Tension-type headache, oro-cranio-facial pain and cranio-mandibular disorders: the importance of a multidisciplinary diagnosis

My clinical experience

My name is Massimiliano Costantino and I am an Osteopath/Posturologist.

In recent years I have devoted much of my clinical work to the study and treatment of tension-type headaches, of oro-cranio-facial pain (OCF), of cranio-mandibular disorders and cervical pain..

I have always believed that such complex conditions cannot be addressed by a single professional. For this reason I carry out my work in close collaboration with medical specialists in dentistry, gnathology and pain therapy.

I also have the privilege of collaborating with Dr. Pasquale Enea, Director of the Pain Therapy Unit of the ARNAS Civico hospital in Palermo. This experience has allowed me to observe closely how chronic headaches and cranio-mandibular disorders can compromise people’s quality of life, affecting their sleep, work, social relationships and psychological well-being.

The role of the masticatory muscles in cranio-facial pain

The involvement of the masticatory muscles is one of the most frequent clinical findings in patients suffering from headache and oro-cranio-facial pain.

According to Prof. Jeffrey P. Okeson, author of one of the leading international texts on temporomandibular disorders, most patients present pain or increased tension of the masticatory muscles on palpation, and about 40% report pain during chewing.

The studies of Janet Travell and David Simons, pioneers in the study of myofascial trigger points, have also shown that a large part of the apparently healthy population presents latent trigger points, potentially responsible for pain and functional limitations.

These data confirm how the muscular component is often underestimated in the evaluation of headaches and pain of the cranio-cervico-mandibular region.

An often complex diagnosis

Many patients arrive at the visit after having consulted numerous specialists and undergone a long diagnostic journey.

It is not uncommon for them to have already undergone many instrumental examinations, taken various medications or begun treatments that have not brought any real benefit.

When the muscular component is not recognized early, the risk is twofold:

^●the patient is subjected to unnecessarily invasive or inappropriate treatments;

^●the pain tends to become chronic, progressively involving the emotional and psychological sphere as well.

The American College of Rheumatology has for years emphasized how an early diagnosis of muscle disorders allows, in most cases, excellent results to be achieved through conservative and non-invasive treatments.

It is also known that patients with chronic pain frequently present higher levels of anxiety, stress and depression than the general population, creating a vicious circle that further fuels the symptoms.

The importance of a multidisciplinary approach

Over the course of my clinical experience I have observed how numerous headaches defined as “atypical”, “essential” or “idiopathic” actually present a marked muscular component.

In particular, the treatment of the masticatory muscles and of the cranio-cervical musculature, when included within a proper multidisciplinary diagnostic pathway, can determine a significant reduction of the symptoms and, in some cases, the complete resolution of the pain.

It is important to clarify that these results never depend on the work of a single professional, but on the collaboration between osteopath, dentist, gnathologist, pain therapist and, when necessary, other specialist figures.

What happens when a muscle remains contracted?

From a physiological point of view, a contracture can develop when a muscle is subjected to prolonged overload or when it works in non-optimal metabolic conditions.

If this situation persists over time, the energy demand exceeds the muscle’s capacity to receive oxygen and nutrients through the blood circulation.

The consequent reduction of ATP alters the normal relaxation mechanisms of the muscle fiber, favoring the maintenance of the contraction and the appearance of pain.

Locally, ischemic phenomena, micro-lesions of the muscle tissue and the release of inflammatory and algogenic substances occur, including prostaglandins, bradykinin, serotonin and histamine, which contribute to increasing pain sensitivity.

Over time the muscle becomes increasingly stiff, painful and less efficient, fueling a vicious circle that can involve the entire cranio-cervico-mandibular system.

The most frequent symptoms

In patients who present a significant muscular component, it is common to find one or more of the following symptoms:

^●a dull, constant headache, often present on waking;

^●a sense of morning fatigue;

^●pain in the temples;

^●pain in the temporomandibular region;

^●pain during chewing;

^●limitation of mouth opening;

^●stiffness of the jaw muscles;

^●difficulty swallowing;

^●a sensation of a blocked ear;

^●tinnitus (ringing in the ears);

^●associated cervical pain;

^●spontaneous muscle pain even at rest in the more advanced cases.

Naturally these symptoms are not exclusive to muscle dysfunctions and must always be interpreted within a complete clinical evaluation.

The main causes

Alterations of the masticatory musculoskeletal system can be favored by numerous factors, often present at the same time.

Among the most frequent we find:

^●direct trauma of the cranio-facial region;

^●dental procedures that modify occlusal balance;

^●bruxism and clenching of the teeth;

^●parafunctions such as nail-biting or biting objects;

^●malocclusions and dental interferences;

^●stress and emotional tension;

^●dysfunctions of the cervical spine;

^●postural alterations;

^●systemic diseases.

In my clinical experience I have observed that alterations of the occlusion and dysfunctions of the masticatory muscles are extremely frequent, even in people who do not complain of jaw pain. In many cases these conditions are associated with persistent cervical pain, muscle stiffness and postural disorders, making a global evaluation of the patient essential.

Conclusions

Tension-type headaches and oro-cranio-facial pain represent complex and multifactorial conditions that require an accurate diagnosis and integrated management.

Identifying early the involvement of the masticatory muscles and of the cranio-mandibular structures allows, in most cases, conservative therapeutic pathways to be set up, reducing the risk of unnecessary treatments and of pain chronicization.

The goal is not to treat only the symptom, but to understand its origin and address all the components involved, giving the patient back a better quality of life through a truly multidisciplinary approach.

Summary and what to expect from the therapeutic pathway

In summary, tension-type headaches and oro-cranio-facial pain are often the result of the interaction between muscular, articular, postural and emotional factors. The involvement of the masticatory muscles is a frequent component and, if recognized early, can be treated effectively with conservative approaches.

The key points

^●Cranio-facial pain is often multifactorial and requires a global evaluation.

^●The masticatory muscles play a central role in many headaches and cranio-mandibular dysfunctions.

^●An early diagnosis reduces the risk of chronicization and unnecessary treatments.

^●The multidisciplinary approach is essential to obtain lasting results.

The benefits of the multidisciplinary approach

^●Complete evaluation of the patient from different aspects (muscular, articular, occlusal, postural and neurological).

^●Greater diagnostic precision.

^●Reduction of the risk of inappropriate or invasive therapies.

^●Better management of chronic pain.

^●Possibility of personalizing the treatment according to the real needs of the patient.

What the patient should expect

A structured diagnostic and therapeutic pathway generally involves:

^●a thorough initial evaluation, with collection of the medical history and analysis of the symptoms;

^●a targeted clinical examination, which includes the evaluation of the masticatory muscles, of the mandible, of posture and of the cervical spine;

^●possible involvement of other specialists (dentist, gnathologist, pain therapist);

^●a personalized therapeutic plan, based on manual treatments, exercises, possible occlusal devices and stress management strategies;

^●a monitoring over time, to assess progress and adapt the treatment.

Addressing the problem with an integrated approach makes it possible not only to reduce pain, but also to improve quality of life, preventing recurrences and favoring a stable and lasting recovery.

Dr. Massimiliano Costantino