Elsevier

Journal of Endodontics

Volume 32, Issue 11, November 2006, Pages 1110-1113
Journal of Endodontics

Case report/clinical technique
Case Series of Four Different Headache Types Presenting as Tooth Pain

https://doi.org/10.1016/j.joen.2006.02.033Get rights and content

Abstract

Case reports in the literature discuss various headache disorders that present as pain in the face. The current understanding of neuroanatomy and headache mechanisms suggests that headache pain originates within intracranial structures and is then referred to the face, jaws, and teeth. This case series describes four patients, one each with migraine headache, cluster headache, paroxysmal hemicrania, and hemicrania continua, all of which who presented to dentists with the chief complaint of tooth pain. This is the first report of hemicrania continua presenting as tooth pain. It is important that dentists be cognizant of headache disorders so that they may be able to identify headache pains masquerading as toothache.

Section snippets

Neuroanatomy

The trigeminovascular system is comprised of sensory fibers that densely innervate the cerebral blood vessels and dura mater (8). The trigeminal innervation is predominantly to the forebrain but extends posterior to the rostral basilar artery, whereas the more caudal vessels are innervated by branches of the C2 and C3 dorsal roots, which also synapse with the central trigeminal neurons at the level of the trigeminal nucleus (9).

The ophthalmic division of the trigeminal nerve innervates the vast

Review of Mechanisms

The current theory for headache is that antidromic release of neuropeptides and inflammatory mediators, such as calcitonin gene related peptide (CGRP), substance P, prostaglandins and neurokinin A, are responsible for neurogenic inflammation (9, 12, 13). Primary headaches such as migraine, cluster and paroxysmal hemicrania are associated with increased levels of CGRP measured from the jugular vein during headache pain. This sterile inflammation has been shown to result in an increase of

Headache Classification

The International Headache Society (IHS) has developed diagnostic criteria for headache disorders that have become the gold standard for headache research and clinical care (20). Listed below are the corresponding IHS diagnostic criteria for each patient who presented to their dentist with presumed odontogenic pain.

Case 1

A 43-year-old white male presented with a dull, aching, throbbing deep pain in the left maxillary molar region. This pain was intermittent, with an intensity of 7 to 8/10, lasted 2 hours to 5 days and caused him to miss work and goes to bed. The pain had been present for 8 years. During that time he had underwent multiple general dental and medical evaluations, as well as seeing an Endodontist, TMD practioner, Oral Surgeon, Chiropractor, Massage Therapist, and a Neurologist without palliation.

Conclusion

Headache disorders can present with pain in any region of the trigeminal neurosensory distribution, including the teeth and jaws. These patients may present to their dentist for evaluation and treatment of a suspected odontogenic reason for their toothache. Often, by the time they see an Orofacial Pain practitioner they have received multiple unsuccessful and irreversible dental treatments in hopes of alleviating their pain. It is important that dentists be able to identify headache pain

Acknowledgments

The authors would like to thank Drs. Donna Mattscheck and Mariona Mulet for their assistance with reviewing the manuscript.

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