent Clin North Am. 2007;51(1):45-59. 57

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How does one diagnose PPTN?

uHistory uClinical examination uDiagnostic tests

Phase 1

Phase 2

Phase 4 Phase 3

Neurosensory Tests: Extraoral

Static vs. Dynamic Allodynia

Video Courtesy of Dr. Rich Cohen and Dr. Arthur Levy 60

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Neurosensory Tests: Intraoral

Video Courtesy of Dr. Rich Cohen and Dr. Arthur Levy 61

Topical anesthetic testing

¡ 3 applications (at 1-2 min intervals), pain goes from 2- 3/10 to 0/10

Local nerve block test

¡ IA/L nerve block with 2% lidocaine, 1:100,000 epi

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64 Clark 2006

Topical Medication

u Neurosensory shield u Topical anesthetic: 20% benzocaine gel, Orabase, Orajel

u Compounded medications: u Heir G et al. 2008: carbamazepine 4%, lidocaine 1%, ketoprofen 4%, ketamine 4%, and gabapentin 4% u Capsaicin 0.025%-0.1%

u 31.6%: complete remission of pain

Heir G, Karolchek S, Kalladka M et al. Use of Topical Medication in orofacial neuropathic pain: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:466-9. Padilla M, Clark GT, Merrill RL. Topical medications for orofacial neuropathic pain: a review. J Am Dent Assoc. 2000;131(2):184-195. 65

Case Management

u Topical application relieved pain 80% u IA/L block with 2% lidocaine 1:100,000 relieved pain completely

u Neurosensory stent

u Capsaicin 0.025% compounded with orabase

Initial pain: 2-3/10 à Current pain with treatment: 0/10

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Systemic Medications (off-label)

1) Gabapentin, 1) Amitriptyline, Pregabalin Nortriptyline

3) Other 2) Venlafaxine, anticonvulsants, Duloxetine Benzodiazepines

4) SSRIs

Clark GT, Padilla M, Dionne R. Medication treatment efficacy and chronic orofacial pain. Oral Maxillofac Surg Clin North Am. 2016;28(3):409-421. 67

Mild Anticonvulsants

Gabapentin Pregabalin -300 mg (3-5 times a day) 50 mg (3 times a -range: 1800-3600 day) Adverse effects: mg/day -Sedation -Fluid retention -Confusion -MOA: binds to -MOA: binds to -Dizziness subunit of voltage- subunit of voltage- -Ataxia gated Ca channel gated Ca channel -inhibits excitatory -inhibits excitatory neurotransmitter neurotransmitter release release

First-line medications Clark et al, 2006 68

Tricyclic Antidepressants

Amitriptyline Nortriptyline Dosage: 50-150 Dosage: 10-25 mg/day, max 300 mg/day, max: Adverse effects: mg 150 mg – blurred vision – cognitive changes – constipation MOA: Na and Ca – dry mouth channel blocker; – orthostatic hypotension serotonin + – sedation norepinephrine – sexual dysfunction reuptake inhibitor – tachycardia – urinary retention First-line medications Clark et al., 2006 69

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Atypical Antidepressants: SNRIs

Venlafaxine Duloxetine Dosage: 75 mg/day TID with 20 mg BID; max food; max 225- 120 mg/day 375 mg/day

MOA: blocks MOA: blocks serotonin and serotonin and norepinephrine norepinephrine reuptake reuptake

Second-line medications Clark et al., 2006 70

Botox and PTTN

u Evidence is supportive for spinal neuropathic pain u Evidence is limited to clinical case reports for PTTN but is promising u Yoon et al 2010: 1 case, 10 units administered, decreased painful area and intensity; 2 month f/u

u Cuadrado et al 2016: 4 cases, 25 U over 10 sites, almost complete pain relief achieved, f/u over 6-20 months u Herrero Babiloni et al 2016: 2 cases

u 1) 100 U, split between maxillary and mandibular teeth, pain reduction 5 to 2 at 3-month f/u, pain-free for 3 months by 9-month f/u u 2) Trigeminal neuralgia

1. OROFACIAL Neurovascular MIGRAINE 2. TRIGEMINAL Orofacial Pain AUTONOMIC OROFACIAL PAIN

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Case 3: 54 yo female with throbbing pain on #8

Onset: 1 year ago, intermittent

Lasts 2-3 days, Occurs once a month 7-8/10

Associated with Worse with eating, nausea, Does not wake her talking, flossing photophobia, and up at night phonophobia 73

Prior visits

Dental and endodontic • Endodontic testing of UR ENT evaluation • Imaging • Medications: Claritin Pain medication trials • Tylenol • Tylenol #3 74

Differential Diagnoses Diagnostic tests

¡ Odontogenic u Medication trial: ¡ Sinusitis u Indomethacin ¡ Myofascial pain u Triptan ¡ TMJ dysfunction u Carbamazepine ¡ Headache disorder ¡ Trigeminal neuralgia ¡ Anesthetic tests: § Trigger point injection § Topical anesthetic § Intraoral nerve block 75

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Neurovascular Pain

u Headache disorders

u Primary Headaches

u Migraine with and without aura ¡ Diagnostic criteria for migraine ¡ A. At least 5 attacks fulfilling criteria B-D. u Tension-type headache ¡ B. Headache attacks lasting 4-72 hours u Cervicogenic headache (untreated/unsuccessfully treated) u Trigeminal autonomic cephalgias (TACs) ¡ C. Headache has at least 2 of the following u Cluster Headache characteristics: u Paroxysmal hemicrania § 1. unilateral u Secondary headaches: red flags 2. pulsating 3. moderate or severe pain intensity 4. aggravation by or causing avoidance of physical activity ¡ D. During headache at least one of the following: § 1. Nausea and/or vomiting § 2. Photophobia and phonophobia

ICHD-3 beta.Cephalalgia 2013. 76

Migraine

u Premonitory symptoms: u Can occur up to hours-2 days before headache u Fatigue, depression, difficulty in concentrating, neck stiffness, blurry vision, nausea, light and sound sensitivity, osmophobia u Typical aura: 30% of migraine patients u Visual, sensory, speech disturbances u Fortification pattern (geometric shapes), photopsia (bright spots/flashing lights), scotoma (partial loss of vision, dark defect in visual field) u Sensory symptoms: pins and needles, numbness u COMPLETELY REVERSIBLE u Prevalence:

u 18% women ! u 6.5% men

Migraine pathophysiology

u Peripheral components of the trigeminovascular system are activated via sterile neurogenic inflammation u Endogenous pain control pathways exhibits dysfunction u à = MIGRAINE!

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Facial/midface migraine

u Unilateral, throbbing pain u Involves teeth, jaws, sinuses, ears

25 yo male presents with CC: “Severe, sharp, stabbing pain on the left TMJ.” 1-2 episodes per week, 9/10 in severity Lasts all day No identifiable trigger Sleep helps, Advil Experiences vomiting with the pain

Mother reports migraines and that the patient experience unexplained abdominal pain in childhood.

Neurovascular Orofacial Pain

u 1) Migraine located in the head and extends to the lower facial region. Wei et al 2019: u Yoon et al 2010: 8.9% of patients with migraine had pain in both the head and lower half of the face u 2) Migraine pain occurs only in the lower face without affecting the head. u Daudia et al 2002: 47% had migraine-associated pain isolated to V2

u Eross et al 2007: 85% of patients with “sinus headache” had migraine, of which 1.6% had pain isolated to V2 u 3) Trigeminal autonomic cephalalgia u Wei et al 2019: 62/142 patients (44%), hemicrania continua was the most common diagnosis

Neurovascular Orofacial Pain

u 1997: Benoliel et al.- 29/55 patients with neurovascular facial pain presented with primary intraoral pain

u Characteristics:

u Average ages of patients affected: 35-55

u Female to male ratio: 3.2:1 u Migraine and TAC-like features: throbbing, pulsating, photophobia, phonophobia, nausea, vomiting, conjunctivitis, tearing, nasal congestion, sweating, swelling

u Dental pulpitis features: strong, short paroxysmal pain associated with hot/cold foods

u Mechanism: neurogenic rather than infective

Sharav Y, Katsarava Z & Charles A. Facial presentations of primary headache disorders. Cephalalgia. 2017;37(7):714-19. 81

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46 yo female with chronic facial pain

Clinical exam: Onset 10-12 years ago CN exam Location Right TMJ Light touch: Quality? Dull, achy, sharp, throbbing, burning Rt V1-3: 50% less intense Pin prick: Intensity 9/10 Rt V1: no sensation Duration Constant Rt V2 and V3: 50% less intense Frequency Daily Palpations: Aggravating factors? “Life in general”; worse in mornings; TMJ capsules: mild Superficial masseters: none clenching; prolonged dental visits Masseter Tendon R: severe Associated symptoms Ear pain, neck pain, migraines, ear C-1: severe ringing/fullness, crunching in the jaw, dizziness Crepitus on Rt.; Passive opening: 45 mm, pain on Rt. TMJ 82

Management for Migraine

u Abortive therapy u NSAIDs, Acetaminophen, OTC analgesics

u Triptans: 5HT1b/5HT1d agonists u CGRP antagonists

u Prophylactic therapy u Nutraceuticals: Magnesium, Riboflavin, CoQ10

u Anticonvulsants: topiramate, valproic acid, gabapentin u Beta-Blocker: propranolol, metoprolol, atenolol

u Tricyclic antidepressant: amitriptyline, nortriptyline Clark GT, Padilla M, Dionne R. Medication treatment efficacy u Botox, CGRP antagonists and chronic orofacial pain. Oral Maxillofac Surg: Clin North Am. 2016;28(3):409-21. 83

Nerve blocks

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Botox PREEMPT CGRP Antagonists Protocol

Trigeminal autonomic cephalgias: Cluster Headache

“Someone’s jabbed a white-hot poker into your eye socket and is holding it there for 45 minutes to an hour and a half.” “Like I just got shot in the face.” “It makes you want to get up and literally run from the pain.”

Key Points

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Thank you!

My contact: [email protected]