S3:Ep24 – The Connection Between TMD and Migraine



Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

This episode is brought to you in part by our generous sponsor, Lilly.

Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re talking all about dental issues, facial pain, and how it can relate with migraine. To fill us in, we have an expert joining us today. It’s Dr. Steven Bender. Dr. Bender is the director of facial pain and sleep medicine with the Department of Oral Surgery at Texas A&M College of Dentistry. Dr. Bender, thanks so much for joining us here today. We’re super happy to have you.

Dr. Steven Bender: Thank you. It’s definitely my pleasure.

Molly: And you have a lot of insight in this area, so I’m excited to pick your brain today. Hopefully, it won’t be too painful. 

Let’s get started just with an easy question off the top. Can you tell us a little bit about the most common facial pain symptoms and dental issues that you see often and how they might relate to migraine?

Dr. Bender: So probably the most prevalent thing we see in a facial-pain practice are temporomandibular disorders. Sometimes, people refer to them as TMJs. But these are disorders of the jaw joints, basically, and these can be related to the joint itself, where it hinges open and closed, or it can be the muscles that control the jaw, the biggest ones. It might be right here and up here. Usually, it’s muscle-related pain, but it can be combinations of both factors, muscle and joint-related.

Molly: And can you tell us a little bit about the temporomandibular joint and how it’s supposed to function. I know mine feels really tight. I don’t know if that’s normal or not.

Dr. Bender: Well, it’s normal for most people these days since COVID and, in our case here in Texas, bad weather and power outages. But, normally, it should function without us even thinking about it. I mean, it should be something that we do just, again, without thinking — speaking, talking, chewing. It should function where we don’t even think about it.

It’s an interesting joint in that its makeup — its histology, or the tissues — are different than other joints, which is a good thing because it’s much more resilient than some of our other joints. It’s also a joint that will actually come out of its socket as part of normal movement. In other words, as we open wider, the little ball up in the socket actually translates forward out of the socket. And so it’s a very unique joint. It’s very important, obviously, to health and day-to-day activity.

Molly: I think it’s also interesting too — when you say that, I’m feeling, I’m opening my jaw. It’s almost easier to grasp than maybe something internal or, say, migraine. You can’t grasp it. It’s hard to physically put an image to it. So I think that’s interesting too, that we might be able to tell if we have pain because we can visualize it.

Dr. Bender: Well, to some degree. But on the other side of that, those of us that have migraine and other head and face pains, we know how difficult it is having chronic pain because people can’t see it. And if they can’t see it, they don’t think it’s real. And so we — and I say “we” because I grew up with migraine myself — we kind of go from spot to spot to spot trying to get answers, trying to get relief. And because it can’t be seen, we sometimes get ignored.

Molly: That’s so true. Very well put, and I’m sorry that you’re one of us with migraine. Another one to the team.

Dr. Bender: That’s right.

Molly: So I’m wondering if you can tell us a little bit more about TMD, maybe some common signs, symptoms, and just a little bit more about it.

Dr. Bender: Certainly. So, again, TMDs are disorders of the jaw joint, basically — not only the bony aspect, but the muscles. And so these disorders can be pain in the muscles, so some people will just have a constant pain in their jaw muscles here, here frequently. It might be stiffness, where it’s more difficult to open wide for a big sandwich or something, and it might be painful to open wide. And then sometimes it’s difficult to chew. You bite down on something, and you feel pain around the ears. People often report noises in their jaw joints, so they’ll say, “I’m chewing, I’m yawning, or even talking. My jaw makes this popping sound or a crunchy noise.” 

So those are some of the most frequently reported symptoms for TMDs, although some people can have ear pain. They feel — and I’ve had this, where it feels like it’s a sharp, stabbing pain in the ear because of the proximity of the jaw joint to the ear. Some people will have ringing in their ear. Some people have dizziness. And then also, very frequently, our patients will have headaches too.

Molly: And can you tell us a little bit more about how TMD and migraine can be connected? Some of the symptoms sound similar. Can you tell us how they correlate?

Dr. Bender: Yeah, and we can go into a real lengthy discussion about our little friend here, the brain.

Molly: Yeah. Not quite as fancy, but mine glows in the dark.

Dr. Bender: Yeah, I’ve got several. I’m a little brain-jealous. So when we think about pain in the head and face, if we looked at the bottom of our brain, there are 12 different nerves that come off each side, 12 pairs of nerves, and they all do different things. So those of us that have migraine, we’ve all been to the neurologist. We’ve had to do all these different tests. That’s a checklist of all these 12 different nerves. 

The biggest one that comes off of that, the base of the brain, is the trigeminal nerve, and it’s trigeminal, or three-headed. So it’s got three big branches: one branch gives us sensation here, one branch in the middle of the face, and then one branch up here.

Well, if we consider what gives us headaches — again, our friend the brain — we could poke around in our brain and not really elicit any painful response. But on the outside of the brain is like this cellophane wrapper. To me, that’s what it looks like. It’s called the dura. In that wrapper is a lot of blood vessels and nerves. And so if we touch that, if we were to put a little hole in our head and touch that, it’s very sensitive. 

Well, our most current theory with headache and migraine in specific is that we get this wave of electrical activity — kind of starts at the back, it goes to the front, very slow-moving. Well, that wave of electrical activity stimulates these blood vessels to release substances that cause swelling and pain.

Now, considering that that part of our nervous system, as it goes back into the base of the brain, connects with the same nerve that gives us sensation here and here, very basically, if we have pain in, let’s say, a muscle right here, that’s going to travel into that big nerve. And when it does, there are a number of nerves that connect with — we call them second-order neurons. They’re basically little connecting points. 

So it’s like trying to put a bunch of plugs into one plug. The information gets all messed up, and so the sensation that we experience from here goes in and could stimulate pain up here. Now, for a non-migraine patient, that doesn’t happen. But those of us that are fortunate enough to be blessed with migraine, the more input we get from here and here into that system, it’s going to make it easier to turn on that wave of electrical activity that causes the migraine. So there you go.

Molly: Actually, that explains a lot, and we all know with migraine, you have a sensitive brain. And it really does help put it into context to have a visual and be able to point out here and where to help better understand it. 

So let me ask you this. If you have TMD, can it be a precursor for migraine or cause it down the road? If you have migraine, are you’re more likely to get TMD?

Dr. Bender: So I think it’s probably the latter. I don’t think that necessarily having TMD can cause a non-migraine patient to start having migraine. It can cause a migraine patient to have more migraine. But the best we know right now is we tend to have different brains. In other words, our brain is less tolerant to change, and so I believe that migraine comes first, and because the backwards approach to what I described earlier, if we get a lot of pain up here, it can turn on the signal in other places.

That’s why a lot of people with migraine feel like they have sinus headache. They feel the pressure here, but their sinuses are fine. It’s because the nerve up here is turning on the switches for the other two branches. And so the nerves get active in our sinus areas, they swell, they feel full, they hurt, and we think, “Oh, gosh, it’s my sinuses.” But it’s really happening up here. 

So a lot of patients that have TMD pain, it could just be because they have migraine, but then there’s some structural aspects too that aren’t necessarily resultant from migraine. I don’t know if that makes sense.

Molly: No, it definitely does, and I think, again, it helps put it in perspective. So we’ve talked a little bit about the mechanisms. We’ve talked about our structure of the nerves within our face and brain and a little bit how they’re correlated. So now for, like you said, those of us who are blessed to have migraine — I love that phrase because we are a unique club — what are some things we can do to help relieve this pain, whether it is facial pain, jaw pain, and it’s migraine-related? What are some things we can do?

Dr. Bender: So part of what we do in our practice is — it’s going to be a little — the examination process is going to be a little bit different than what you’d get from a neurologist. In other words, we are going to — now, we’re trying to change that. We’re trying to encourage our neurologist friends to assess more than just the nervous system. But what I tell my patients is I’m going to push on a lot of different things, and if I can push on an area and it elicits discomfort or pain, that tells me that I can treat that. And if I do treat that, that’s less information going into that big bucket, the trigeminal nerve.

And so what we try to do with our patients is eliminate as much of the different pain aspects as we can. Let’s say they have neck pain; let’s get that treated. If they have jaw joint issues, let’s get that treated. But we also talk about some lifestyle things with all our pain patients. There are some things that we can do outside of just in-clinic treatments, such as learning to breathe properly, learning to have better posture — not only posture with our neck and shoulders and back, but jaw posture. 

So we tell our patients, “You probably have your teeth together a large part of the day and don’t even realize it.” So we have them use timers. So you get your little phone, and you plug in 30 minutes. Then every 30 minutes when the timer goes off, I want them to be aware of their posture. Are their teeth touching? Because as soon as they touch, it’s going to make muscle activity increase. And if they are touching, I want them to puff some air out, so just separate the teeth a little bit, close the lips. 

So posture, posture of the jaws, breathing. We want them breathing with their diaphragm. So if they’re feeling their chest move when they’re breathing, that’s not good. If they feel their stomach moving, we want them to feel that. We want them also to slow down the breathing.

So in this little 30-second interval, they’re going through just this quick chest checklist to try to lower what we call sympathetic activity — in other words, that fight-or-flight response. So if we can breathe, if we can posture good, if we can meditate or pray during that time, we can lower the fight-or-flight response, and that ultimately helps with pain as well. So it’s some mechanical things that we can do to address the jaw issues, and then there’s some self-help or self-regulation things.

Molly: I think that’s really important to point out, and that was one of my questions is, What can we do ourselves? Because I know from grinding my teeth or just going through — say, you have a stressful day, and you can feel it right through here, so just being conscious and aware.

Is it a good idea to talk to your doctor about this kind of stuff if you’re interested in some steps that you can take — not necessarily medical treatments, but just doing things at home, lifestyle changes and behavioral changes?

Dr. Bender: Absolutely. Yes, I think it is important to discuss these with your — and I hesitated because you want to talk to the right person about it. As we all know, we go from place to place, and there are some practitioners that may be not as accepting of what’s going on with us as others. But, yes, talk to your caregiver on, What can I do myself to help reduce my pain?

And so when I was talking about these things, these self-regulation things, to change a behavior takes a month. So we tell them, “I want you to do this consistently for a month.” So it’s relatively simple, and our patients love it, and they say this has helped more than sometimes medications or other things. So, absolutely patients should talk to their caregivers about, What can I do to regulate this myself? Because there are things that we can do and that do work.

Molly: That’s so good to know. So a good first step is to try to implement some of those changes, and don’t expect results right away. You said about a month for things to kick in to notice a difference. So that’s also really good to know. 

People do that. Maybe it improves a little; maybe it improves a lot. Are there any types of medical treatments that are available for people who have facial jaw pain and also have migraine?

Dr. Bender: So with our patients with jaw pain — and, again, a lot of them have migraine or other tension-type headaches — we do talk about the self-regulation strategies and we really reinforce that on every visit. But sometimes we also will use devices that patients wear while they sleep. The jaw will move rhythmically, if you will, during sleep, similar to if you’ve ever seen somebody sleeping and you see their legs kind of move a little bit. Well, periodically during sleep, when we’re going from deep sleep to light sleep, probably at least 60 percent of us will have this rhythmic movement of our jaw, kind of looks like a rudimentary chewing pattern. 

Most of the time it’s pretty innocuous. In other words, it doesn’t really cause any problems. It comes and goes. We consider it a behavior. But for some people with jaw issues, jaw pain, jaw muscle tightness, those things we talked about, sometimes we need to control that. We can’t stop it. We can’t use medications. Botox doesn’t stop it. Even the night guards we make doesn’t stop it. But if we can make the night guard or mouthpiece appropriately and provide a surface that when our teeth do come together, by the thickness that we make it, by the material that we use, it does decrease the intensity of the activity.

So what we’re trying to do is help the body adapt. Again, the jaw joint is super adaptable. We as individuals are super adaptable. But sometimes we have to help that out, so that’s why the breathing. That’s why we’re using these devices. We’re trying to help the body to adapt. And, again, fortunately or unfortunately, those of us with migraine tend to be poor adapters.

Molly: We can always work to get better. We can always strive, right?

Dr. Bender: Or accept the way we are.

Molly: That is also true. I think both. We’ll say both.

So, Dr. Bender, you talked a little bit about how we can work on this, and you also said it is a good idea to talk to your healthcare provider. When does someone know that it might be good to see someone like yourself, a specialist in this area? Are there any classic signs or symptoms that maybe they need a little bit more help? And, if so, who should we look for? What should we look for in a specialty care provider?

Dr. Bender: So I would say the person with a chronic, ongoing refractory-type migraine. In other words, you’ve tried a lot of different preventatives. You use more abortives than you would care to use or that is really safe. And you start feeling some of these things we were talking about. You might go, “You know what? My jaw does get really tired when I talk a lot,” or, “I can’t eat the things I used to eat. I can’t take a bite of a big hamburger or chew this or that anymore.” That might be indicative that this cofactor, if that’s properly treated, could decrease the migraine events. It’s not going to stop them, but if we can decrease the events, we all know how wonderful we feel if we get like weeks in a row without a headache. 

So that would be a good clue to search out somebody that can help you. Now, my bias is that it would be an orofacial pain specialist. This is a specialist that has gone to dental school but then also gone to two years of postgraduate work just studying head and face pain. And it’s pretty comprehensive. We treat neuralgia, trigeminal neuralgia. We treat all different kinds of head and face pain.

I often tease my patient. It’s like, “OK, you’ve gone everywhere else. Now it’s our turn.” That’s our job. But we’re not easy to find. We’re not a big group of specialists. So there’s the American Academy of Orofacial Pain — can be a resource of looking up providers. And then the American Board of Orofacial Pain is the certifying board. Now, again, they’re not going to be in every area, so you just need to find somebody that is competent.

And when I say “competent,” if somebody recommends invasive treatments like adjusting the teeth or braces or surgery, that is just not a good thing. The science tells us that that’s not appropriate. In fact, we can make people worse with aggressive therapies. Most people with these disorders can be managed very conservatively, like doing the self-regulation, maybe using devices to wear during sleep. So I would shy away from any repositioning of the jaw, any orthodontics, any surgical, grinding on the teeth, crown, new crowns, things like that.

Molly: I’m making flinches when you say this because I think, “Oh, readjusting the jaw. That doesn’t sound pleasant whatsoever.”

Dr. Bender: No, no, it doesn’t. But, unfortunately, some of these treatment philosophies go back to the ’30s, believe it or not, that were postulated by an otolaryngologist, or ear specialist, named Costen. And he believed that if you could reposition the jaw, you would stop some of these headaches and jaw pain. And it was ultimately disproven, but it’s still practiced.

Molly: Wow. Well, thank goodness for modern medicine, and we continue to find new things that work better than that stuff that was in the ’30s.

Dr. Bender: Correct.

Molly: So if you are up for it, Dr. Bender, we have a few questions from our followers —

Dr. Bender: Absolutely.

Molly: — and if you’re for it, we’ll hit those and we’ll leave you alone to enjoy the rest of your day. So we touched on this a little bit, but this person wants to know if their neck pain could be caused by some teeth grinding.

Dr. Bender: The neck pain can be associated with what we’ve termed temporomandibular disorders. Now, there, again, the relationship is not necessarily bracing the teeth; it’s that wiring that goes into the central nervous system. Because if we look at our little brain friend and we look even further down into the neck, some of the inputs from the neck go into that brain stem and connect with our trigeminal nerve too. So now we’ve got another source mixing up into that already-crowded circuitry. So a lot of headache patients will also have neck pain. We’re not sure if the neck pain is primary — in other words, it’s pain by itself — or if it’s a result from all this getting turned on and being brighter, making the neck hurt. Same with jaw issues — we’re not sure if the neck pain is independent or if it’s just the ramped-up nervous system not only making it hurt here, but also in the neck because all those nerves connect. 

So that’s why it’s important, what we do as far as the examination. I put my finger on all these places that might hurt, and if it hurts when I push on it, that’s a problem right there. If it doesn’t hurt when I push on it, that means it’s being referred from something else.

Molly: OK. That seems like a simple test. Good to have. 

Dr. Bender: [crosstalk] 

Molly: Good to have. All right, this person wants to know if a chiropractor might be able to relieve some tension within the head and within the jaw.

Dr. Bender: Short answer, yes, but I always tell people be very careful of the chiropractor that they choose, just like the dentist that they choose or other caregiver. There are some chiropractors that are really good at helping us in what we do. Now, as far as jaw pain, the only — and I might get in trouble with some of my chiropractic friends — I think the only rationale for chiropractic in jaw pain is if the jaw is getting stuck. They can do a really good job of manipulating the structures to get it unstuck.

The other things, again, are a little bit more complicated, and manipulations are not necessarily the best thing for the jaw at that point. Certainly, if neck structures are not where they need to be, we find that a good chiropractor is very helpful. I usually recommend a chiropractor that does slow-velocity or low-velocity manipulations as opposed to quick snapping, especially as we get older like me. If you start popping things around real quickly, you can possibly cause some problems.

Molly: OK, good to know. Yeah, I’m just thinking of all the times that I had [sound]. As I get older, that sounds less relieving.

Dr. Bender: Yeah, more stressful than it should be.

Molly: Yeah, exactly, exactly. All right, Dr. Bender, this has been such an excellent conversation. I know I’ve learned a lot, and I think our followers have really learned a lot as well. I’m wondering if there’s anything else that you want to touch on or if there’s anything else you want to share with our fellow migraineurs out there.

Dr. Bender: Well, it’s certainly been a pleasure. I would like to share that as those of us with migraine, we know that it’s very confusing and can be disappointing. I know I was very disappointed. So I want people to not give up. I want people to understand that there may be more to the story and that sometimes other caregivers can help us. 

So in our field of orofacial pain, there’s a lot of times where we can do — in addition to what the neurologists, say, may be doing — that we can add to the care. So it’s not like you’re discounting what the other practitioner is doing. It’s just adding to. And it often takes multiple methods of care to treat these really bad headaches that we all have. 

So I would encourage people to just seek out — especially in our field, we get a lot of training in headache and migraine in specific in our training. So if you can find an orofacial pain specialist, they may be able to offer some avenues of care that haven’t been tried yet.

Molly: We really appreciate your time today, Dr. Bender, and that is some great advice. Don’t give up, and open things up a little bit. The old phrase “It takes a village” — it really can help when you have support from a lot of different areas.

Dr. Bender: Absolutely.

Molly: Well, again, thank you, all of you at home, for watching today. My name is Molly O’Brien. I’d like to thank our guest, Dr. Steven Bender, to help us with this episode of Spotlight on Migraine. We’ve been really happy to have you.

Dr. Bender: Thank you.


Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

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