Dentaltown September 2024 - 48

* During the headache, the patient
experiences one of the following:
nausea and/or vomiting, and photophobia
and phonophobia.
While uncommon, patients can
experience migraine in the V2 and V3
distributions, and this is known as
orofacial migraine. Pain can involve
the teeth, jaws, sinuses and the ears.
Autonomic symptoms may also
accompany the migraine.
In some, migraine begins with
a prodrome phase, during which a
patient can experience fatigue, depression,
diffi culty concentrating, neck
stiff ness, blurry vision, nausea, light
and sound sensitivity and osmophobia.
Th e prodrome starts a few hours
to two days before the headache.
In 30% of patients with migraine,
an aura occurs, which immediately
precedes the headache and can last
fi ve to 60 minutes. Th e classic aura
is a visual disturbance but can also
include sensory and speech dysfunction.
It's important to remember that
the aura is completely reversible. Th en,
the headache occurs, after which there
is the postdrome phase, when the
patient feels very tired and may also
experience a lower-intensity headache.
Th e pathophysiology of migraine
is not completely understood, but
current understanding explains that
in migraine, the dural trigeminovascular
system is activated. Both
peripheral and central mechanisms
are at play. When migraine is triggered,
trigeminal aff erents in the dura
are stimulated and secrete specifi c
neurotransmitters that act on the
dural vasculature, ultimately leading
to vasodilation and infl ammation.
Th is causes pain and leads to central
activation in the trigeminal nucleus,
where painful neurotransmitters are
released, leading to sterile neurogenic
infl ammation.
Because of the trigeminocervical
inputs to the trigeminal nucleus
caudalis, symptoms of neck pain
and jaw pain can accompany the
migraine. In addition, pain modulatory
pathways in the central nervous
system can be dysfunctional in those
with migraine.
Migraine management depends
on attack frequency and disability.
Abortive medications can be used as
needed for migraine attacks. Th ese
include over-the-counter analgesics,
the triptan class of medications,
and calcitonin gene-related peptide
(CGRP) antagonists. For frequent
migraines, preventive therapy is
recommended. Th ese include medications,
supplements and injections.
Preventive medications include anticonvulsants,
beta-blockers, tricyclic
antidepressants, CGRP antagonists
and onabotulinum toxin injections.
In addition, trigeminal and occipital
nerve blocks can be helpful.
Clinical pearl: Migraine presents
with specifi c clinical features that are
easily diff erentiated from odontogenic
pains. It is also important to recognize
that sinusitis-like symptoms
often accompany migraine and can
lead to a misdiagnosis of sinusitis in
these patients.
Conclusion
Non-odontogenic pains can be
complex and challenging, but understanding
the various sources of such
pains will help clinicians make more
accurate diagnoses and, most importantly,
avoid unnecessary invasive
and irreversible dental procedures.
SEPTEMBER 2024 | 48 | DENTALTOWN.COM
It is important to communicate these
causes with the patient and work with
an orofacial pain specialist to help
manage these cases. DT
References
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fiction. Cephalalgia. 2017 Jun; 37(7):670-679.
Kim ST. Myofascial pain and toothaches. Aust Endod J 2005;
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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.
International Classification of Orofacial Pain, 1st edition (ICOP).
Cephalalgia. 2020; 40(2):129-221.
Klasser GD, Reyes MR, American Academy of Orofacial Pain.
Orofacial Pain: Guidelines for Assessment, Diagnosis, and
Management 7th Edition. Quintessence Publishing. 2023.
Clark GT, Padilla M, Dionne R. Medication treatment eff icacy and
chronic orofacial pain. Oral Maxillofac Surg: Clin North Am.
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Sharav Y, Katsarava Z, Charles A. Facial presentations of primary
headache disorders. Cephalalgia. 2017; 37(7):714-19.
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.
Gronseth G, et al. Practice parameter: the diagnostic evaluation
and treatment of trigeminal neuralgia (an evidence-based
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71(15):1183-1190.
Seena Patel, DMD, MPH, is the director
of oral medicine and an associate
professor at A.T. Still University's Arizona
School of Dentistry & Oral Health (ATSUASDOH).
Patel is also an associate at
Southwest Orofacial Group in Phoenix,
practicing orofacial pain, oral medicine
and dental sleep medicine since 2012.
A diplomate of the American Board of
Orofacial Pain and the American Board of
Oral Medicine, she earned her DMD and
MPH degrees from ATSU-ASDOH and
completed her residency in orofacial pain
and oral medicine at the Herman Ostrow
School of Dentistry at the University of
Southern California.
http://www.DENTALTOWN.COM
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