Incidence of ′headache attributed to temporomandibular disease′ in patients with clicking sound in the region temporomandibular joint

Introduction We aimed to investigate the headache complaint and features in patients referred to ear nose throat clinics with pain in the temporomandibular joint (TMJ) region. Materials and methods Forty-seven patients with complaints of a clicking sound in the TMJ region and pain were included in our study. Patients completed a questionnaire on the headache and the nature of the pain. The patients were asked to mark the level of pain on a visual analogue scale. Results Of a total of 47 patients, 28 were women (59.6%) and 19 were men (40.4%); their age ranged from 19 to 56 years (mean=30.5±9.8 years). There were 33/47 patients with cephalalgia in the head region, except TMJ disorders (70.2%); 12 of these were bilateral and 21 were unilateral. In all, 14/47 patients described pain only in the TMJ region (29.8%). Four patients described at least one experience of jaw locking in their life time (4/47). Visual analogue scale scores of the patients were 3.9±1.7. The nature of the pain was also analyzed. Conclusion TMJ 2014 consortium network showed that headache attributed to TMD may be in associated with cephalalgia. The rate of headache is higher in patients with TMJ disorders. TMJ disorders should also be kept in mind in the differential diagnosis of cephalalgia considering the quality of life of patients.


Introduction
Temporomandibular joint (TMJ) is a joint located in the front of the external ear that allows movement of the lower jaw joint. TMJ consists of dense fi brous tissue and an articular disk between condyles of the mandible and the mandibular fossa of temporal bone [1]. Th e joint is surrounded by ligaments and muscles. Disorders of TMJ can arise from joint to chewing muscles.
TMJ disorders are observed at a frequency of 5-16% in the community. Th e incidence of the disease is more common in women and increases with age [2].
Disorders of TMJ may be related to intra-articular diseases or extra-articular diseases. A clicking sound can be heard over the joint during palpation because of disorders of the joint. Th ere is a certain degree of disk displacement with patients with a clicking sound in the joint.
Disorders of TMJ can lead to complaints and diff erent symptoms in clinical practice. Headache is one complaint. A description of the subheader of 'headache attributed to temporomandibular disease' is provided in the 2014 pressed TMJ diseases research committee report [3]. We aimed to investigate the headache complaint and specialties in patients referred to ear nose throat clinics with a clicking sound and pain in the TMJ region.

Materials and methods
Patients with complaints of a clicking sound in the TMJ region and pain around the head were included in our study. Ear nose throat, neurological, and dental examinations were performed in all patients. Patients with a history of any neuropsychological, chronic ear, and dental problems were excluded from the study. Patients with chronic otitis media, tympanic membrane perforation, and external otitis were excluded from

Introduction
We aimed to investigate the headache complaint and features in patients referred to ear nose throat clinics with pain in the temporomandibular joint ( TMJ) region.

Materials and methods
Forty-seven patients with complaints of a clicking sound in the TMJ region and pain were included in our study. Patients completed a questionnaire on the headache and the nature of the pain. The patients were asked to mark the level of pain on a visual analogue scale.

Results
Of a total of 47 patients, 28 were women (59.6%) and 19 were men (40.4%); their age ranged from 19 to 56 years (mean=30.5±9.8 years). There were 33/47 patients with cephalalgia in the head region, except TMJ disorders (70.2%); 12 of these were bilateral and 21 were unilateral. In all, 14/47 patients described pain only in the TMJ region (29.8%). Four patients described at least one experience of jaw locking in their life time (4/47). Visual analogue scale scores of the patients were 3.9±1.7. The nature of the pain was also analyzed.

Conclusion
TMJ 2014 consortium network showed that headache attributed to TMD may be in associated with cephalalgia. The rate of headache is higher in patients with TMJ disorders. TMJ disorders should also be kept in mind in the differential diagnosis of cephalalgia considering the quality of life of patients.
the study. Patients with connective tissue rheumatic disease (rheumatoid arthritis) and a history of any ear/TMJ surgery were excluded from the study. TMJ was investigated radiologically by transcraniooblique lateral graphy. Assessments of sedimentation, C-reactive protein, and hemoglobin were carried out. We included a total of 47 patients in our study.
Written informed consent was obtained from each patient following a detailed explanation of the objectives and protocol of the study, which was carried out in accordance with the ethical principles stated in the Declaration of Helsinki and approved by the institutional ethics committee. Patients completed a questionnaire on their headache and the nature of the pain.
Patients was asked to score the level of pain on a visual analogue scale (VAS) during pack removal. VAS was created as a column of 10 cm in length on the directives has not been made. Th e lower end of the column represented no lack of pain and the upper end of the column represented the most severe pain as reported. Th e patients were instructed on how to use a VAS. Th e values marked on the scale were measured in millimeters.
Laboratory tests, blood biochemistry tests, sedimentation, and C-reactive protein tests were normal.
Durations of symptoms in patients are shown in Table 1. In our study, in 42/47 patients (89%), symptoms lasted more than 1 month. Th e nature of the pain was also analyzed. Th e nature of pain also varied with region. We have described the nature and localization of pain in Tables 2 and 3. VAS scores of the patients were 3.9±1.7.
Four patients described at least one experience of jaw locking in their life time (4/47) (8%). Two of these patients were treated successfully with muscle relaxants and anti-infl ammatory medications. Reduction therapy of the jaw in hospital was performed in the other two patients. None of the patients had limited opening in TMJ.
In all, 33/47 patients described cephalalgia in the head region, except TMJ disorders (70.2%). Twelve of these were bilateral and 21 were unilateral. Regions of cephalalgia are described in Table 2. A total of 14/47 patients described pain only in the TMJ region (29.8%). We found that headache in the temporal region has higher rates in TMJ disorders. In all, 19/21 (90%) of unilateral headaches and 11/12 (91%) of bilateral headaches involved headache in the temporal region. A total of 9/21 (42%) patients had headache in the parietal region unilaterally and 6/12 (50%) patients had bilateral headache in the parietal region. Frontal region headaches were present in 4/21 (19%) unilateral and 2/12 (16%) in bilateral headaches. Occipital region headaches were present 3/21 (14%) in unilateral patients and 2/12 (16%) in bilateral headaches.

Discussion
Diseases of TMJ are chronic disorders. Pathology in the joint and disk can progress over the years. With progression of the disease, painful joint/jaw movements may increase and a clicking sound can be heard by the patient. Joint and jaw immobility can develop in later stages of the disease.
In all, 42/47 (89%) patients with symptoms for more than 1 month were included in our study.
TMJ disorders may occur in fi ve diff erent ways in clinical practice [3].  (1) Local myalgia.
One of these disorders can be found in 40-60% of individuals in the community [2]. A total of 3-7% of patients in this population require treatment. We investigated the 'headache attributed to TMD' group in our study.
TMJ disorders are classifi ed into six pathways in the consortium network [3].
(2) Disk displacement with reduction with intermittant locking. TMJ disorders can lead to complaints and signs in daily clinical practice. Cephalalgia, ear pain, tinnitus, vertigo, swallowing disorders, Eustachian tube dysfunction, and hearing loss have been described in the literature [4,5]. Toller and Juniper [6] described 40% ear pain, 26% hearing loss, 18% tinnitus, 8% vertigo, 5% ear fullness, and 1.7% ear pressure in patients with TMJ disease. Assessment of medical history and a physical examination are essential in the diagnosis of disease. Clicking sound in the joint, TMJ disorder in the medical history, and a history of reduction contribute toward a high rate of diagnosis. Disk displacement with reduction with intermittent locking has 97% specifi city and 80% sensitivity in the diagnosis of the disease [7]. Th e diagnosis of disk displacement without reduction is more diffi cult. Th ere is a need for advanced methods of examination such as computed tomography and magnetic resonance of TMJ. We need advanced methods for determining treatment and prognosis.
Diff erent hypotheses have been suggested in the literature on the pain in TMJ disorders. Some authors claimed that tensor veli palatini muscle stimulation because of Eustachian tube dysfunction may cause ear pain [8]. Costen [9] claimed that posterior displacement of the condyles may compress the auriculotemporal branch of the trigeminal nerve. Th is may lead to neuropathic pain. Stress on the joint capsule and spasm caused by chewing muscles may also cause pain around the TMJ region.
Cephalalgia is a multifactorial and subjective symptom. Th e TMJ 2014 consortium network showed that headache attributed to TMD may occur in association with tension-type headache and migraine [3]. Although the pathophysiologies of the diseases are diff erent, the prevalence of headache is higher in TMJ disorders. Treatment of the temporomasticator system may decrease headache in patients [10,11]. Th is is a new area in the study of TMJ disorders. Th erefore, we cannot clearly discuss the rates of headaches in TMJ in conjunction with our study. Further prospective studies should be carried out on this topic.
TMJ disorders can also occur in association with myofascial pain syndrome [12]. Myofascial pain syndrome can occur with clenching of the masticatory muscles, bruxism, headaches, and back pain caused by the disease. Anxiety and psychological disturbances such as depression may occur in patients with myofascial pain syndrome [13]. Patients need further neuropsychological diagnosis because of higher rates of headache when inquired.
We found incidences of diff erent unilateral/bilateral headaches in TMD in the patients in our study. Although there is an association between tension-type headache and migraine, there is a mischallenge in diagnosis. Th e medical history of the patient is more crucial than imaging methods in diagnosis [14]. Challenges in the diff erential diagnosis and association of the diseases make cephalalgia a complex complaint. Th is is a weakness of our study.

Conclusion
In this study, 33/47 patients had cephalalgia in the head region, except TMJ disorders (70.2%). Th e rate of headache is higher in patients. Th e ache is importantly observed in temporal region regardless of other sides of cranium. Patients with TMJ disorders should be assessed for a history of cephalalgia and neuropsychological disorders. Cephalalgia is a complex and multifactorial issue and we cannot explain cephalalgia basically. TMJ disorders are one of the causes of cephalalgia and ear nose throat specialists, dentists, and neuropsychological teams must be aware of this disease.

Financial support and sponsorship
Nil.

Confl icts of interest
Th ere are no confl icts of interest.