Benign Indomethacin-Responsive Presenting in the Orofacial Region: Eight Case Reports

Elizabeth Moneada. DDS, MS Indomethacin-responsive headaches can present in the orofacial Assistant Clinical Professor region. According to the classification of beadacbe by tbe Center for TMD and Crofacisl Pain International Society, indometbacin-responsive headaches Section of Restorative Dentistry include chronic paroxysmal hemicrania, bemicrania continua, University of California, San Francisco benign cough beadacbe, benign exertional beadache, and sbarp, School of Dentistry sbort-lived beadacbe pain syndrome. The mechanism by which San Francisco, California indomethacin produces its therapeutic effects in these headache dis- Steven B. Graff-Radford, DDS orders remains speculative. A review of indomethacin-responsive Associate Clinical Professor headaches and eight cases in wbicb the presenting symptom was Section of Orofacial Pain orofacial pain are reported. Because these headache disorders are University of California. Les Angeles rare but may present as facial pain, they sbould be considered in the School of Dentistry differential diagnosis of orofacial pain. A comprehensive evaluation Los Angeles. California and Director. Section of Head and prior to performing irreversible treatments is essential wben an idio- Neck Pain patbic facial pain presents to tbe dental clinician. The Pain Center J OROFACTAL PAIN I 99.î;9:276-284. Cedars-Sinai Medicai Center Los Angeies. California key words: orofacial pain, indomethacin-responsive headache Correspondence to: Dr Elizabeth Moneada Center for TMD and Orofacial Pain Section of Restorative Dentistry University of California. San Francisco School of Dentistry 707 Parnassus Avenue, Room D1050 San Francisco, California 94143-9768 any conditions that are considered primary headache dis- orders can present as orofacial pain.'' Some are poten- Mtiaily iife threatening (eg, cerebrovascular hemorrhage, neoplasm, infections), and others are benign. Nevertheless, these conditions must be ruled out prior to any irreversible dental treat- ments. Guidelines for classification and diagnosis of headache and temporomandibular disorders have been published by the Internarional Headache Society (IHS)' and tbe American Academy of Orofacial Pain.'' The use of these classification systems helps when considering rbe differential diagnosis of orofacial pain. At times, after performing the necessary diagnostic procedtjres (eg, musculoskeletal examination, neurologic examination, intra- oral examination, blood work-up, and imaging], the clinician is left without an obvious local cause for the presenting pain. Careful evaluation of the presentmg symptoms and the diagnostic proce- dures in conjunction with the current classification systems can be the key to tbe diagnosis of an orofacial pain disorder. Tbere have been reports of cbronic paroxysmal hemicrania (CPH) and benign cougb headache ¡BCH) presenting as toothache or orofacial pain.''*" Otber indometbacin-responsive headaches include , henign exertional headache, and sharp, sbort-lived beadache pain syndrome.""" Many of these benign headacbe disorders can be provoked by physical stimulation (eg, exertion, cough, flexion/extension of the neck). Some are asso- ciated with and autonomie symptoms (eg, nausea, vomit- ing, photophobia, phonophobia) and may respond to migraine

276 Volume 9. Number 3, 1995 Moncads/Graff-Radford therapy. Nonetheless, the clinical features (eg, The patient reported that the pain on the left location, laterality, intensity, quality, age range, side of his jaw started after a routine dental exami- gender, and other associated symptoms) for each nation and tooth cleaning tinder local anesthesia. of these headache disorders are unique. A review After having had his mouth open for the duration of the IHS "Classification and diagnostic criteria of the procedure, he noted pain on the left side of for headache disorders, cranial neuralgias and his jaw and some limitation in mouth opening. facial pain" is recommended.' The bruising pain occurred during functioning and The pathophysiology of the indomethacin- was aggravated by jaw movements to the right. responsive headache disorders is not known. The past medical history was within normal limits, Raskin'" speculates that they may result from sud- except for positive vegetative signs ot depression, den and/or repeated intracranial pressure eleva- including feeling low and difficulties concen- tions. The mechanism by which indomerhacin pro- trating. duces its therapeutic effects in these benign headache disorders remains speculative. Currently, the proposed mechanisms of action of indo- Examination methacin in these benign headache disorders are The review of systems was noncontributory, reduction of cerebral blood flow,'" reduction in except for the spontaneous loss of balance and the cerebrovascular permeability," and reduction in dizziness. The neurologic screening examination of cerebrospinal pressure.'- dental and cranial nerves II to XII were noted to The following cases describe orofacial pain pre- be within normal limits. The stomatognathic senting as lndomethacin-responsive pain. It is examination revealed limited interincisal opening worthwhile to discuss the issue of making a diag- (35 mm), protrusion (4 mm), and right laterotru- nosis based on a treatment response. One could sion (7 mm). Fluori-Methane spray (Gebauer, argue that indomethacin provides excellent analge- Cleveland, OH) was sprayed on the masseter and sia, which may detract from the specificity of the temporalis areas, resulting in a 9-mm increase in indomethacin effect. However, it is generally the interincisal opening. There was also evidence accepted that, for indomethacin-responsive pains, of intermittent clicking of the left temporo- other equiporent analgesics do not provide as effi- mandibular joint (TMJ). There was no sign of joint crepitus or tenderness of the TMJ. cient and complete a response. Examination of the upper quarter and the cervical spine revealed the head to be slightly bent to the right side, with the left shoulder elevated. There Case 1 was an anterior head position of 9 cm from a tan- gent to tbe thoracic vertebrae. Left lateral flexion A white man aged 38 years presented with three and right rotation of the neck was limited. The complaints: (1) severe, intermittent, stabbing myofascial examination revealed active trigger occipital headaches on the right side; (2) unilateral, points in the lefr anterior temporalis and left throbbing and pressing frontal headaches; and (3) superficial masseter muscles, and latent trigger intermittent "bruising" pain in the left jaw. points in the right temporalis and the right mas- seter muscles. History

When the stabbing occipital headaches started, Diagnosis and Treatment they were associated with exertion or just prior to . The stabbing pain occurred several times The initial differential diagnosis included (1) a day and could last anywhere from a few minutes migraine without aura, (2) benign coital migraine to 20 minutes. (benign exertional migraine), (3) myofascial pain At the time of the evaluation, the throbbing and secondary muscle splinting, and (4) temporo- frontal headaches were occurring every 2 to 3 days mandibular dysfunction not contributing to pain. for up to 30 minutes and cotild be ameliorated by Fach condition was approached separately. coffee or Excedrin (Bristol-Myers, New York). These The musculoskeietal pain was addressed using throbbing headaches were associated with loss of an exercise program to restore range of motion balance and sometimes with photophobia and aided by Fluori-Methane spray and stretch. An phonophobia. Dizziness or the loss of balance was existing mandibular stabilization appliance was also reported without pain. Anxiety appeared to be adjusted and the patient was instructed to use it an aggravating factor for the throbbing headaches. nocturnally.

Journal of Orofacial Pain 277 Moncada/Graff-Radford

The headache was treated initially with inJo- Examination methacin, which was titrated to 100 mg per day. The oral examination and the neurologic screening This prevented tbe coital pain. The patient devel- examination of the cranial nerves II to XII were oped sensitivity to indomethacin, resulting in itch- within normal limits , except for hearing loss in the ing. This has caused the patient to use 50 to 100 right ear. The hearing loss had been progressive for mg of indomethacin intermittently prior to sex. He many years. The stomatognathic and cervical spine reports that the majority of times he can prevent examinations were witbin normal limits, except for the onset of pain. some evidence of alteration in posture, with the Because of the potential for neurologic prob- head being slightly bent to tbe right, and the pres- lems, the patient underwent a comprehensive ence of an elevated shoulder. There was mild ten- neurologic evaluation that included magnetic res- derness over the transverse process of the first cer- onance imaging (MRI) and eiectronystagmogra- vical vertebra (C-1), The myofascial examination phy. The neurologist reported abnormalities revealed some latent trigger points in tbe right mas- and believed that the dizziness was related to seter and right trapezius muscles at the nuchal hne. migraine. The migraine was treated with amitriptyline hydrochloride at doses between 75 and 100 mg, in Diagnosis and Treatment conjunction with withdrawal from caffeine and analgesics. This trearment produced a significant The patient was diagnosed with one of the result. Financial constraints have prevented furtber indomethacin-responsive headaches that are often treatment for depression. described as ice-pick pain or jabs and jolts. Al- though her pain was somewhat longer in duration tban commonly seen in most cases of ice-pick pain, Case 2 tbe location, quality, description that included an autonomie sign (temperature change in the face), A white woman aged 61 years presented with the and the responsiveness to indomethacin were sug- complaint of severe, intermittent, postauricuiar gestive of an indomethacin-responsive headache. pain and sharp, boring, auricular pain on the right Since a trial of indomethacin at a low dose was side. She described tbe pain as a sharp, wood attempted with some resulting success, the dose object being driven into her head and reported a was gradually increased to 150 mg per day, which sensation of increased temperature on the right controlled her pain. At 1-year follow-up, she con- side of her face with the pain. No other autonomie tinues to use between 100 and 150 mg of signs were present. There was no associated aura, indomethacin per day, Sbe has no sequelae from photophobia, or phonophobia. this medication.

History Case 3 The headaches began in 1960, witb one severe attack. It was not until 5 years prior to the evalua- A wbite man aged 34 years presented with the tion for the present study that the pain reoccuried. complaint of an intermittent left parietal and tem- The attaclis, which could wake her from her sleep, poral pressing-to-throbbing headache. The pain lasted from a few seconds to 1 minute and was associated with nausea and photophobia, and occurred two times per day. it typically occurred after 20 to 30 minutes of The patient's had treated the attacks physical exertion. The frequency of pain depended as part of an arthritic condition with injections of on the level of exertion. cortisone at the base of tbe skull, which she believed may have helped her. An MRI of the History brain was within normal limits. Treatments with several anti-inflammatory medications only upset The patient first noticed the pain, while jogging, 3 her stomach. The patient stated that there were no years prior to the evaluation of the present study. aggravating factors and that the only alleviating The pain was triggered by any exertion, lasted sev- factors appeared to have been indomethacin and eral minutes, and occurred several times per week. meperidine hydrochloride (Demerol, Sanofi Win- The pain did not abate unless the specific exer- throp, New York). Reviews of systems and psy- tional activity was stopped. The patient noticed chosocial history were noncontributory. that the headache was associated with a slight

278 Volume 9, Number3, 1995 Moncada/Graff-Radford droopini; of the left eye lid (ptosis) and warmuig of quency of his shorter-lasting postexertion rhe left car. There were rimes when the headaches headaches. The 0,2 mg of methylergonovine were associated with nausea. In conjunction with maléate (Methergine, Sandoz Pharmaceuticab, these short-lived pains was a longer-lasting, dull, East Hanover, NJ) four times per day and an aching headache that did not have to be triggered Ergoramine Medi-haler (3M Pharmaceuticals, St by exertion but could be aggravated by stress. The Paul, MK) completely controlled the pain prophy- only alleviaring factor for this dull pain was a left lacrically and at the onset. auricular-temporal block with steroid .Tdministered by an anesthesiologist. Additionally, the patient was evaluated by his internisr, who rhought his Case 4 labile hypertension may be contributing to tbe headaches, A medication trial of prazosin A white woman aged 64 years presented with the hydrochloride (Minipress, Pfizer, New York) was complaint of mtermitrent, boring, aching temporal attempted with no relief from the headaches, headaches on the left side and a daily bilateral Amirripryllne hydrochloride was tried, but the posrorbital and temporal pressurelike headache. headaches did nor remit. Prior to this evaluarion, The pain lasred 15 minutes and occurred sponta- the patient had been placed on 75 mg of neously up ro six rimes per day. indomethacin rwice a day and was not getting any relief from his headaches- Angiography, urine analysis, and brain MRIs were ordered ro rule our History inrracranial pathology and pheochromocytoma, The headaches hegan 12 years prior to the evalua- and all were wirhin normal limits. Evaluarions by tion for the present srudy. The patient had received an ear, nose, and throat doctor; an ophthalmolo- rhree neurologic consultarions, which were within gist; and a neurologist were also within normal normal limits. A computerized tomography (CT) limits. Review of systems was noncontriburory, of the brain was normal. She had seen a dentist excepr for hypertension conrrolled with 40 mg of who diagnosed a TMJ problem, A complete mouth lisonopril (Prinivil, Merck, Wesr Point, PA) per reconstruction was performed to increase her verti- day. He also had an asymptomatic ruptured disc cal dimension, htit her headaches did not remit. between the first and second lumbar vertebrae. Arthrograms of the TMJ were obtained. An oral Tbe psychosocial hisrory was noncontributory. surgeon recommended condyloplasty of the lefr TMJ, hut rhe parient declined this surgery. Re- views of systems and psychosocial history were Examination noncontributory. Aggravating facrors included hunger, certain foods, stress, combing and washing The neurologic screening examination of cranial her hair, and hot and cold temperatures in her nerves II to XII and the oral, sromatognathic, and mouth. Alleviating factors included aspirin cervical examinations were within normal limirs, (Ecotrin, Smithklme Beecham Consumer Brands, excepr for some evidence of minimal postural Pittsburgh, PA) and naproxen (Naprosyn, Syntex abnormalities. The myofascial examination revealed Laboratories, Palo Airo, CA), latent trigger points in rhe left and right posterior remporaiis and the left sternocleidomastoid muscles. Examination Diagnosis and Treatment The neurological screening examinarion of cranial It was believed that based on rhe history and nerves II ro XII and the oral examinarion were examination, the parient was suffering from (I) within normal limirs. The stomatognathic exami- benign exertional headache and (2) myofascial nation revealed limited passive range of morion of pain. Perpetuaring factors included work, stress, the mandible (37 mm) with slight deviation ro the and poor postural habits. Management included a lefr. Examination of the upper quarter and the cer- home exercise program to improve posture and vical spine was normal, except for some minimal body mechanics. There was some improvement in postural abnormality. The myofascial examination rhe parient's longer-lasring, dull, aching headaches revealed trigger poinrs in rhe lefr anterior tempo- after initiation of rhe exercise program and rdgger- ralis, left srernocleidomastoid, and left anrcrior point injections of 2% procaine hydrochloride. trapezius muscles. The patient's headache com- Concomitantly, the indomethacin was increased to plainrs were not reproduced by rhe myofascial 250 mg per day with some improvement in the fre- examination.

Journal of Orofacial Pain 279 Moncsda/Graff-Radford

Diagnosis and Treatment nation of cranial nerves II to XII was within nor- mal limits. It was believed that based oti the history and examinatioti, the patient was suffering from (Í) chronic paroxystiial hemicrania and (2) myofascial Diagnosis and Treatment pain. Administration of indomethacin was started, The history of migraine headache with the regular and within 24 hours of 75 mg per day, she was use of drug rebound-producing medications pain free. She has continued to tise indomethacin resulted in a chronic daily headache with myofas- for 4 years. cial pain. Nonetheless, the tinilateral nature of her continuous headache associated with autonomie symptoms warranted the ruling-otit of hemicrania Case 5 continua. The analgesic rebound medications were discontinued. A behavioral medicine program was A white wotnan aged ,)7 years presented with the started after a psychologic evaluation, an upper chief complaint of continuous sensations of pain, quarter exercise program, and a medication proto- which varied from nagging to stabbmg, in the right col (25 mg of amitriptyline hydrochloride at bed- occipital region radiating to the right eye. The time and 75 mg of indomethacin three times per headaches were sometimes associated with nausea, day) were all instituted. At a 1-month follow-up vomiting, photophobia, and phonophobia. The visit, the patient had not had daily headache or pain was associaœd with drooping and tearing of migraine, and her myofascial pain was resolving. her right eye. There was no associated aura. She She had maintained 25 mg of amitriptyline had difficulty saying certain wurds when the pam hydrochloride at bedtime and was down to 25 mg was present. of indomethacin per day for control of her hemi- crania continua. History The patient first reported headaches approxi- Case 6- mately 13 years prior to the evaluation for the pre- sent study. Her headaches were initially intermit- A white woman aged 53 years presented with the tent but had become continuous over the last 7 complaint of an intermittent, sharp pain that was years. She reported that aggravating factors in- localized in the maxillary and temporal regions on cluded stress, and alleviating factors included rhe left side. The pain was described as occurring sumarriptan succinate (hnitrex, Cerenex Pharma- several rimes per day and was ofren associated with ceuticals Research, Triangle Park, NC¡ and rearing in the ipsilateral eye and with sweating. Fiorinal (Sandoz), She also had been treated with hydrochloride (Propranolol, Mylan, Morgantown, WV), Cafergot ¡Sandoz), carba- History mazepine, amitriptyline hydtochloride, chiroprac- The pain attacks were initially felt as pain in the tic manipulations, and biofeedback. Review of sys- maxillary premolar area, prompting the patient to tems was within normal hmits. Psychosocial visit her dentist. The dentist proceeded to perform history was positive for depression and sexual root canal treatment on the premolar, which did abuse at age 10 years. not substantially reduce the pain. The patient then consulted numerous , including internal medicine and neurologic specialists, and was even- Examination tually diagnosed as suffering from migraine. Trials Dental and stomatognathic examinations were using a number of migraine prophylactic medica- negative, except for signs of tongue mucosal ridg- tions, including Propranolol and amitriptyline ing and accelerated tooth wear. The myofascial hydrochloride, were attempted without any bene- examination revealed active trigger points in the fit. The patient reported that her pain had been right anterior temporalis muscle, both of the deep most successfully reduced by the use of six to 12 masseter muscles, the right splenius muscle of the aspirin per day. The pain could be triggered by the head, and the right trapezios muscle. The cervical patient extending her head up and back, as would spine examination was essentially within normal occur when the patient reached to get a teacup limits, with the exception of minimal postural from a cupboard above her head. The pain had abnormalities. The neurological screening exami- also been noted to be worse during cold weather.

280 Volume 9, Number3, 1995 Moncada/Grafï-Radford

Examination cian thought that was a possi- Tbe medical history revealed a family history of hility and prescribed 100 mg of phenytoin migraine, and the patient reported ù previous his- (Dilantin, Parke-Davis, Morris Plains, NJ) tbree tory of some intermittenr migrainous symptoms. times a day, but this treatment failed to produce The review of systems was within normal limits. any relief from the attacks. Tbe patient was referred to an otolaryngologist. 1 be ensuing exam- The dental, sromatognathic, myofascial, cervical ination, together witb sinus radiography, proved vertebrae, and cranial nerve examinations were all negative for pathology, and it was suggested to the within normal limits. Psychosocial questioning and patient that perhaps a TMJ problem was present. psychometric testing with the Minnesota Multi- The patient tben consulted a second dentist, who phasic Personality Inventory were within normal thought the problem was unlikely to he related to limits and unelevated, respectively. the TMJ, and be was referred to the Cedars-Sinai Anesthesia Pain Center. Diagnosis and Treatment The inrermitrent, chronic nature of tbe attacks, Examination occurring several times per day with associated Tbe review of systems was within normal limits. autonomie features and triggerable by certain head Tbe medical history revealed a family history of movements, led to a preliminary diagnosis of CPH. headaches. Dental, stomatognathic, myofascial, The fact tbar only aspirin had been belpful was cervical spine, and cranial nerve screening exami- also suggestive of CPH. The patient was started on nations were negative or within norma! limits. a rnal of 25 mg of indometbacin three times per Psychosocia! questioning was negative for possibie day. The patient called 48 bours later to advise depression and did not reveal a need for psycho- thac she w^as pain free. The initial controlling dose metric evaluation. was found to be 125 mg, hut she is now being mainrained on 25 mg witbout any side effects. Tbe patient has found tbat the longest she can stay off Diagnosis and Treatment the indomethacin is 7 days before her symptoms Assessment of rhe chronic nature of the attacks, remrn. comhined with the unilateralness, regularity, dura- tion, and lack of remission periods or triggers, led to a preliminary diagnosis of CPH. It was there- Case 7' fore thought tbat an indomethacin trial might be helpftil, and the patient was started on 75 mg of A retired white man aged 65 years presented with indometbacin slow release (SR) per day, which rhe complaint of intermittent, daily attacks of pain was increased to 75 mg twice per day after 4 days. that were localized ro the maxillary molar area. One week later the patient reporred total relief The pain was described as feeling as if a denrist from the attacks. One month later be was still free were drilling a tootb witbout using local anesthe- of the pain and was being maintained on 75 mg of sia. The attacks generally lasted 10 to 20 minutes, indomethacin SR per day. occurred regularly in the afternoon and during rbe nigbt, and occasionally woke bim from sleep. Case 8'

History A white man (a physician) aged 45 years presented The pain attacks had been present over a 3-year witb the complaint of intermittent, sharp, aching period, and no triggers that would precipitate the pain in the maxillary right region, with radiating attacks bad been identified. There were no associ- patterns to the ipsilateral temporal region as well ated autonomie symptoms with the pain. When as tbe ear and the back of the head. asked if anything aggravated tbe pain, the patient reported tbat stress could be a factor. Aspirin was History the only alleviating factor described by the patient and was also reported ro belp stave off an attack. The patient first reported the problem 2 years Tbe patient had initially thought tbe pain was of prior to his examination at the Cedars-Sinai Anes- dental origin, and so he had consulted a dentist, thesia Pain Center. The pains lasted seconds to wbo failed to find any dental pathology. A physi- minutes and occurred up to 20 times per day.

Journal of Orofacial Pain 281 Moncada/Graff-Radford

Bending forward, straining, yelling, or coughing root canal therapies, extractions) are not recom- triggered the pain. Alleviating factors included mended until a thorotigh evaluation is completed nonsteroidal anti-inflamniatory agents. He initially and the diagnosis of a dental pathology can be thought this condition was of dental origin and substantiated. The evaluation may include pulp consulted a dentist, who found nothing. He was testing, dental radiographs, neurologic examina- then seen by an endodontist who performed two tion, blood work-ups, sinus imaging, and brain root canal treatments of the mandibular right first imaging. Short-term observation and conservative and second premolars, although there was no evi- treatment modalities (eg, pharmacologie trials) are dence of local pathology. Through further dentai recommended if the thorough evaluation is incon- treatment, the patient had a premolar extracted clusive, because it can take up to 4 months for any and fixed partial denture placed, both with no possible dental pathology to manifest. rehef from pain. Although a neurologic evaluation suggested a possible contributing factor in the cervical area, an Conclusion MRI of the cervical spine was normal. An MRI of the TMJ, a TMJ Doppler study, an MRI of the In the majority of the cases reviewed, muscu- brain, and a CT of the sinuses were performed. All loskeletal abnormalities needed to be addressed. results were within normal limits. An occipital Although most cases did not reveal significant psy- nerve block was also performed with equivocal chosocial issues that warranted a psychologic eval- results. uation, specific psychosocial screening questions are useful to make the appropriate referral. In case 1, the indomethacin-responsive pain was Examination benign coital migraine or benign exertional The oral, stomatognathic, myofascial, and cervical headache. This pain presented in a patient com- spine examinations and the neurologic screening plaining of jaw pain after dental treatments. examination of cranial nerves 0 to XII were within Altbough the indomethacin-responsive pain and normal limits. Palpation of the right carotid artery the pain after dental treatment are deemed to be produced a slight vasovaga! response and some separate and independent, confusion may exist in pain referral to the right maxiila area. It was diffi- such cases if careful differential diagnosis is not cult to assess the meaning of this response, because employed. In case 3, indomethacin was only par- repeat testing was not carried out for fear of pro- tially helpful in controlling the pain. It is recom- ducing syncope. mended tbat when symptoms like migraine appear, additional consideration be given to combination therapy. Withdrawal of either indomethacin or Diagnosis and Treatment methylergonovine maléate, in this case, resulted in The diagnosis after the evaluation was BCH. Due a resurgence oí pain. to the carotid artery tenderness, an erythrocyte Caffeine withdrawal and analgesic rebound sedimentation rate (ESR) was ordered to rule out headache were also significant factors in cases 1 carotodynia. The ESR was within normal limits. and 5. Food sensitivity was a significant factor in The patient was started on 75 mg of indomethacin case 4. The impact that substances, musculoskele- SR. At the follow-up evaluation 9 days later, the tal abnormalities, and psychosocial, systemic, and headaches were controlled. At a 1-year foliow-up, other factors can have on the mechanisms of these the patient was still pain free while taking 75 mg pain syndromes must also be taken into considera- of indomethacin per day. tion in the overall evaluation and treatment. Unfortunately, the pathophysiology of the indomethacin-responsive headaches that can pre- Discussion sent as an orofacial pain is not known. The prac- ticing clinician is encouraged to maintain a broad Because the indomethacin-responsive headache perspective when presented with an orofacial disorders are so rare and are part of the differen- pain without obvious pathology. The fact that tial diagnosis of orofacial pain, a comprehensive these benign headache disorders presenting as evaluation prior to performing irreversible treat- orofacial pain are responsive to indomethacin ments is needed when a patient with an idiopathic warrants a careful évaluation by the dental clini- toothache presents to the dental clinician. cian so that unnecessary irreversible treatment can Irreversible dental treatments (eg, fiOings, crowns. be avoided.

282 Volume 9, Number 3, 1995 Moncada/Graff-Radford

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Resumen Zusammenfassung

Cefaleas Benignas de la Región Orofacial que Gutartige, mit Indomethacín beeinflussbsre Kopf- Responden a la Indometacina: Reporte de Ocho Oasos schmerzen in der Kiefer-Gesichtsregion: Acht Fal- Ibeispiele LBS cefaleas que responden a la indometacina se pueden pre- sentar en la región orofacial. De acuerdo a la clasificación de In der Kiefer-Gesichtsregion können indometinacin-beeinfluss- cefaleas de la Sociedad internacional de Cefaleas, las que bare Kopfschmerzen auftreten, Gemäss der Klassifikation der resporiden a ia indometacina incljyen ia hemicránea paroxistica Kopfschmerzen durch die international iHeadache Society crónica, la hemicránea continua, ia cefalea con tos benigna, la umfassen Indomethacin-beeinflussbare Kopfschmerzen die cefalea de esfuerzo benigno, y el síndrome doioroso cefálico chronisch paroxysmale fHemikranie, die liemicrania continua, das agudo de corla duración, Ei mecanismo por el cuai la gutartige Hustenkopfvjeh, das gutartige Anstrengungskopfweh indometacina produce sus efectos terapéuticos en estos desór- und das stechende kurzandauernde Kopfvjeh Syndrom, Der denes cefáiicos es todavía especulativo. Se presenta una Mechanismus, nach dem das Indomethacin in diesen revisión de ias cefaleas que responden a ia indometacina y Kopfschmerzzustanden therapeutisch wirksam wird, bieibt ocho casos en ios cuaies el sintonía que se manifestó fue el Gegenstand von Spekuiationen, Es vnird eine Übersicht über dolof orofacial. Debido a que estos desórdenes son raros pero indomethacin.beeinflussbare Kopfschmerzen geboten und que se pueden presentar corno dolof facial, se deben consid- aussefdem über acht Fälie berichtet, bei denen das erar en el diagnóstico diferencial del doior orofacial. Es esencial beobachtete Symptom Schmerz m der Kiefer-Gesichts reg ion realizar una evaluación comprensiva antes de llevar a cabo war. Diese Kopfschmerzíuslénde sind zwar Seiten, können aber tratamientos irreversibies, cuando se presente un caso de doior als Gesichtsschmerzen imponieren, und soilten deshaib in die faciai i di o pático. Differentialdiagnose orofacialer Schmerzen einbezogen werden. Für den kiinisch tatigen Zahnarzt ist im Zusammenhang mit idiopathischen Gesichtsschmerzen eine sorgfaltige Evaluation wichtig, bevor irreversibie Behandiungsschntte in die Wege geieitet werden.

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