Pediatric Concussions and Temporomandibular Disorders
By Dr. Bradley A Eli | Reviewed by Dr. Sachi Mehrotra
There is a connection between pediatric concussions and temporomandibular disorders (TMD).
Table of Contents: Pediatric Concussions & Temporomandibular Disorders
- The Migraine-Phenotype in Pediatric Concussions’ Relationship to TMD
- What is a Migraine Phenotype Headache?
- What is Pediatric Chronic Orofacial Pain?
- Why be Concerned About TMDs if a Child has Migraines?
- What is Central Sensitization?
- Children with Concussions should be Screened for TMDs
- Self-reported TMD Pain Screening Questions
- Pediatric Caregivers Important Role in Reducing TMD Risks
- Signifigance of How Pediatric Concussions and TMDs are Related
Jaw pain is not the first thing you think of when considering concussions. However, scientific, and clinical evidence suggests a strong connection between concussions and TMJ pain, specifically in cases where the child has migraine-like symptoms at the time of injury, called the “migrainephenotype headaches.”
In a landmark 2023 study, researchers found that 80% of those with a history of concussion also had temporomandibular disorder (TMD) symptoms, and those with headaches had a significantly higher incidence of TMD symptoms than those with no headaches. [1]
It’s important to raise awareness about the risk of TMD development in these children and its potential impact on concussion outcomes. Our goal is to encourage parents and clinicians alike to become proactive about screening for TMD with young people at the time of concussion injury. Here’s what you need to know about how concussions and TMDs.
The Migraine-Phenotype in Pediatric Concussions’ and its’ Relationship to TMDs
Even outside of the context of concussions, migraine headaches and TMDs (TMDs) are closely associated. Furthermore, both conditions are initiated and perpetuated by neuroinflammation.
Both transmit pain signals through the same cranial nerve, the trigeminal nerve. Clinically, migraine headaches and TMDs are often seen in the same patients (they are “comorbid”). The two conditions are connected through their primary mechanism, their shared anatomy, and their clinical comorbidity.
The phenomenon of “central sensitization” is the foundation for the association between concussions, migraines, and TMDs. Central sensitization describes a remodeling process in the brain where acute pain, when sustained, transitions into chronic pain. Chronic low back pain, whiplash associated disorder, and post-traumatic headaches are all examples of chronic pain that develop through central sensitization.
What is a Migraine Phenotype Headache?
Researchers are focusing more on what is known as “migraine phenotype headaches” in children with concussions.
Definition: A migraine phenotype headache is defined as having the core symptoms of a migraine; a moderate to severe headache, the presence of nausea/vomiting, and/or light or sound sensitivity (photophobia and phonophobia).
These may appear slightly different from regular migraines on brain imaging scans, but the symptom set is highly consistent with clinical migraines.
What is Pediatric Chronic Orofacial Pain ?
According to medical literature, pediatric headaches are common, with the prevalence ranging from 10-30%. Linda Sangalli, DMD, MS, an orofacial pain specialist, discusses pediatric pain in her December 2021 article Pediatric Chronic Orofacial Pain: A Narrative Review of Biopsychosocial Associations and Treatment Approaches.
“Pediatric chronic orofacial pain (OFP) is an umbrella term which refers to pain associated with the hard and soft tissues of the head, face, and neck lasting > 3 months in patients younger than 18 years of age”.
New research is showing that concussion injuries increase the risk of pediatric chronic OFP development and that migraine phenotype headaches are a warning sign that this risk is increased.
Children with migraines have a longer concussion recovery time
In children with PCH, those with migraine phenotype headaches in the acute period show significantly longer concussion recovery times. They also experienced higher symptom burdens and a lower quality of life. [3]
If the migraine phenotype is present, it raises the risk for having poor outcomes. Clinicians should be on the lookout for the migraine phenotype in the initial weeks after injury. This child will need to be observed a bit more closely.
These types of presentations are not uncommon. The Nature Journal’s scientific report cites that up to 44% of concussions present with the migraine phenotype headaches in the acute period. [4] The problem right now is raising awareness to look for and document symptoms on a regular basis, given their association with poor outcomes down the road.
Why children may need clinicians’ TMD assessment if they have concussions:
- Typically, youth lack a historical perspective.
- They may experience unique symptoms that vary from adult experiences.
- They may not request early treatment as often.
The significant role of clinicians, caregivers, and healthcare pain providers in shaping children’s pain experiences needs to be better understood. Pain in children affects well-being and functioning in multiple domains. Although children may report feeling anxious, fatigued, pain, and having mobility restrictions, this isn’t always easy for them.
Dr. Sangalli’s statement below underscores an important reason why clinicians need to educate parents about how to manage pain in their children.
Parents who tend to catastrophize about their child’s pain may also engage in more solicitous and overprotective parenting behavior in order to mitigate their child’s distress as well as their own. Though well-intentioned, these behaviors limit adaptive coping and are associated with poorer child functioning. – Dr. Sangalli
Why be Concerned About TMDs if a Child has Migraines?
TMDs and migraines are a volatile combination. To begin with, TMD symptoms are surprisingly common in children. NIH studies estimate that one in five children suffer from TMDs. [5].
Further, up to 50% exhibit bruxism, a risk factor for TMD development. Despite this high prevalence, checking for the presence of TMD symptoms in a child who just had a concussion is not typically a high priority. This is a big mistake, and here’s why.
A large prospective NIH study showed that when TMDs develop in migraine patients, the frequency of migraine headaches can increase 10-fold. [6] Because of their shared mechanism and anatomy, the two conditions can amplify each other. This makes the presence of TMD symptoms highly relevant for pediatric concussion patients who present with migraine phenotype headaches.
What is Central Sensitization?
Migraines, TMDs, and PCHs are all classified as central sensitization syndromes.
Migraines, TMDs, and PCHs are both examples of central sensitization syndromes. These conditions are where symptoms like chronic headache, jaw pain, or other somatic symptoms become chronic. Central sensitization syndromes follow a typical pattern.
First, there is some initial injury or illness that causes brain inflammation. When this inflammation is sustained, the nerves in the brain become sensitized and the threshold for pain signaling becomes lowered.
If this lasts for long enough, the brain starts to rewire (a process called “neuroplasticity”) such that pain signaling becomes chronic. Since the pain is now coming from central nerves and not peripheral nerves, the overall process is called “central sensitization.”
Central sensitization is the shared mechanism behind migraines, TMDs, and PCHs. From a biochemical point of view, the process is linked to the release of calcitonin gene-related peptide (CGRP), a trigger for pronounced inflammation in the brain. This prolonged brain inflammation then sets the stage for the brain wiring changes responsible for chronic pain symptoms.
Migraines and TMDs are closely related
The phenomenon of central sensitization explains why migraines and TMDs are so frequently seen together in the same person. We’ve previously reported that between 55% and 80% of people with TMDs have comorbid headaches. The percentage range varies depending on the number of TMD symptoms the patient experiences. Migraines are the most common headache phenotype. Simultaneously, greater than 50% of those seeking chronic headache treatment have symptoms of TMDs.
Central sensitization also explains the connection between concussion injuries and migraine-like headaches. In animal models, when CGRP is blocked after a concussion injury, symptoms of central sensitization do not develop. [7] In human studies, when patients with PCHs are injected with CGRP, they manifest migraine-like headaches. [8]
While further study is needed, migraine phenotype headaches in pediatric concussions are most certainly related to prolonged brain inflammation, CGRP expression, and central sensitization.
Children with Concussions should be Screened for TMDs
Because migraine phenotype headache in the acute time frame after a concussion is linked to poor outcomes, there is a growing consensus that all children should be screened for migraine phenotype headaches. It’s a simplified screening test for migraine phenotype headaches developed by Lipton and colleagues.
Here is the “3-Item Screener”:
| The ”3-Item Screener” to Screen for Migraine Phenotype Headaches: | |
|---|---|
| “During the last three months, did you have any of the following with your headaches?” | |
| 1. | You felt nauseated or sick to your stomach when you had a headache? (Y/N) |
| 2. | Light bothered you (a lot more than when you don’t have headaches?) (Y/N) |
| 3. | Your headaches limited your ability to work, study, or do what you need to do for at least one day? (Y/N) |
| * A positive answer of 2 out of 3 has a sensitivity of 81% and specificity of 75% for a migraine phenotype headache. (Lipton Theory, NIH 2016 [9]) | |
The test notes that an affirmative response on 2 of 3 questions is highly sensitive and specific for the migraine phenotype.
We also recommend universal screening for TMDs and bruxism and performing a focused orofacial exam. As noted above, around one in five children suffer from TMD symptoms and around 80% of those with a concussion will have TMD-like symptoms. We also know that players in contact sports have a higher prevalence of TMD disorders. [10]
In short, there’s a strong rationale for performing TMD screening in all children who’ve suffered a concussion. Here are some simple survey questions that can be used with children.
| Self-reported TMD Pain Screening Questions: | |
|---|---|
| Question 1 | “Do you have pain in your temples, face, temporomandibular joint, or jaw once a week or more?” |
| Question 2 | “Do you have pain when you open your mouth wide or chew once a week or more?” |
Pediatric Caregivers Important Role in Reducing TMD Risks
If there’s any history of TMDs or positive findings on exam, caregivers should be counseled both on the increased risk of poor outcomes and of interventions they can take to mitigate these risks. This counseling may be prudent even in the absence of immediate TMD symptoms, as delayed development of symptoms is possible.
In cases when there is limited access to health care, kit-based TMD care is an excellent alternative. A kit-based TMD protocol can act as a proxy for expert care, supplying the child and caregiver with the tools they need to optimize their recovery.
When children have a concussion, it’s important to do everything possible to optimize
their recovery. This starts by educating parents and clinicians to be watchful for migraine phenotype headaches. Beyond this, given the highly volatile nature of migraines and TMDs together and the high prevalence of TMDs, children with concussions should also be screened for the presence of TMDs.
Significance of How Pediatric Concussions and TMDs are Related
If either the migraine phenotype is present or there’s a history of TMD, both clinicians and parents should have an increased level of concern for the risk of poor outcomes. Supportive care in the acute period may have the ability to stop the development of chronic pain.
Ask your pain specialist or dentist about clinical management to prevent chronic TMD.
Author bio
Dr. Brad Eli, DMD, MS is a graduate of UCLA’s post-doctoral Orofacial Pain program. The field of orofacial pain and temporomandibular disorders became the 12th specialty of dentistry in 2020. Over the past 29 years of clinical practice specializing in orofacial pain, often treating both adults and children with headache disorders from injury. Dr. Eli has also been on the educational staff at university hospitals, pain centers, and the clinical staff of Southern California hospitals.
Reviewed by
Dr. Sachi Mehrotra is an orofacial pain specialist at Facial Pain Specialists in Encinitas CA. She is a Diplomate of the American Board of Orofacial Pain and a member of the American Academy of Orofacial Pain. Dr. Mehrotra completed a 2-year residency program in Orofacial Pain at UCLA and served as Chief Resident during her senior year. She’s an attending physician with Facial Pain Specialists and treats complex chronic pain syndromes.
References
[1] S. Karpuz, et al., “Evaluation of temporomandibular joint dysfunction in traumatic brain injury patients”, Mar. 2023, https://onlinelibrary.wiley.com/doi/abs/10.1111/joor.13445
[2] S. F. Kothari et al., “Characterization of persistent post-traumatic headache and
management strategies in adolescents and young adults following mild traumatic brain injury”, Feb. 2022, https://pubmed.ncbi.nlm.nih.gov/35140235/
[3] J. J. van Ierssel et al., “Association of Posttraumatic Headache With Symptom Burden After Concussion in Children”, Mar. 2023, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802126
[4] E. Fried et al., “Persistent post-concussive syndrome in children after mild traumatic brain injury is prevalent and vastly underdiagnosed”, March 2022, https://www.nature.com/articles/s41598-022-08302-0
[5] R. Ibragimova, et al., “Relationship between pathogenic factors and the prevalence of temporomandibular joint dysfunctions in children”, Jan. 2023,
https://pubmed.ncbi.nlm.nih.gov/36817029/
[6] I. E. Tchivileva, et al., “Temporal change in headache and its contribution to risk of developing first-onset TMD in the OPPERA study,” Jan. 2017, https://pubmed.ncbi.nlm.nih.gov/27984525/
[7] E. Navratilova et al., “CGRP-dependent and independent mechanisms of acute
and persistent post-traumatic headache following mild traumatic brain injury in
mice”, Dec. 2019, https://journals.sagepub.com/doi/10.1177/0333102419877662
[8] H. Ashina et al., “CGRP-induced migraine-like headache in persistent post-traumatic
headache attributed to mild traumatic brain injury”, Oct. 2022, https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-022-01499-5
[9] Osman Özgür Yalın et al., “Phenotypic features of chronic migraine”, March 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791410/
[10] V. Crincoli et al., “Effects of Contact Sports on Temporomandibular Disorders: An Observational Study”, Sep. 2022, https://www.mdpi.com/2304-6767/10/10/180
