Effect of comorbid migraine on propranolol efficacy for painful TMD in a randomized controlled trial.

INTRODUCTION: The migraine-preventive drug propranolol is efficacious in reducing pain from temporomandibular disorder, suggesting potential modifying or mediating effects of comorbid migraine. METHODS: In this randomized controlled trial, myofascial temporomandibular disorder patients were treated with propranolol or placebo for 9 weeks. The primary endpoint was change in a facial pain index derived from daily symptom diaries. Linear and logistic regression models tested for a migraine × treatment-group interaction in reducing facial pain index. Counterfactual models explored changes in headache impact and heart rate as mediators of propranolol's efficacy. RESULTS: Propranolol's efficacy in reducing facial pain index was greater among the 104 migraineurs than the 95 non-migraineurs: For example, for the binary ≥ 30% reduction in facial pain index, odds ratios were 3.3 (95% confidence limits: 1.4, 8.1) versus 1.3 (0.5, 3.2), respectively, although the interaction was statistically non-significant (p = 0.139). Cumulative response curves confirmed greater efficacy for migraineurs than non-migraineurs (differences in area under the curve 26% and 6%, respectively; p = 0.081). While 9% of the treatment effect was mediated by reduced headache impact, 46% was mediated by reduced heart rate. CONCLUSIONS: Propranolol was more efficacious in reducing temporomandibular disorder pain among migraineurs than non-migraineurs, with more of the effect mediated by reduced heart rate than by reduced headache impact. STUDY IDENTIFICATION AND REGISTRATION: SOPPRANO; NCT02437383; https://clinicaltrials.gov/ct2/show/NCT02437383.

Chronic atypical first bite syndrome and primary squamous cell carcinoma of the parotid.

BACKGROUND: First bite syndrome is a well-recognized complication of parapharyngeal space surgery. There are no reported cases of protracted first bite syndrome and subsequent diagnosis of a primary squamous cell carcinoma (SCC) of the parotid. METHODS: We present the case of a 73-year-old man with no surgical history and 9 years of first bite syndrome who was ultimately diagnosed with a primary SCC of the parotid. Diagnostic workup, including MRI and biopsy, along with oncologic treatment, were performed. RESULTS: Surgical treatment confirmed malignancy and also resulted in complete resolution of the first bite syndrome. CONCLUSION: First bite syndrome without prior surgery may warrant further diagnostic workup with imaging to evaluate for salivary gland pathology. When no radiographic mass lesion is detected but the patient displays protracted symptoms unresponsive to conservative therapy, one should maintain an index of suspicion for malignancy, especially in the presence of symptom escalation.