Did you know your headache could be associated with neck and jaw pain?
There is evidence that temporomandibular disorder (TMD) may be a contributing factor to cervicogenic headache (CGH), in part because of the influence of dysfunction of the temporomandibular joint (TMJ) on the neck (Piekartz, Hall 2012).
In our office, I see patients with varying origins of headache. Some have often already seen their family physician, and in some cases, a neurologist. They have been managing with medications. Some people have migraine type symptoms. They will report of a distinguishable headache and migraine. Many have had a CT scan or x-ray, which is often unremarkable for any profound problem. Even by this time, recommendations for physical therapy have not even been considered.
When I begin my subjective history of the patient, it’s a given that I ask if they’ve experienced any neck pain. Most often, there is a reported tension and/or limited movement in the neck; perhaps a relation to a motor vehicle collision; possible trauma due to work or sport; postural influence, or arthritis. Over the years, I’ve come to habitually include asking about whether or not they are experiencing any facial pain. To no surprise, they are or have been. Upon asking further, these patients will also admit to clenching or grinding their teeth, some degree of psychological stress, and perhaps TMJ noise or erratic movements when they open and close. Without doubt, there is a close anatomical and functional relationship between the neck and TMD.
One of the main reasons, or mechanisms that TMD may contribute to headache is based on the nerve-muscle relationship that exists. There can be a hypersensitivity that occurs in the nervous system, affecting what is known as the Trigeminocervical nucleus. This is a region of the upper spinal cord where nerves that transmit sensation interact with nerve roots exiting the upper spine. The result of this interaction can result in a referral pattern in the head, neck and face, when there is insult to create pain.
Manipulation or graded mobilization to the neck, in combination with manual therapy treatment to the TMJ has shown a greater beneficial effect than just usual care alone for neck movement problems. Prior to treatment, a skilled physical therapy practitioner with expertise in TMJ management should assess you. Treatment of the TMJ can involve manual therapy to desensitize muscles; restoration of normal functional movement pattern through exercise, and providing education regarding prognosis and self applied maintenance. Treatment for the neck and TMJ may also include other muscle re-education techniques such as Intramuscular Stimulation (IMS). In the end, it’s our duty to examine for features of TMD as part of our examination of patients with headache, particularly when they do not respond to usual manual therapy care for the neck. For us, it’s simply asking about facial pain. For you, it’s certainly worth mentioning when we ask, to ensure that we optimize the treatment benefit by also treating your jaw, or at the very least referring to someone who can.
Vince Cunanan is a Registered Physiotherapist and Associate at Sun City Physiotherapy. He is a member of the Canadian Physiotherapy Association, Chair of the National Orthopaedic Division, and Fellow of the Canadian Academy of Manual and Manipulative Physical Therapists (FCAMPT). He can be contacted by phone at 250-861-8056 or by email.