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

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. However, if he took Cafergot after he had felt another beta blocker also had similar effectiveness. headache, pain resolved slowly after an hour. At this visit, However, he came back one month later, having not fol- another tricyclic antidepressant (TCA), imipramine, was pre- lowed the doctor’s order during the last follow-up period. scribed instead of amitriptyline along with Cafergot. He was Blood pressure was 110/79 mmHg with pulse rate of 85 directed to take 12.5 mg of imipramine a day at bedtime, bpm. These values were not different from those measured for eight days. during the time he had taken atenolol. It was inferred that atenolol as little as 12.5 mg per day had no significant in- fluence on his blood pressure. He reported an interesting symptom related to smoking at this visit. When he smoked a cigarette, headache pain arose faster than when not smoking. He had no pain during the time he did not smoke. Atenolol was prescribed for two months because he pre- ferred it to propranolol.

DISCUSSION

Fig. 3. A panoramic radiograph showing no significant pathology, except a periapical rarefaction lesion of the mandibular left lateral The diagnosis of the present case presentation was ‘prob- incisor. able migraine without aura’, which differs from migraine

www.journalomp.org Yeong-Gwan Im et al. Rare Odontalgia of Mandibular Teeth Associated with Migraine 95 without aura in that its attacks fulfill all but one of criteria Caffeine is added to enhance absorption and potentiate A-D for migraine without aura. The patient did not show analgesia.11) Acute treatment of headaches with caffeine any of nausea, vomiting, photophobia, and phonophobia, is sometimes effective, but an excessive use of caffeine is however, other clinical characteristics were all well within known to induce dependence or increase the frequency of the criteria for migraine without aura. migraine and should be used with caution.

Migraine is regarded as a neurovascular disorder with al- Sumatriptan is a 5-HT1B/1D receptor agonist, the first drug terations in trigeminal sensory processing.8) Until recently, in a new class of specific antimigraine drugs.12) Sumatriptan the mechanism of migraine has not been clearly elucidated. reduces increased blood flow and neurogenic inflammation It seems to be a disorder of the trigeminal sensory system of the trigeminal nerve terminals. This inhibits the neuronal occurring at the brainstem level, and is thought to induce release of vasoactive peptides.13) The two abortive medica- neurogenic inflammation.9) When an antidromic transmis- tions used in this case, both ergotamine tartrate with anhy- sion occurs in the primary nociceptive neurons, vasoactive drous caffeine and sumatriptan succinate were effective. neuropeptides, such as substance P and calcitonin gene- Many classes of pharmacological agents including anti- related peptide are released and cause vasodilation. These epileptic drugs, beta blockers, calcium channel blockers, substances, additionally induce the release of algogenic antidepressants, and serotonin antagonists have been used substances, such as serotonin, histamine, bradykinin, and in the treatment of migraine for prophylactic purposes.14) prostaglandin.8) These algogenic substances sensitize pri- Medication is appropriately selected and adjusted to the mary afferent nociceptors and this leads to central sensiti- medical condition of the patient. Conditions may include zation, which is associated with allodynia and hyperalgesia. depression, anxiety, hypertension, cardiovascular disease, Therefore, when migraine occurs, hypersensitivity of the and sleep disorders. Possible therapeutic mechanisms in- intracranial and extracranial regions is present, where the clude stabilization of the reactive central nervous system, trigeminal nerve branches are distributed. This can be ex- enhancement of anti-nociceptive pathways, and inhibition plained by the sensitized second-order neurons receiving of peripheral sensitization.14) converging inputs in other adjacent regions.4) In this case, two kinds of prophylactic medications were Orofacial pain associated with migraine can occur any- tried. Atenolol, belonging to beta blockers, as low as 12.5 where in the area where the trigeminal nerve is distributed mg/day was sufficient to prevent pain attacks, although a and is more prevalent in the maxillary branch.5,7) In rare generally recommended adult dose with established efficacy cases, migraine-related toothache has been reported in the is 50-150 mg/day.14) TCAs, both amitriptyline 10 mg/day mandible.4,10) In this case, there were no abnormal findings and imipramine 12.5 mg/day, had little effect after one week in the clinical and radiological examinations and the tooth- of administration. However, the duration of administration ache was always accompanied by headache. As such, it of these two agents seems not enough long to evaluate their could be diagnosed as toothache associated with migraine. effectiveness. They were tried but switched to another agent The results of pharmacological therapy supported the diag- hastily to find out more effective ones. In general, TCAs are nosis of migraine and related dental pain. known to take several weeks to show their effectiveness. Pharmacologic treatment of migraine can be divided into Interestingly, the patient reported an increase in head- drugs that abort migraine and those that prevent migraine ache after smoking. The relationship between migraine and attacks.7) Analgesics may be effective for the treatment of smoking is still controversial. However, recent studies have migraine, and can be used alone or in combination with reported that smoking may be a precipitating factor of mi- caffeine. However, most of these drugs are over-the-coun- graine.15,16) In addition to smoking, lifestyle factors associ- ter, so overuse can lead to medication overuse headaches.11) ated with migraine include dieting and fasting, exercising Ergotamine is an alpha-adrenergic blocker and vasocon- and physical activity, stress, and sleep pattern. It is neces- strictor of the cranial smooth muscle and is considered in sary to modify these factors, which can trigger headaches, the treatment of patients with moderate or severe migraine. for the treatment of migraine.17)

www.journalomp.org 96 J Oral Med Pain Vol. 43 No. 3, September 2018

Migraine is a common headache disorder. If migraine is recommendations for nonodontogenic toothache. J Oral Rehabil accompanied by pain felt in the teeth, face, or maxillary 2014;41:843-852. 2. Alonso AA, Nixdorf DR. Case series of four different headache sinus, patients may visit dental clinics for evaluation and types presenting as tooth pain. J Endod 2006;32:1110-1113. treatment of such pain. If there are no abnormalities of the 3. Headache Classification Committee of the International Headache teeth and its surrounding structures, clinicians must consid- Society (IHS). The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013;33:629-808. er non-odontogenic pain including neurovascular disorders, 4. Obermann M, Mueller D, Yoon MS, Pageler L, Diener H, Katsar- such as migraine. A differential diagnosis is crucial in pa- ava Z. Migraine with isolated facial pain: a diagnostic challenge. tients with non-odontogenic toothaches to avoid inappro- Cephalalgia 2007;27:1278-1282. priate and unnecessary dental treatments including root ca- 5. Daudia AT, Jones NS. Facial migraine in a rhinological setting. Clin Otolaryngol Allied Sci 2002;27:521-525. nal therapy, periodontal treatments, and tooth extraction, as 6. Benoliel R, Elishoov H, Sharav Y. Orofacial pain with vascular- these would fail to alleviate the symptoms of the patients. type features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Dentists should be aware that migraine may present as 1997;84:506-512. 7. Peñarrocha M, Bandrés A, Peñarrocha M, Bagán JV. Lower- pain anywhere within the areas innervated by the trigemi- half facial migraine: a report of 11 cases. J Oral Maxillofac Surg nal nerve. They should be able to differentiate pain associ- 2004;62:1453-1456. ated with migraine with common dental pain conditions. 8. Nixdorf DR, Velly AM, Alonso AA. Neurovascular pains: implications of migraine for the oral and maxillofacial surgeon. Oral Clinicians should be able to establish an accurate diagno- Maxillofac Surg Clin North Am 2008;20:221-235. sis through a comprehensive evaluation and careful history 9. Bernstein C, Burstein R. Sensitization of the trigeminovascular evaluation. Prescribing drugs specific to migraine, such as pathway: perspective and implications to migraine pathophysiol- triptans, may be useful for diagnostic purposes. ogy. J Clin Neurol 2012;8:89-99. 10. Namazi MR. Presentation of migraine as odontalgia. Headache In conclusion, migraine can present as a toothache in the 2001;41:420-421. mandibular posterior teeth, like in this case presentation, 11. Weinberg MA, Gopinathan G. Recognition and treatment of mi- without a definite odontogenic cause. Proper understand- graine patient in dental practice. N Y State Dent J 2009;75:28-33. 12. Tfelt-Hansen P, Hougaard A. Sumatriptan: a review of its phar- ing of the disease and a comprehensive evaluation of the macokinetics, pharmacodynamics and efficacy in the acute treat- patient can help correct diagnosis and can prevent unnec- ment of migraine. Expert Opin Drug Metab Toxicol 2013;9:91- essary dental treatments. Such pain is effectively managed 103. with migraine therapies and may require a referral to a spe- 13. Silberstein SD, Marcus DA. Sumatriptan: treatment across the full spectrum of migraine. Expert Opin Pharmacother 2013;14: 1659- cialist in orofacial pain. 1667. 14. Rizzoli P. Preventive pharmacotherapy in migraine. Headache CONFLICT OF INTEREST 2014;54:364-369. 15. López-Mesonero L, Márquez S, Parra P, Gámez-Leyva G, Muñoz P, Pascual J. Smoking as a precipitating factor for migraine: a No potential conflict of interest relevant to this article survey in medical students. J Headache Pain 2009;10:101-103. was reported. 16. Sarker MA, Rahman M, Harun-Or-Rashid M, et al. Association of smoked and smokeless tobacco use with migraine: a hospital- based case-control study in Dhaka, Bangladesh. Tob Induc Dis REFERENCES 2013;11:15. 17. Nazari F, Safavi M, Mahmudi M. Migraine and its relation with 1. Yatani H, Komiyama O, Matsuka Y, et al. Systematic review and lifestyle in women. Pain Pract 2010;10:228-234.