Pain, headache, and oromandibular structures

Simy Parikh MD (Dr. Parikh of The Jefferson Headache Center at Thomas Jefferson University has no relevant financial relationships to disclose.)
Stephanie J Nahas MD (Dr. Nahas of Thomas Jefferson University received honorariums from Allergan, Amgen, Electrocore, Eli Lilly, and Supernus for consulting work, and from Amgen for speaking engagements.)
Stephen D Silberstein MD, editor. (

Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.

Originally released April 11, 1994; last updated March 25, 2018; expires March 25, 2021

This article includes discussion of pain, headache, and oromandibular structures; craniomandibular disorders; oromandibular disorders; and temporomandibular joint dysfunction syndrome. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.


The relationship between headache and oromandibular disorders, such as temporomandibular joint dysfunction, is confusing to many physicians. In this article, the authors explore this complex relationship and specifically describe overlapping disorders, such as atypical odontalgia, contact point headache, and “lower-half migraine,” that create diagnostic difficulties. This article also includes guidance for diagnosis and management, including current treatment with onabotulinum toxin A, of oromandibular disorders and associated headache.

Key points


• Temporomandibular joint disorders are common and are comorbid with headache disorders such as migraine.


• Evidence suggests central sensitization is a very common problem in temporomandibular joint disorders, atypical odontalgia, and chronic headaches.


• It is unclear whether successful treatment of temporomandibular joint disorders will improve coexisting headache.


• In many common headache disorders, such as migraine, cluster headache, and trigeminal neuralgia, pain is referred to dental structures.

Historical note and terminology

Head pain and pain in the oromandibular structures (eg, teeth, gums, jaw, tongue) may be related in 2 ways: (1) headache arising in the oromandibular structures and referred to the head and (2) head pain perceived in oromandibular structures. The ala-tragus line, running from the lateral surface of the external nose to the inferior boarder of the tragus (van Niekerk et al 1985) is an artificial division of the head: neurologists treat problems that arise from structures above the line and dentists treat problems that arise from structures below the line. Because of this division, there has not been as much exploration of the relationship between oromandibular structures and head pain compared to investigation regarding one or the other. This article reviews the relationship between head pain and oromandibular structures and the importance of considering both cranial and oromandibular pathologies in the differential diagnosis of oromandibular or head pain.

As several disorders of oromandibular pain do not have an identifiable structural cause, understanding that pain can occur even without nociceptive stimuli (Mersky 1986) is important to the diagnosis and management of these disorders.

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