Classification of Headaches and Orofacial pains

Differential diagnosis of headaches and orofacial pains

The approach to differential diagnosis of orofacial pains and headaches cannot be separated from the concept that, being periodontal dental and arthromuscular diseases of the masticatory system vastly prevalent, they are also of great significance.

Any different diagnostic hypotesis must, therefore, be formulated only after excluding the above pathologies through a careful assessment (see chapter on Pains).

Henceforth we will deal with the subject matter concerning headaches and craniofacial neuralgias, which, in differential diagnosis, are to be considered in combination with odontostomatology -related pains (biblio 1, 2, 3, 4)

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3)mayohealth.org
4)tna-support.org
5)drshankland.com

Headache from pulpitis

Localization/projection of pain in 55 cases of molar pulpitis (pulpal dental pain) from the upper (left) and lower arch (right) (maxillary, mandibular, zygomatic, mandibular angular, auricular, ocular, temporal zone) By Sharav et all, 1984

Headaches
The classification of headaches and orofacial pains proposed by the International Association for Studies on Pain (IASP) involves dividing all pains into the following categories:

1) pains of the head and neck region
2) thoracic pains
3) abdominal pains
4) extremity pains

In turn, head and neck pains are subdivided into:

A) orofacial pains
B) headaches
C) cervical pains
(biblio 5)

I.H.S. Classification of headaches and orofacial pains.
In 1988 the International Headache Society (I.H.S.) published the first classification of headaches and orofacial pains. (biblio 6)
According to this classification temporo mandibular joint and orofacial pains fall into category number 11 (Headache or facial pain associated with disorders of cranium, neck , eyes, nose, sinuses, teeth, mouth, or other facial or cranial structures).
Category number 11 is divided into 3 subgroups (11.1, 11.7, 11.8) to identify original pains from occlusal masticatory problems (dysfunctional arthropathy, myofascial pain syndrome and arthrosis).

Classification of Headaches, Cranial neuralgias and Orofacial pains (International Headache Society, 1987) 1) Migraine headache 2) Tension-type headache 3) Cluster headache 4) Miscellaneous headaches, unassociated with structural lesions 5) Headache associated with head trauma 6) Headache associated with nonvascular intracranial disorders 7) Headaches associated with vascular intracranial disorders 8) Headache associated with substances or their withdrawal 9) Headache associated with noncephalic infection 10) Headache associated with metabolic disorder 11) Headache or facial pain associated with disorder of 11.1 – cranium 11.2 – neck 11.3 – eyes 11.4 – ears 11.5 – nose or paranasal sinuses 11.6 – teeth and other facial or cranial structures (see picture*) 11.7 – temporo mandibular joint** 11.8 – chewing muscles-mouth*** 12) Cranial neuralgias, nerve trunk pain, deafferentation pain 13) Headaches not classifiable * 11.1 Cranial bones including mandible (International Headache Society,1987) 11.1.1 Congenital and malformative pathologies (developmental conditions) 11.1.1.1 Aplasias 11.1.1.2 Hypoplasias 11.1.1.3 Hyperplasias 11.1.1.4 Dysplasias 11.1.2 Acquired conditions 11.1.2.1 Neoplasias 11.1.2.2 Fractures ** 11.7 Temporo mandibular joint (International Headache Society, 1987) 11.7.1 Congenital and malformative pathologies (developmental conditions) 11.7.1.1 Aplasias 11.7.1.2 Hypoplasias 11.7.1.3 Hyperplasias 11.7.1.4 Neoplasias (see picture**) 11.7.2 Condyle disc displacement pathologies (incoordinations, intracapsular alteration ‘internal derangement’) 11.7.2.1 reducing disc displacement 11.7.2.2 nonreducing disc displacement (see picture***) 11.7.3 Temporo mandibular joint displacement (subluxation) 11.7.4 Inflammatory pathologies 11.7.4.1 Capsulitis / Synovitis (see figure****) 11.7.4.2 Polyarthritis 11.7.5 Osteoarthrosis (noninflammatory) 11.7.5.1 Primary osteoarthrosis 11.7.5.2 Secondary osteoarthrosis 11.7.6 Ankylosis 11.7.7 (Condyle) fractures *** 11.8 Masticatory muscles pathologies (International Headache Society, 1987) 11.8.1 Myofascial pain 11.8.2 Myositis 11.8.3 Myospasm 11.8.4 Local myalgia (non classified) 11.8.5 Myofibrotic contracture 11.8.6 Neoplasia *Dysodontiasis caused by dental inclusion 26: left: panoramic radiographic image; right: three-dimensional computerized reconstruction. **Left temporo-mandibular joint osteoma: inspection (preauricular tumefaction), infraocclusion (opening of the left bite), tomoscintigraphy (SPECT) and computerized tomography (the tumor is in the center of the red circle) images ***Dysfunctional arthropathy with condyle derangement and anterior disc displacement (report in RNM) ****TMJ arthritis (synovitis) with escape into the superior compartment. (effusion) (report in RNM/T2)

However, this classification does not include neuropathic and psychogenic pains. On the basis of the origin of pain, it is indeed necessary to take into account the fact that somatic and psychogenic pains arise from different and particular ‘structures’ and ‘conditions’ respectively:
(biblio 7)

Somatic pain (nociceptive)
1) cutaneous and mucogingival
2) mucous from pharynx, nose and paranasal sinuses
3) dental
4) musculoskeletal structures, mouth and face
5) mouth and face visceral structures
6) mouth and face neurologic structures

Psychological conditions (of psychogenic origin)
1) anxiety disorders
2) mood disorders
3) somatoform disorders
4) other conditions (psychological factors determining a medical condition)
(biblio 8)

In this regard, more exhaustive appears the classification proposed in 1996 by Okeson, on behalf of the American Academy of Orofacial Pain (A.A.O.P.). Such classification is divided into two ‘axis’ , on the basis of ‘physical’ (axis I) and ‘psychologic’ (axis II) conditions, as follows:

(biblio 6)

The location of pain is not necessarily the same as that of the pathology. In particular, pains arising from muscular, vascular and neuropathic structures can be referred to locations far away from the lesion.

Patients affected by orofacial chronic pains and headaches must be carefully examined to distiguish pains of different origins that may cohexist (concomitance of two or more pathologies). It is widely believed that a patient affected by headache my find the adjuvant, predisposing cause in the temporo mandibular arthromuscular pathology (temporo mandibular arthropathy). This is usually true only for tension-type headaches but not for other headache categories.

Indeed, it seems that in tension-type headaches:
- the episodic attack may be triggered by a prolonged, intense parafunctional activity (bruxism)
- treatment of the temporo mandibular arthropathy may improve the headache (reduction of headache frequency and intensity)

In a survey carried out by Ciancaglini et al. the number of cases of headache associated with temporo mandibular disorders (TMJ) turned out to be almost double to that of cases of headache nonassociated with TMJ disorders.
(biblio 9, 10, 11, 12, 13, 14, 15, 16)

Prevalence of headache and temporomandibular disorders in a sample of 483 adults in the area of Segrate (Mi)

The relationship between headache and symptoms of temporomandibular disorders in the general population - R. Ciancaglini, G. Radaelli J. Of Dentistry. 29 (2001) 93-98

Therefore, knowledge of the main types of headache and a summary competence in their differential diagnosis can help to identify the tension forms and make the best of the gnathologic therapeutic contribution (diagnosis and therapy of the temporomandibular musculoskeletal disorders), so as to improve health and quality of life of many patients affected by (episodic tension) headache.
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In order to make it easier, the most common type of (sintomatic and primary) headaches and (paroxysmal and continuous) craniofacial neuralgias will be hereafter illustrated.

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