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.)
Stephen D Silberstein MD, editor. (

Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, received honorariums from Abbie, Curelator, Ipsen Therapeutics, Lundbeck Biopharmaceuticals, Supernus Pharmaceuticals,  and Theranica for consulting. He is also the  principal investigator for clinical trials conducted by Amgen, ElectroCore Medical, and Teva.

Originally released April 11, 1994; last updated October 16, 2020; expires October 16, 2023


The relationship between headache and oromandibular disorders, such as temporomandibular joint dysfunction, is confusing to many physicians. This article explores this complex relationship and specifically describes overlapping disorders, such as atypical odontalgia, chronic orofacial pain (COFP), contact point headache, and “lower-half migraine,” which create diagnostic difficulties. This article also includes guidance for diagnosis and management, including updated treatment options such as onabotulinum toxin A and pulsed sphenopalatine (pterygopalatine) ganglion treatment for oromandibular disorders and referred facial pain.

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 primary headache disorder.


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


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


• It is important to know that dental pain can be referred from primary headache disorders to avoid unnecessary antibiotics and surgical interventions.

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 the 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 (Renton 2020). 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 external nociceptive stimuli (Mersky 1986) is important to the diagnosis and management of these disorders.

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