Case report/clinical techniqueCase Series of Four Different Headache Types Presenting as Tooth Pain
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.
References (26)
- et al.
Paroxysmal hemicrania: case studies and review of the literature
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(1998) - et al.
SUNCT syndrome: case report and literature review
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(1998) - et al.
Anatomy of headache and facial pain
Otolaryngol Clin N Am
(2003) - et al.
Benign indomethacin-responsive headaches presenting in the orofacial region: eight cases reports
J Orofac Pain
(1995) - et al.
Chronic paroxysmal hemicrania: a case report and review of the literature
J Orofac Pain
(2003) - et al.
Chronic paroxysm hemicrania presenting as toothache
J Orofac Pain
(1993) Presentation of migraine as odontalgia
Headache
(2001)- et al.
Functional neuroimaging of headaches
Lancet Neurol
(2004) - et al.
The trigeminovascular system in humans: pathophysiologic implications for primary headache syndromes of the neural influences on the cerebral circulation
J Cereb Blood Flow Metab
(1999)