Association between periodontitis and chronic migraine: a case-control study.

The aim of this investigation was to examine whether chronic periodontitis (CP) is a risk indicator of chronic migraine (CM). We performed a case-control study consisted of 102 cases (patients diagnosed with CM) and 91 controls (non-CM individuals) matched by age and gender. Full-mouth periodontal charts, demographic, medical, clinical, as well as neurological data were obtained. In addition, high sensitive C-reactive protein serum levels were determined from blood samples of both cases (taken during migraine interictal period) and controls. The prevalence of CP was significantly higher in patients with CM compared to those without CM (58.8 vs. 30.8%, p < 0.0001). Logistic regression analysis showed that CP was significantly associated with the presence of CM, independently of well-known chronifying factors of migraine (OR 2.4; 95% CI 1.2-4.7; p = 0.012). Based on our results, CP could be considered as a risk indicator of CM. However, more evidence is necessary to investigate if this relationship is causal or not.

Pain. Part 10: Headaches.

This last in a series of 10 papers aims to provide the dental and medical teams with an update in headache conditions relevant to dentistry and medicine. Headache is the most common presenting symptom for patients presenting to A&E departments. CPD/Clinical Relevance: Most of the dental team take for granted their knowledge and ability to manage acute dental pain. However, the education and preparation in managing patients with headache conditions remains poor. Dentists are in a privileged position to be able to advise their patients about common conditions including headaches.

Association between tension-type headache and migraine with sleep bruxism: a systematic review.

AIM: To evaluate the association between tension-type headache and migraine with sleep bruxism (SB). BACKGROUND: The association between SB and headaches has been discussed in both children and adults. Although several studies suggested a possible association, no systematic analysis of the available published studies exists to evaluate the quantity, quality, and risk of bias among those studies. METHODS: A systematic review was undertaken, including articles that classified the headaches according to the International Classification of Headache Disorders and SB according to the criteria of the American Association of Sleep Medicine. Only articles in which the objective was to investigate the association between primary headaches (tension-type and migraine) and SB were selected. Detailed individual search strategies for The Cochrane Library, MEDLINE, EMBASE, PubMed, and LILACS were developed. The reference lists from selected articles were also checked. A partial grey literature search was taken by using Google Scholar. The methodology of selected studies was evaluated using the quality in prognosis studies tool. RESULTS: Of 449 identified citations, only 2 studies, both studying adults, fulfilled the inclusion criteria. The presence of SB significantly increased the odds (study 1: odds ratio [OR] 3.12 [1.25-7.7] and study 2: OR 3.8; 1.83-7.84) for headaches, although studies reported different headache type. CONCLUSION: There is not enough scientific evidence to either support or refute the association between tension-type headache and migraine with SB in children. Adults with SB appear to be more likely to have headache.

How to investigate and treat: migraine in patients with temporomandibular disorders.

Migraine and temporomandibular disorders (TMD) are highly prevalent conditions that frequently coexist in the same patient. The relationship between migraine and TMD is complex. Migraineurs often have pain in the TMD area; TMD sufferers, in turn, often experience headaches in addition to the pain in the jaw. Finally, migraine and TMD are comorbid, and the final phenotype of patients with the comorbidity may represent the aggregated contribution of both. Herein we briefly discuss the clinical commonalities of migraine and TMD, and the differential diagnosis of these conditions with other causes of facial pain. We close by presenting our experience in the treatment of patients with the comorbidity.

[Severe odontalgic pain preceding migraine attacks]. / Ernstige odontogene pijn voorafgaand aan een migraineaanval.

A 30-year-old woman appeared at the gnathology department of a centre for special dentistry complaining of migraine attacks which were preceded each time by severe odontalgic pain. Furthermore, she suffered from an autoimmune disease as well as from tension headaches. The oral health care provider in charge suspected that the episodes of odontalgic pain, which lasted for several hours or even several days, were caused by bruxism. Treatment of the bruxism resulted in reduced pain as well as reduced severity of the migraine attacks.

Changes in salivary prostaglandin levels during menstrual migraine with associated dysmenorrhea.

OBJECTIVE: To measure prostaglandin levels in the saliva of individuals during menstrual migraine associated with dysmenorrhea (MMaD) and in response to treatment with a single tablet combination of sumatriptan succinate and naproxen sodium. BACKGROUND: Prostaglandins are thought to play a role in MMaD as elevated serum prostaglandin levels have been reported during attacks of menstrual migraine and are increased in the menstrual fluid of women with dysmenorrhea. While triptans are the primary line of migraine treatment, nonsteriodal anti-inflammatory drugs are the most commonly prescribed therapy for dysmenorrhea symptoms. Data from recent clinical studies have provided evidence that treatment with a single tablet combination of sumatriptan and naproxen sodium is an effective abortive therapy for attacks of MMaD. METHODS: Women diagnosed with MMaD were treated with a sumatriptan succinate and naproxen sodium single tablet combination or placebo at time of migraine attack. Saliva samples were collected at time of attack as well as 2 and 4 hours after treatment. PGD(2), PGE(2), PGF(2), PGI(2), and TXA(2) levels were determined by enzyme-linked immunosorbent assay. RESULTS: Elevated levels of PGD(2), PGF(2), and TXA(2) at 2 and 4 hours and PGE(2) at 4 hours were found in saliva obtained from placebo subjects when compared with onset of attack levels. However, in subjects treated with a single tablet combination of sumatriptan and naproxen sodium, the levels of PGD(2), PGF(2), and PGE(2) were not elevated at either time point while TXA(2) levels were still elevated at 4 hours. CONCLUSIONS: Data from this pilot study provide evidence that saliva levels of several prostaglandins increase during attacks of MMaD and that treatment with a single tablet combination of sumatriptan and naproxen sodium prevents elevation of prostaglandin levels.

Chronic migraine headache and multiple dental pathologies causing cranial pain for 35 years: the neurodental nexus.

We report a case that illustrates how chronic migraine headaches and multiple dental pathologies caused severe and long-standing cranial pain that affected the quality of life of a man for more than 35 years. His case was investigated at several settings including the neurology outpatient clinic of the hospital without a definitive diagnosis or resolution. After investigations, multiple oral pathologies including two occult dental abscesses were diagnosed. Once both affected teeth and associated abscesses were surgically removed, with subsequent antibiotic therapy the headaches resolved.

The International Classification of Headache Disorders: accurate diagnosis of orofacial pain?

The aim was to apply diagnostic criteria, as published by the International Headache Society (IHS), to the diagnosis of orofacial pain. A total of 328 consecutive patients with orofacial pain were collected over a period of 2 years. The orofacial pain clinic routinely employs criteria published by the IHS, the American Academy of Orofacial Pain (AAOP) and the Research Diagnostic Criteria for Temporomandibular Disorders (RDCTMD). Employing IHS criteria, 184 patients were successfully diagnosed (56%), including 34 with persistent idiopathic facial pain. In the remaining 144 we applied AAOP/RDCTMD criteria and diagnosed 120 as masticatory myofascial pain (MMP) resulting in a diagnostic efficiency of 92.7% (304/328) when applying the three classifications (IHS, AAOP, RDCTMD). Employing further published criteria, 23 patients were diagnosed as neurovascular orofacial pain (NVOP, facial migraine) and one as a neuropathy secondary to connective tissue disease. All the patients were therefore allocated to predefined diagnoses. MMP is clearly defined by AAOP and the RDCTMD. However, NVOP is not defined by any of the above classification systems. The features of MMP and NVOP are presented and analysed with calculations for positive (PPV) and negative predictive values (NPV). In MMP the combination of facial pain aggravated by jaw movement, and the presence of three or more tender muscles resulted in a PPV = 0.82 and a NPV = 0.86. For NVOP the combination of facial pain, throbbing quality, autonomic and/or systemic features and attack duration of > 60 min gave a PPV = 0.71 and a NPV = 0.95. Expansion of the IHS system is needed so as to integrate more orofacial pain syndromes.

Primary Headaches.

The primary headaches are composed of multiple entities that cause episodic and chronic head pain in the absence of an underlying pathologic process, disease, or traumatic injury. The most common of these are migraine, tension-type headache, and the trigeminal autonomic cephalalgias. This article reviews the clinical presentation, pathophysiology, and treatment of each to help in differential diagnosis. These headache types share many common signs and symptoms, thus a clear understanding of each helps prevent a delay in diagnosis and inappropriate or ineffective treatment. Many of these patients seek dental care because orofacial pain is a common presenting symptom.

Case of primary Sjogren's syndrome preceded by dystonia.

There are only six cases in literature that describe development of dystonia with Sjogren's syndrome (SS). We describe a case of a 43-year-old woman who presented with symptoms including movement disorder, sensory neurogenic bladder, sensory loss and neuropathic pain, migraine like headaches, musculoskeletal pain, Raynaud's phenomenon and dysautonomia. Symptoms started in 2000, with weakness that progressed to dystonia in 2003. Diagnostic work-up was inconclusive with negative inflammatory serologies, cerebrospinal fluid and MRI for many years. After patient developed sicca syndrome with dry eyes and mouth in 2009, her rheumatoid factor titre was elevated (550 IU/mL), erythrocyte sedimentation rate, anti-Sjogrens syndrome-related antigen A (anti-Ro/SSA) and anti-SSB/La: anti-Sjogrens syndrome-related antigen B (anti-La/SSB) became positive. Lip biopsy confirmed diagnosis of SS. She was diagnosed with primary SS with neurological involvement. Her symptoms responded well to intravenous methylprednisolone. Symptoms stabilised with trials of immune-suppressive therapy. This is a case that demonstrates the delay of diagnosing SS with preceding unique neurological association.

Is stress a trigger factor for migraine?

BACKGROUND: Although mental stress is commonly considered to be an important trigger factor for migraine, experimental evidence for this belief is yet lacking. OBJECTIVE: To study the temporal relationship between changes in stress-related parameters (both subjective and objective) and the onset of a migraine attack. METHODS: This was a prospective, ambulatory study in 17 migraine patients. We assessed changes in perceived stress and objective biological measures for stress (saliva cortisol, heart rate average [HRA], and heart rate variability [low-frequency power and high-frequency power]) over 4 days prior to the onset of spontaneous migraine attacks. Analyses were repeated for subgroups of patients according to whether or not they felt their migraine to be triggered by stress. RESULTS: There were no significant temporal changes over time for the whole group in perceived stress (p=0.50), morning cortisol (p=0.73), evening cortisol (p=0.55), HRA (p=0.83), low-frequency power (p=0.99) and high-frequency power (p=0.97) prior to or during an attack. Post hoc analysis of the subgroup of nine stress-sensitive patients who felt that >2/3 of their migraine attacks were triggered by psychosocial stress, revealed an increase for perceived stress (p=0.04) but no changes in objective stress response measures. At baseline, this group also showed higher scores on the Penn State Worry Questionnaire (p=0.003) and the Cohen Perceived Stress Scale (p=0.001) compared to non-stress-sensitive patients. CONCLUSIONS: Although stress-sensitive patients, in contrast to non-stress-sensitive patients, may perceive more stress in the days before an impending migraine attack, we failed to detect any objective evidence for a biological stress response before or during migraine attacks.

Evaluation of pericranial tenderness and oral function in patients with common migraine, muscle contraction headache and 'combination headache'.

Oral function was evaluated in a group of 13 patients with muscle contraction headache (MCH), 7 patients with common migraine (CM) and 18 patients with 'combination headache' (CM + MCH) and in a control group of 25 normal persons who had never had a headache. Malocclusion and loss of molars were rare in both groups. Impaired denture function and joint disturbances were more frequent in the headache patients but not significantly so. Clenching and grinding teeth and tongue pressure were all significantly more common in headache patients. Tenderness of pericranial muscles was present in all headache patients with severity increasing in the order CM, MCH, CM + MCH; it was absent in all the controls. On the average 9 tender spots were found per patient. Pressure on tender spots evoked pain in other areas (referred pain) in 29 of 38 headache patients. The abnormal tonic hyperactivity in the masticatory muscles and the neck may be the cause of tenderness which again may be an important source of pain in these patients.

A spectrum of exertional headaches.

Headaches that have an explosive onset with exercise, including sexual activity, generally are benign in origin. A subarachnoid hemorrhage, a mass lesion in the brain, or an anomaly of the posterior fossa must be considered, however. The mechanisms that produce sexually induced or cough headaches of abrupt onset are unknown. It is known, however, that a rapid increase in intrathoracic pressure suddenly reduces right atrial pressure and presumably decreases venous sinus drainage from the brain. This situation results in a transient increase in intracranial pressure. Jaw pain that occurs with chewing often is considered to be TMJ dysfunction when arthritic in quality and if subluxations of the jaw can be shown on the physical examination. Giant cell arteritis and common or external carotid artery occlusive disease should be considered when the pain is ischemic in quality. An anginal equivalent is another possibility. Headaches that worsen with vigorous exercise are commonly migrainous. When their onset is apoplectic with exertion (particularly exertion against a closed glottis), the most likely diagnoses are increased intracranial pressure, a posterior fossa abnormality, or benign exertional headaches. Most cardiac induced headaches, but not all, are of a more gradual onset. If there are significant risk factors for coronary artery disease, an exercise stress test is appropriate. A therapeutic trial of nitroglycerin may help to establish a diagnosis if it improves the headache. Using antimigraine drugs as a diagnostic test is inappropriate because triptans and ergots are contraindicated in the presence of coronary artery disease, and a positive response is not diagnostic of migraine.

What is the genetic factor in migraine?

Migraine is frequently assumed to have an hereditary origin, but what this hereditary factor is, no one really knows. Researchers are currently trying to find defects in genes which could either cause, or tend towards, the development of migraine. This approach is deemed mistaken for two reasons: firstly, pain, being only a signal of an essential monitoring system, cannot be an inheritable factor on its own without the accompanying physiological or pathological processes which give rise to it; and secondly, physicians, almost universally, fail to examine a large part of the head, viz., the mandible and maxillae and their appendages, before making their diagnoses or providing treatment, thereby contravening the fundamental principle of properly examining patients. It is hereby suggested, and evidence is offered showing that impacted teeth could be the long sought-after 'hereditary' factor causing migraine.

Treatment of chronic paranasal sinus pain with minimal sinus disease.

A common problem for otolaryngologists are patients who present with recurrent, persistent sinus pain that appears out of proportion to the findings on physical examination. Often these patients have a history of recurrent sinusitis that required antibiotics or surgical intervention. Many have had repeated surgical procedures because of this pain. Other common past medical histories may include allergic rhinitis, facial trauma, or dental disease. Patients who have experienced documented acute sinusitis in the past will often present de novo with similar symptoms, but lack any objective evidence of a new active sinus infection. However, the diagnosis of sinusitis is not clearly removed from the patient's or clinician's mind, and the patient is further frustrated by the lack of adequate diagnosis, treatment, and resolution of symptoms. These patients may or may not be experiencing an upper respiratory tract infection or allergy with nasal drainage. Often, they are emotionally distraught from recurrent and persistent pain, the lack of resolution of their symptoms, dependency on narcotics and other analgesics, multiple consultations with a variety of clinicians, and the impingement of their symptoms on employment, interpersonal relationships, and societal and family obligations. If sinusitis is not found to be present, the otolaryngologist must help the patient understand this point, reassure him or her that the otolaryngologist will still be vigilant for the development of sinusitis, and refocus the history and workup for some other cause of the recurrent and persistent paranasal pain. We review various treatment approaches to paranasal pains that are not the result of sinusitis.

Mandibular tori, migraine and temporomandibular disorders.

In this study the presence of mandibular tori was related to conditions associated with parafunctional activity. Parafunction in the form of tooth clenching or grinding has been associated with temporomandibular disorders (TMD) and recently migraine. Patients attending a facial pain clinic in Belfast were assessed for the presence of tori and results compared to age and gender matched controls. The findings were that mandibular tori were present significantly more commonly in both migraineurs and TMD patients. The results support an association with parafunction in the aetiology of mandibular tori and suggest that tori are a useful marker of past or present parafunction in some patients.

Clinical effectiveness of occlusal splint therapy in patients with classical migraine.

A clinically similar entity to classical migraine is seen in certain dental patients suffering from temporomandibular joint (TMJ) pain dysfunction syndrome. Patients selected for study gave symptoms of classical migraine on waking. Facial pain on waking is typical of some cases of TMJ dysfunction syndrome and the hypothesis was tested that some patients with symptoms of classical migraine were at the extreme end of the spectrum of dysfunction syndrome. However, rather than experience muscle or temporomandibular joint pain these patients had symptoms on waking which were typical of classical migraine. Nineteen patients with migraine symptoms were provided with acrylic occlusal splints for nocturnal wear. A good clinical response with considerable reduction in frequency and severity of pain attacks was achieved.

Prevalence of modalities of headaches and bruxism among patients with craniomandibular disorder.

This study compared the presence of headache and bruxing behavior among 133 craniomandibular disorder patients (CMD) referred to the The Center For the Study Of Craniomandibular Disorders and to the presence of headache and bruxing behavior occurring in 133 controls seeking routine dental care. Both patients and controls were consecutive referrals to the clinic occurring over a three year period. The mean age of the CMD group was 38 years (range 28-42), and the mean age of the controls was 37 years (range 25-44). The information gathered included questionnaire and clinical examination. Different types of headaches, signs and symptoms of CMD, and bruxing behavior were assessed both in the CMD group and in the corresponding control group. Results of this study showed that bruxing behavior and headache pain were significantly more prevalent in the CMD group (57%, 76%) than in the corresponding control group (37%, 49%). Of the three types of headache observed, tension and combination headaches were more prevalent in the CMD group (n = 48 = 36% and n = 37 = 28%). Migraine headache was more prevalent in the CMD group (n = 16 = 12%) than in the control group (n = 3 = 2%). It was concluded that headache and bruxing behavior predominated in CMD patients. This data reinforces the need to assess headache pain and signs and symptoms of bruxing behavior in CMD patients, particularly in those suffering chronic facial pain and headache.