Journal of Oral & Facial Pain and Headache, 01/2020

Aims: To assess the reimbursement options and accessibility of three effective medicines for cluster headache (CH) (subcutaneous sumatriptan, oxygen, and zolmitriptan spray) across the European Union (EU). Methods: A brief survey investigating the availability of symptomatic treatments for CH was sent by email in January 2017 to at least one headache specialist for every single country in the EU. Results: The questionnaire was completed by 26 headache specialists (93% of the EU countries, representing 99.75% of the European population) and by 10 CH patients representative of patient organizations. Oxygen was reimbursable for 63% of the CH population. Oxygen device was reimbursable for 50% of the CH EU population. Subcutaneous sumatriptan was reimbursable for 66% and was accessible without restrictions for 45% of the CH EU population. Zolmitriptan spray was reimbursable for 23.7% and accessible without restrictions for 30.9% of the CH EU population. Conclusion: Only 47% of the EU population had unrestricted access to effective CH treatments, with unacceptable inequalities between eastern countries and the rest of Europe. Headache societies and patient associations should pressure European and national health authorities to improve the availability of effective symptomatic treatments for CH. Keywords: access to care, cluster headache, oxygen, sumatriptan, symptomatic treatment

Aims: To evaluate the efficacy of low-level laser therapy (LLLT) for the therapeutic management of neuropathic orofacial pain. Methods: This systematic review was conducted according to PRISMA guidelines. A comprehensive search of the literature was conducted in the PubMed/MEDLINE, Scopus, and Cochrane Library databases up to March 8, 2018, using terms such as low-level laser therapy, neuropathic pain, orofacial pain, neuralgia, neuropathy, and all the entities described in section 13 of the International Classification of Headache Disorders, third edition. The primary outcome was measurement of pain intensity. Results: A total of 997 studies were obtained with the initial search; 13 (8 randomized controlled trials, 2 prospective studies, and 3 case series) met the inclusion criteria and were analyzed for data extraction. Three provided data for the treatment of trigeminal neuralgia, 1 for occipital neuralgia, and 10 for burning mouth syndrome. All studies showed a reduction in pain intensity (most of them significant). The different studies analyzed LLLT alone and compared to placebo, to another treatment, or to different LLLT application protocols. Conclusion: LLLT seems to be effective as a treatment option for different neuropathic orofacial pain entities such as trigeminal neuralgia, occipital neuralgia, and burning mouth syndrome as a single or combined treatment. However, more quality studies assessing all outcome measures of chronic pain are needed in the medium and long terms. Furthermore, due to the lack of standardization of the application technique, more well-designed studies are required to confirm the results of this systematic review. Keywords: low-level laser therapy, neuropathic pain, orofacial pain, systematic review

Aims: To investigate the prevalence and overlaps of headaches and painrelated temporomandibular disorders (TMD) among the Polish urban population. Methods: The study was conducted in four Polish cities (Wroclaw, Lublin, Katowice, and Lodz) between February and November 2017. Participation in the study was voluntary. The examination consisted of two parts: a clinical examination of TMD using the Diagnostic Criteria for TMD Examination Form and the Head-HUNT Study questionnaire filled in by the participants to determine the occurrence and type of headaches. An experienced and qualified clinician trained all the examiners in the clinical examination protocol. Statistical analyses were based on descriptive and nonparametric statistics. In addition, univariate logistic regression was used. The significance level was set at α = .05. Results: Overall, 213 individuals were examined (149 women and 64 men). The mean age of the participants was 37 ± 15.82 years. The diagnosis for 55.9% of the participants was pain-related TMD, including myalgia (47.4%), myofascial pain (14.1%), arthralgia (21.1%), or headache attributed to TMD (10.3%). In the study population, 48.8% were diagnosed with temporomandibular joint disorders, most frequently disc displacement with reduction (47.9%). A total of 73% of the individuals had experienced headaches in the previous 12 months. The majority of the participants described the headache episodes as occurring less than 7 days/month and lasting less than 4 hours. Among people with painful TMD, the frequency of headaches was almost twice as high as that in nondisordered individuals (48.35% and 25.35%, respectively; P < .0001). The logistic regression model confirmed a significant overlap between headache and painful TMD (OR = 4.77, 95% CI 2.44-9.32, P = .0000). For the entire studied population, no statistically significant connections were established between the occurrence of identified TMJ disorders and headache reports or diagnoses (P > .05). Conclusion: Headaches and pain-related TMD are major problems among the Polish urban population. Headache was a much more frequent problem for participants with painful TMD. This issue requires further research and identification of cause-and-effect relationships. Considering the entire studied population, the relationship between identified TMJ disorders and headache is negligible. Keywords: epidemiology, headache, migraine, temporomandibular disorders, tension-type headache

Aims: To test the hypothesis that experimental noxious stimulation of the right masseter muscle results in a reorganization of motor unit activity within the right temporalis and right masseter muscles during jaw closing tasks. Methods: A total of 20 healthy participants received hypertonic saline (5% sodium chloride) infusion into the right masseter muscle, and pain intensity was maintained at 40-60/100 mm on a visual analog scale. Standardized isometric biting tasks were performed with an intraoral force transducer while single motor units (SMUs) were recorded from the right masseter and temporalis muscles. Tasks were repeated in four blocks: block 1 (baseline 1), block 2 (hypertonic saline [HS] infusion or isotonic saline [IS] infusion), block 3 (infusion of the other solution), and block 4 (baseline 2). The occurrences of SMUs were tabulated across blocks. Statistical significance was considered to be P < .05. Results: There were no significant effects of block on the tasks. A total of 83 SMUs were discriminated in the temporalis and 58 in the masseter. For the comparison between HS and IS across tasks, the occurrences of 74.6% to 82.8% of SMUs were unchanged (70.2% to 94.3% for masseter), while during HS, 10.3% to 17.1% of SMUs were recruited (0% to 12.8%, masseter) and 6.9% to 12.7% were de-recruited (5.7% to 17%, masseter). Conclusion: The present findings suggest that most biting-task-related jaw muscle SMUs remain active during experimental muscle noxious stimulation. There was some evidence in both the anterior temporalis and masseter muscles for motor unit recruitment and de-recruitment consistent with a motor unit reorganization during experimental pain. Keywords: electromyography, hypertonic, isometric contraction, masticatory muscles, saline solution

Aims: To provide an update of knowledge regarding the clinical presentation and neurophysiologic aspects of orofacial pain of cardiac origin in the form of a literature review. Methods: The peer-reviewed databases Scopus/Embase, NCBI (PubMed), and Science Direct were searched up to December 2018. Results: Patients with myocardial infarction presenting without chest pain run a higher risk of death due to missed diagnosis and subsequently a significantly greater delay between the onset of symptoms and arrival at the hospital. During myocardial ischemia, orofacial pain is reported by 4 in 10 patients and described as oppressive and/or burning. Up to 4% of myocardial infarction patients experience pain solely in the orofacial structures, women more often than men. Orofacial pain during myocardial ischemia is associated with ischemia within the inferior wall of the heart, suggesting the involvement of the vagal system. Conclusion: The clinician's awareness of the full spectrum of clinical characteristics of a myocardial infarction constitutes a key factor in accurate diagnosis. Health care professionals and the general public should be aware of the possibility of myocardial infarction presenting with orofacial pain, toothache, or ear/temporomandibular joint pain as the only symptom. Keywords: cardiac ischemia, cardiac pain, myocardial infarction, orofacial pain, toothache

Aims: To evaluate the possible relationship between sleep disturbances and primary headaches. Methods: This prospective study was carried out in a random group of patients with active primary headaches (case group) and a control group. Patients with active primary headaches were further stratified into two groups: patients with migraine and patients with tension-type headache (TTH). Participants were questioned using the following standardized tests: Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Berlin Sleep Apnea Questionnaire (BSAQ), and a custom-made headache questionnaire. The results of the questionnaires were compared among patients with TTH, patients with migraine, and age- and sex-matched controls. Results: Of the 143 participants, 22.4% had TTH, 30.8% were diagnosed with migraine, and 46.9% did not have a diagnosed headache disorder. Patients with TTH were more likely to have insomnia (ISI score > 7) than patients with migraine (75% vs 50%, respectively) or controls (75% vs 37.3%, respectively) (P = .002). Frequency of poor sleep quality (global PSQI score ≥ 6) was significantly highest in the TTH group (87.5%), while the migraine and control groups had better sleep quality (47.7% and 43.3%, respectively) (P = .0001). TTH patients were more likely to have insufficient sleep (sleep efficiency < 85%) (53.1%) than those with migraine (25%) or the control group (29.9%) (P = .025). Conclusion: Patients who suffered from TTH were more likely to have insomnia than patients with migraine or controls. Nearly all patients with TTH had poor sleep quality, which was also observed in approximately half of the individuals in the migraine and control groups. Three-quarters of patients in the TTH group and more than half in the migraine group indicated inadequate sleep as a trigger factor for headache. Keywords: headache, insomnia, migraine, poor sleep quality, tension-type headache

Aims: To analyze cervical tenderness scores (CTS) in patients with various temporomandibular disorders (TMD) and in controls and to examine associations of CTS with demographic and clinical parameters. Methods: This case-control study included 192 TMD patients and 99 controls diagnosed based on a questionnaire and a clinical examination following the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) guidelines. CTS, adapted from the widely used total tenderness score, was the mean sum of the palpation scores from the suboccipital, sternocleidomastoid, and trapezius muscles. Depending on the variables, data were analyzed using Pearson chi-square, analysis of variance, t test, Bonferroni post hoc adjustment, and/or multivariate linear regression analyses. Results: CTS was higher in TMD patients compared to controls (P < .001). Across TMD subgroups, CTS was notable only in those with a myogenous TMD diagnosis, but not in arthrogenous TMD (P = .014). CTS was positively associated with: female sex (P = .03), whiplash history, higher verbal pain scores, comorbid headaches, body pain, increased pain on mouth opening, and higher masticatory muscles tenderness scores (MTS) (P < .001 for all). Sex (P < .001), MTS (P < .001), comorbid headache (P = .042), and pain on opening (mild: P = .031; moderate: P = .022) retained significant associations with CTS in the multivariate analysis, and these main effects were influenced by interactions with whiplash history and comorbid body pain. Conclusion: CTS differentiated between TMD patients and controls and between TMD diagnoses. Specific patient and pain characteristics associated with poor outcome in terms of CTS included effects of interactions between myogenous TMD, female sex, whiplash history, comorbid body pain and headaches, and pain on opening. It can therefore be concluded that routine clinical examination of TMD patients should include assessment of the cervical region. Keywords: cervical muscle tenderness, masticatory muscle disorders, muscle tenderness score, temporomandibular disorders

Aims: To evaluate the effectiveness of counseling on pain intensity and oral health-related quality of life (OHRQoL) in temporomandibular disorders (TMD) patients. Methods: Fifty female patients diagnosed with TMD were divided into two groups: a group of waiting list patients (control group) and a group of patients who received counseling therapy (experimental group) involving education about etiologic factors, avoidance of parafunctional habits, and sleep, as well as dietary advice. All patients were evaluated at baseline and 7, 15, 30, and 60 days later. Patients reported pain intensity using a visual analog scale (VAS), and the Oral Health Impact Profile (OHIP-14) was used to assess the impact of pain on OHRQoL. Statistical analyses were performed using the split-plot analysis of variance (SPANOVA) design, with post hoc Student t tests for independent samples and for dependent samples, adopting a significance level of P < .05. Results: The control group consisted of 24 female patients with a mean age of 39.96 ± 13.93 years, and the experimental group consisted of 26 female patients with a mean age of 35.15 ± 10.78 years. Counseling was considered effective for reducing pain intensity, with a significant improvement observed at 7 days (P < .001). Counseling was also responsible for a significant improvement in the impact of TMD on OHRQoL at all follow-up time points analyzed (P < .001). When comparing the groups, a significant difference was observed for both pain intensity and TMD impact on OHRQoL during follow-up (P < .05). Conclusion: Counseling seems to significantly improve pain and OHRQoL in patients. Keywords: counseling, OHRQoL, orofacial pain, self-care, temporomandibular disorder

Aims: To investigate the associations between signs of painful temporomandibular disorders (TMD) and number of tender points (TPs) and fibromyalgia in adolescents, as well as the relationship between TPs and pressure-pain threshold (PPT) in individuals presenting with local, regional, or widespread pain as a way to investigate the presence of central sensitization (CS). Methods: The sample consisted of 690 Brazilian adolescents with and without signs of painful TMD, aged 12 to 14 years old. Painful TMD was classified according to the Research Diagnostic Criteria for TMD (RDC/TMD) Axis I. The criteria established by Yunus were applied to assess juvenile fibromyalgia and TPs. Mann-Whitney and chi-square tests were applied to test the associations between signs of painful TMD and demographic variables. Regression models were used to estimate the association between signs of painful TMD and number of TPs and to determine which additional predictive variables were associated with TPs. Regression analyses were performed to test the associations between PPT values and number of TPs. Fisher test was used to estimate the association between signs of painful TMD and FM. Results: Significant associations between signs of painful TMD and the number of TPs (P < .001), as well as between TPs and the PPT values for local, regional, and widespread pain (P < .001), were found. No association between signs of painful TMD and fibromyalgia was found (P = .158). Conclusion: Individuals with signs of painful TMD presented with more TPs compared to pain-free adolescents. Moreover, the higher the number of TPs, the lower the PPT. This finding suggests that adolescents with signs of painful TMD are at increased risk of presenting with CS. Keywords: adolescent, central sensitization, fibromyalgia, pain, temporomandibular disorders

Aims: To assess the pain and/or unpleasantness and the somatosensory changes caused by two experimental models of trigeminal nerve damage (topical application of capsaicin and local anesthetics) in healthy participants using extensive evaluation tools. Methods: This double-blinded, randomized, placebo-controlled, crossover study included 20 healthy adult participants who underwent three separate sessions of testing. In each session, the psychophysical quantitative sensory testing (QST) and the electrophysiologic electrically evoked trigeminal "nociceptive-specific" blink reflex (nBR) investigations were performed at baseline. Following a 15-minute topical application of 0.1% capsaicin, 5% EMLA, or Vaseline (placebo) agents, the maximum numeric rating scale pain and unpleasantness scores were recorded. Additionally, qualitative sensory testing and somatosensory mapping were performed. The QST and nBR investigations were repeated immediately after each application. Data were analyzed using repeatedmeasures analysis of variance. Results: Capsaicin application was associated with significantly higher pain and unpleasantness scores when compared to EMLA and Vaseline (P < .001), with varied bidirectional somatosensory changes among the participants and significant loss of thermosensory function (P < .030). EMLA application induced loss of thermal and mechanical somatosensory function (P < .030) and a significant reduction in electrically evoked pain scores on nBR investigation (P < .001). No significant changes were seen in the electrophysiologic component of the nBR after any of the applications (P = .922). Conclusion: Topical capsaicin and EMLA application mimicked certain aspects of somatosensory changes seen in trigeminal nerve damage patients and may be used as surrogate models of such changes. Keywords: blink reflex, capsaicin, EMLA, quantitative sensory testing, trigeminal nerve damage