My initial thoughts on the patient diagnosis would be centered around TMJ with accompanying cervicogenic headaches. The patient’s history of chronic jaw pain with clicking and popping would lead me to strongly consider TMJ. With her high stress levels and intermittent symptoms, this could be associated with grinding or clenching the jaw at times during the day and overnight. It would not be out of the question to expect tension in the neck and shoulders with trigger points and associated headache referral symptoms. Question and discussion of correlation of symptoms with periods of higher stress, pain/clicking with jaw opening, chewing, and speaking, and any successful interventions self learned or prescribed by the dentist would be helpful. Questioning into any history of migraines, association of neck tension with headaches, and if symptoms are more common on one side than the other or if always in the halo distribution would also give further insight.

Thanks for your input Hunter – here’s something to consider.

Sometimes with a history of TMD, we can bias ourselves thinking that ALL headaches are cervicogenic headaches.

In fact, based on the International Headache Society (IHS) classification system, there are more than 100+ diagnoses that contribute to headaches and cervicogenic headaches being only ONE possible diagnosis.

I would recommend considering other diagnoses (tension-type headaches, migraines, etc) and ensuring that we do a thorough subjective history on her headaches and avoid immediately assuming this is cervicogenic in nature.

Why is this important? Management and decision making:
– Does this require referral or multi-disciplinary management?
– Is this within our scope of practice?
– What prognosis do I expect? Will this improve with management of TMD?

Thanks for your feedback in my initial first thoughts.

In reference to the Central sensitization article, there is evidence to support the presence of central and peripheral sensitization (pain pressure threshold) in many TMJ patients. The article also references the association of increased stress and anxiety being a factor in the development of these hypersensitivities. Therefore assessment of the level of stress/anxiety the patient is under, as well as her pain beliefs would be beneficial to inform treatment and prognosis.

One tool found on the orthopt.org website is the OSPRO-YF outcome measure, which is described as a concise yellow-flag assessment that allows for accurate estimate of individual, full length psychological questionnaires for depression, anxiety, anger, fear-avoidance, kinesiophobia, catastrophizing, self-efficacy, and pain belief with decreased burden on the patient. This could be a valuable tool for this case. There are three versions of this test, with the 17 question version achieving a minimum accuracy of 85% according to the Academy of Orthopedic Physical Therapy website.

I have never utilized this tool, and plan to look into it further.

Have any of you used it? Do you have thoughts on this? What tools do you prefer to assess yellow flags in cases such as this?

As for my initial comment and mention of cervicogenic headaches, I did not do a good job of differentiating it from tension type headaches, which would be more in line with the description of the patients symptoms. Differentiation of various headaches requires attention to detail and noting triggers and symptom behavior.

Both migraine and cervicogenic headaches are often more one sided.
Migraines typically more moderate to severe and are associated with aura, nausea, dizziness, hypersensitivity to light and sound, speech and language difficulty, they are often unilateral and may side shift, and they are not often associated with neck movement. The pain is often throbbing, pulsating, and intense. They often have known triggers, which may be certain foods or chemicals, stress, dehydration, and changes in sleep.
Cervicogenic headaches are often chronic or episodic and associated with upper cervical spine dysfunction, are associated with neck movements, are typically one sided and perceived to be in the head or face. They are commonly confused with migraines, though pain is typically non throbbing/pulsating, starts in the neck, and also moderate to severe. Can last for hours to weeks.
Tension type headaches are more diffuse and bilateral, not typically caused by neck movements, more mild to moderate, and associated with tension in the muscles in the shoulders, neck, and suboccipital area. They are often associated with increased emotional stress and anxiety, postural deviations, and sleep disturbance.

Initial Differential List:

Disk displacement with reduction with a myogenic component:
o Subjective findings: Chronic (4 years) intermittent joint noises and pain that resolve spontaneously, unilateral symptoms, age, gender PMHx of anxiety and depression
o Any locking of the jaw?
o Do the jaw symptoms tend to worsen when stress/anxiety levels increase?
o Any significant dental history?
o Jaw pain with taking lager bites, chewing food on one side versus the other?

Myogenic TMD:
o Subjective findings: chronic headaches and jaw symptoms, age/gender, PMHx of anxiety and depression, high stress lifestyle
o Provocation of symptoms with mastication, especially tougher foods?
o Significant dental history?
o Relationship between stress/anxiety and jaw pain?
o Any history of grinding and/or clenching teeth?

Cervicogenic Headache:
o Subjective findings: chronic headaches, high stress lifestyle
o Provocation of headache with neck movements or prolonged postures?
o Does your pain start around the head and neck and then radiate to the jaw?

Cervical Arterial Dissection:
o Subjective findings: chronic headaches, symptoms in the jaw, chronic stress/anxiety
 5D’s and 3N’s ?
 Description and location of headache?
 Do you feel like the headaches are worsening? Are the more recent headaches unlike any others before?
 Any history of trauma?
 PMHx – HTN, DM, HLD
 History of smoking?

Screening tools:

A screening tool that I feel would appropriate for this case is the OSPRO-YF screening tool. This tool covers a variety of domains and will help identify the domains that are of greatest impact for this patient. Depending on the factors that are identified as most limiting, we may alter our treatment approach or even provide referral to other medical professionals. If the anxiety and stress are chronic and not well managed it may be beneficial for this individual to consult with a therapist who specializes in these domains.