Migraine is associated with pain in joint connecting jawbone to skull

Study shows patients with chronic migraine are three times as likely to suffer from severe temporomandibular disorder.

By Maria Fernanda Ziegler  |  Agência FAPESP – Migraine is known to be associated with pain in the chewing muscles and has hitherto been associated with temporomandibular disorder (TMD) regardless of the frequency of migraine attacks. The temporomandibular joint acts like a sliding hinge connecting the jawbone to the skull.

A recently published study by researchers at the Medical School of the University of São Paulo – Ribeirão Preto campus (FMRP-USP, in São Paulo State, Brazil) finds that the more frequent the attacks (chronic migraine), the more severe the symptoms of TMD, such as difficulty chewing and tension in the temporomandibular joint, will be.

“Our study shows that patients with chronic migraine, meaning attacks occurring on more than 15 days per month, are three times as likely to report more severe symptoms of TMD than patients with episodic migraine,” said Lidiane Florencio, the first author of the study, which is part of the Thematic Project “Association study of clinical, functional and neuroimaging in women with migraine”, supported by FAPESP.

The study, published in the Journal of Manipulative and Physiological Therapeutics, involved 84 women in their early to mid-thirties, with 21 with chronic migraine and 31 with episodic migraine; 32 with no history of migraine were included as controls. 

Signs and symptoms of TMD were observed in 54% of the control participants without migraine, 80% of participants with episodic migraine, and 100% of those with chronic migraine.

For Florencio, central sensitization may explain the association between the frequency of migraine attacks and the severity of TMD.

“The repetition of migraine attacks may increase sensitivity to pain,” she said. “Our hypothesis is that migraine acts as a factor that predisposes patients to TMD. On the other hand, TMD can be considered a potential perpetuating factor for migraine because it acts as a constant nociceptive input that contributes to maintaining central sensitization and abnormal pain processes.” Nociceptive pain is caused by a painful stimulus on special nerve endings called nociceptors. 

Which came first?

TMD and migraine are comorbidities. However, while people who suffer from migraine are predisposed to have TMD, people with TMD will not necessarily have migraine.

“Migraine patients are more likely to have signs and symptoms of TMD, but the reverse is not true. There are cases of patients with severe TMD who don’t present with migraine,” said Débora Grossi, the lead researcher for the study and principal investigator for the Thematic Project.

The researchers believe that TMD may increase the frequency and severity of migraine attacks, even though it does not directly cause migraine.

“We do know migraine isn’t caused by TMD,” Florencio said. “Migraine is a neurological disease with multifactorial causes, whereas TMD, like cervicalgia – neck pain – and other musculoskeletal disorders, is a series of factors that intensify the sensitivity of migraine sufferers. Having TMD may worsen one’s migraine attacks in terms of both severity and frequency.”

Migraine and TMD have very similar pathological mechanisms. Migraine affects 15% of the general population, and progression to the chronic form is expected in about 2.5% of migraine sufferers.

TMD has multifactorial causes, including stress and muscle overload. It involves a constellation of signs and symptoms, including joint pain, reduced jaw movement, clicking or popping of the temporomandibular joint, muscle pain and fatigue, and/or radiating face and neck pain.

The journal article concludes that an examination of TMD signs and symptoms should be clinically conducted in patients with migraine.

“Our findings show the association with TMD exists but is less frequent in patients with rare or episodic migraine,” Grossi said. “This information alone should change the way clinicians examine patients with migraine. If migraine sufferers tend to have more severe TMD, then health professionals should assess such patients specifically in terms of possible signs and symptoms of TMD.”

The article “Association between severity of temporomandibular disorders and the frequency of headache attacks in women with migraine: a cross-sectional study” (https://doi.org/10.1016/j.jmpt.2017.02.006), by Lidiane Lima Florencio, Anamaria Siriani de Oliveira, Gabriela Ferreira Carvalho, Fabiola Dach, Marcelo Eduardo Bigal and César Fernández-de-las-Peñas and published in Journal of Manipulative and Physiological Therapeutics, can be retrieved from jmptonline.org/article/S0161-4754(17)30045-3/pdf.