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Rare Odontalgia of Mandibular Teeth Associated with Migraine: a Case Report

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Rare Odontalgia of Mandibular Teeth Associated with Migraine: a Case Report Case Report pISSN 2288-9272 eISSN 2383-8493 J Oral Med Pain 2018;43(3):92-96 JOMP https://doi.org/10.14476/jomp.2018.43.3.92 Journal of Oral Medicine and Pain Rare Odontalgia of Mandibular Teeth Associated with Migraine: A Case Report Yeong-Gwan Im1, Jin-Kyu Kang2 1Department of Oral Medicine, Chonnam National University Dental Hospital, Gwangju, Korea 2Department of Orofacial Pain and Oral Medicine, Wonkwang University Daejeon Dental Hospital, Daejeon, Korea Received August 17, 2018 A 39-year-old male presented with severe pain in right posterior mandibular teeth and tempo- Revised September 19, 2018 ral area. Initially, the pain in the mandibular teeth was moderate, but the concomitant head- Accepted September 20, 2018 ache was unbearably severe. His medical history was non-contributory. The clinical and ra- diographic examination failed to reveal any pathology in the region. There was no tenderness to palpation in the temporalis and masseter muscles or temporomandibular joints. The clinical Correspondence to: impression was migraine. The pain in the teeth and headache were aborted using ergotamine Jin-Kyu Kang Department of Orofacial Pain and tartrate and sumatriptan succinate. Atenolol prevented further pain, while amitriptyline and Oral Medicine, Wonkwang University imipramine had no effect. Migraine can present as non-odontogenic pain in the mandibular Daejeon Dental Hospital, 77 Dunsan- teeth, although not as frequently as in the maxillary teeth. A correct diagnosis is essential ro, Seo-gu, Daejeon 35233, Korea to avoid unnecessary dental treatments and to manage pain effectively. Clinicians should be Tel: +82-42-366-1125 Fax: +82-42-366-1115 able to identify migraine with non-odontogenic dental pain and establish a proper diagnosis E-mail: [email protected] through a comprehensive evaluation. This paper was supported by Wonkwang University in 2017. Key Words: Facial pain; Headache; Migraine without aura; Toothache INTRODUCTION vomiting. The diagnostic criteria for migraine according to the International Headache Society are shown in Table 1.3) The majority of toothaches are caused by inflammation During the migraine attack, stimulation of the trigemi- or infection of the pulp and periradicular tissues. However, nal nerve may induce the release of vasoactive peptides and there are various non-odontogenic sources that may be re- cause referral pain to any of the three branches. This results sponsible for pain felt in the teeth. Non-odontogenic tooth- in pain in the orofacial structures, such as orbit, maxillary aches may be caused by muscle, maxillary sinus, neuro- sinus, cheek, teeth, and jaws.4,5) pathic, neurovascular, cardiac, and psychogenic problems.1) Among the neurovascular diseases that may cause pain in Headache disorders can present with pain in the orofacial the tooth area, cluster headache and paroxysmal hemicra- area because of at least two reasons: it shares the trigemi- nia are comparatively easily distinguished, because of the novascular system and by pain mechanisms, such as neuro- distinct characteristics, such as the location, intensity, fre- genic inflammation.2) It has been reported that several types quency, and duration of the pain. However, migraine may of headaches including migraine, tension type headache, be difficult to differentiate because they are characterized cluster headache, and paroxysmal hemicrania can cause by pulsating pain, which is like pulpal pain.6) toothache.2) Dental pain associated with migraine have been re- Migraine is characterized by unilateral pain with pulsa- ported infrequently and mostly in the maxillary teeth.2,4,5,7) tile quality, accompanied by symptoms, such as nausea and In this case presentation, we describe a rare case of Copyright Ⓒ 2018 Korean Academy of Orofacial Pain and Oral Medicine. All rights reserved. CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.journalomp.org Yeong-Gwan Im et al. Rare Odontalgia of Mandibular Teeth Associated with Migraine 93 migraine-associated non-odontogenic pain in the mandibu- days a week. There was no nausea, photophobia or phono- lar teeth. phobia around the time of the toothache and headache. He had esophageal reflux disease, which had been treated CASE REPORT pharmacologically, for about one year at a local commu- nity hospital. He had suffered a traumatic injury of his head A 39-year-old male visited the Department of Oral from a traffic accident 15 years ago, but he completely re- Medicine, Chonnam National University Dental Hospital covered from the injury without complication. He also had complaining of recurrent pain of his lower right molars and a smoking habit lasting 10 years. No other specific systemic a concomitant headache of the right temporal area (Fig. diseases were reported. 1). The pain symptoms had been present for nine months. Clinical examination of the head, face, jaw, teeth, gin- Pain attacks always began from the mandiblar molar on the giva, and oral mucosa did not suggest significant findings right side, and then a headache on the right unilateral side (Fig. 2). No tooth was tender to percussion. Upper and lower followed the toothache. The headaches were far more se- teeth on right side responded within normal limits to palpa- vere than the preceding toothaches. They were described as tion and bite test and showed positive response to vitality unbearably painful (NRS=9/10), nearly causing tearing and tests. Dental occlusion was favorable. Slight gingival reces- disabling him. Each pain episode lasted several hours, un- sion was noted on the palatal side of the right maxillary less controlled with analgesics. The pain usually subsided first and second molars. None of the temporalis muscles, 30 minutes to one hour, after taking an over-the-counter medication, such as a Tanaxen tablet (acetaminophen 500 mg and caffeine 65 mg; Yuhan Corp., Seoul, Korea). The pain symptoms usually occurred once a day, recurring four Table 1. Diagnostic criteria for migraine A. At least five attacks fulfilling criteria B-D B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated) C. Headache has at least two of the following four characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe pain intensity 4. Aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs) D. During headache at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia E. Not better accounted for by another ICHD-3 diagnosis. Fig. 1. The pain diagram illustrating the initial pain of the posterior ICHD, International Classification of Headache Disorders. mandibular teeth and subsequent headache of the right side. Fig. 2. Intraoral photographs showing no noteworthy lesion on the teeth, gingiva, and oral mucosa of the right side. www.journalomp.org 94 J Oral Med Pain Vol. 43 No. 3, September 2018 masseter muscles, or temporomandibular joints of either At the third visit, he stated that there was no improve- side were tender to palpation. Panoramic radiography did ment in recurrent pain symptoms, although he took imipra- not reveal significant pathology, except a periapical rarefac- mine every day. During the previous eight days, he had to tion of the mandibular lateral incisor on the left side (Fig. 3). take Cafergot five times (one tablet each time) to control the The root canal of the involved tooth was radiopaque with pain. At this time, abortive and preventive medications were filling materials. The rarefaction lesion had a thick sclerotic replaced with oral sumatriptan succinate (50 mg tablet, pro border. re nata) and atenolol (25 mg tablet per day), respectively. A careful review of the patient history and examination At the fourth visit nine days later, the patient reported findings gave the clinical impression of probable migraine that he had no pain during the past four to five days and he without aura, according to the International Classification had not suffered from a severe headache. He took sumatrip- of Headache Disorders. The preceding pain of the mandibu- tan succinate twice, only for mild to moderate pain attacks. lar posterior teeth on the same side of the headache was Furthermore, there had been no pain attack for the last thought to be an atypical manifestation of referred pain. three days, although he could not take atenolol, due to a To abort pain episodes, several tablets of Cafergot lack of medication. Blood pressure was 117/89 mmHg with (Novartis, Basel, Basel-Stadt, Switzerland) (ergotamine tar- pulse rate of 89 beats per minute (bpm). The daily dosage of trate 1 mg and anhydrous caffeine 100 mg) were prescribed atenolol was reduced to 12.5 mg from this visit on. At the with the usage of ‘pro re nata’ (as needed). In addition, we fifth visit five weeks later, he experienced neither toothache prescribed amitriptyline 10 mg once a day at bedtime, for nor headache after the last visit. one week for prophylactic purposes. At the sixth visit three months later, he reported that the At the follow-up visit one week later, the patient reported headaches had nearly disappeared, after he started tak- that amitriptyline had no effect in preventing the pain. On ing atenolol. He had taken oral sumatriptan succinate only the contrary, Cafergot was very effective in resolving the twice during the last three months. He tried taking ateno- toothache and in suppressing the headaches. If he admin- lol 12.5 mg every other day for 1 week and found no pain istered Cafergot at the time of initial toothache develop- recurred. At this time, propranolol 40 mg per day was pre- ment, the toothache was soon relieved and headache did scribed, instead of atenolol for one month to check whether not follow.
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