Orofacial Pain

A Guide for the Headache Physician

Martina K. Shephard, BDent(Hons), MBBS(Hons), FRACDS; E. Anne MacGregor, MD, FFSRH; Joanna M. Zakrzewska, MD, FDSRCS, FFPMRCA


Headache. 2014;54(1):22-39. 

In This Article

Headache-related Facial Pain

Migraine and Neurovascular Orofacial Pain

Migraine may manifest as facial pain either because of referral or as a phenomenon referred to as atypical or lower half migraine.[91] Some authors have suggested the presence of a separate entity that they have named neurovascular orofacial pain (NVOP).[92] This is a rare presentation and may mimic a number of other orofacial pain diagnoses. The pain is usually experienced in the distribution of the second or third divisions of the trigeminal nerve and is episodic. Attacks generally last for longer than 60 minutes. It is often described as "throbbing" and may have accompanying autonomic signs or systemic symptoms such as nausea. Patients may also complain of dental sensitivity, which can introduce diagnostic difficulties as patients pursue treatment for a perceived dental source of pain. NVOP has features in common with migraine as well as trigeminal autonomic cephalalgias, and it is suggested that NVOP may represent "relocated" migraine.[93] It is important to differentiate NVOP from dental pulpal pathology, with which it is often confused due to the presence of dental sensitivity during attacks. A case series of 7 lower facial migraines showed that all cases responded to triptans, and 3 responded to migraine prophylactic measures.[94] Case–control studies from a range of different clinical settings are necessary in order to provide more evidence for the presence of this entity, as its management can be substantially different to other orofacial pain diagnoses.

Trigeminal Autonomic Cephalalgias

This group includes cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with cranial autonomic features, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. These headaches are characterized by unilateral head or facial pain with cranial autonomic features that occur ipsilaterally and at the same time as the pain.[18] Patients with these disorders may present to facial pain clinics, as the facial pain component may be more significant than the headache. Accurate history-taking is essential in formulating this diagnosis, as patients may be unaware of the autonomic symptoms unless specifically asked. Comprehensive discussion of these disorders may be found in the literature. However, more careful phenotyping and larger case series are necessary to determine which of these diagnoses are unique entities and which may represent a continuum in the natural history of these disorders.[95,96]

TMD-Related Headache

Recent studies have described an association between TMD and headache. Many patients with TMD also report headache, and in some cases, there is a clear relationship between temporomandibular joint-related triggers and headache onset.[97] TMD is also common among migraine and tension-type headache sufferers.[98]