Pediatric Concussions and Temporomandibular Disorders

The connection between pediatric concussions and Temporomandibular Disorders

Pediatric Concussions and Temporomandibular Disorders

By Dr. Bradley A Eli | Reviewed by Dr. Sachi Mehrotra

It is often asked if there is a connection between pediatric concussions and Temporomandibular Disorders (TMD).

Table of Contents: Pediatric Concussions & Temporomandibular Disorders Relationship

Let’s take the scenario of a child who has migraine-like headaches after a concussion. If you are the parent, you should be on the lookout for possible jaw pain. This article covers the reasons why a jaw sprain or strain is important to evaluate.

Jaw pain is not the first thing you think of when considering concussions. However, scientific, and clinical evidence suggests a strong connection, specifically in cases where the child has migraine-like symptoms, called the “migraine-phenotype”.

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]

The Migraine-Phenotype in Pediatric Concussions’ Relationship to TMD

Even outside of the context of concussions, migraine headaches and temporomandibular disorders (TMDs) are closely associated. 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. 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.

What is a Migraine Phenotype Headache?

Researchers are focusing more on what is known as the “migraine phenotype” headache in children with concussions. 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. This is called “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 Does Pediatric Chronic Orofacial Pain Refer to?

According to Linda Sangalli, Pediatric headaches are common, with the prevalence ranging from 10-30%. The December 2021 Pediatric Chronic Orofacial Pain: A Narrative Review of Biopsychosocial Associations and Treatment Approaches article discusses why this prevalence is more relevant now.

Sangalli states that “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”. We see increased attention being paid to concussion injuries. This is because concussions often result in chronic post-concussive headaches (PCHs).

Of those children with PCH, the most common presentation is the migraine phenotype. A National Institute of Health (NIH) 2022 study of pediatric PCHs found that 76% had migraine-like symptoms and around 50% experienced aura-like prodromal symptoms. [2] An aura is a set of sensory symptoms, like visual changes or facial tingling, that occur just before a migraine hits.

Children with migraines have a longer concussion recovery time

Having this knowledge is significant. In children with PCH, those with migraine phenotype headaches in the acute period showed 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 are rightly advised to 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. A sports dentists can assess possible TMJ damage.

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.

A child’s adaptive coping skills help avoid long-term pain-related issues

Youth who are suffering with OFP often experience difficulties in verbalizing pain-related symptoms. Adults typically are better at identifying and expressing their concussion-related pain stories.

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 youth affects well-being and functioning in multiple domains. As well, chronic OFP comorbidities in childhood have the potential to prevent long-term pain-related disability in adulthood. Although children may report feeling anxious, fatigued, pain, and having mobility restrictions, this isn’t always easy for them.

The statement below underscores an important reason why clinicians need a strong role in chronic pain care following pediatric concussions.

Furthermore, 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?

The Increased frequency of migraine-headaches after developing TMD

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 are Overlapping Pain Syndromes with TMD and Migraines?

Migraines, TMDs, and PCHs are all classified as central sensitization syndromes.

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 comorbid. 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 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 CGRP expression and central sensitization.

Children with Concussions should be Screened for TMDs

Given that 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 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.

If either the migraine phenotype is present or there’s a history of TMD, pain 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 stem the development of chronic pain.

Ask your pain specialist or dentist about clinical management to prevent chronic TMD.

Author bio

Dr. Brad Eli, DMD, MDr. 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 orofacial pain specialist at Facial Pain Specialists in Encinitas CADr. 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

By Bradley Eli

Bradley A. Eli, DMD, MS: Orofacial Pain Specialist and Sleep Disordered Breathing Expert Dr. Brad Eli is nationally recognized by colleagues in both medicine and dentistry as a leader in pain management and the treatment of sleep disordered breathing. He is one of an elite group of board-certified Orofacial Pain Specialists in the nation with the advanced training and experience to diagnose and manage complex orofacial pain conditions. In over 25 years of dedication to the advancement of orofacial pain medicine, Dr. Eli has helped thousands of patients find pain relief and manage their chronic pain conditions. His patient-centered method matches each patient with the best treatment for their symptoms and lifestyle. He advances the field of orofacial pain medicine by developing treatment protocols and specialized products that improve care and provide better outcomes for patients with life-changing orofacial pain disorders and conditions. He actively collaborates with peers across the profession and has been a contributing author to the Journal of the American Dental Association, Pain Medicine and Management, Oral Health Journal, and Dental Economics. He has provided educational courses, webinars, and other orofacial pain and obstructive sleep apnea instruction to dental associations, study clubs, and medical groups.