Headache Medicine, v.3, n.4, p.198-235, Oct./Nov./Dec. 2012 223

Headache complaints increase the risk for

temporomandibular disorder among Brazilian

adolescents: A population-based study

Ana L. Franco, DDS. MSc

; Giovana Fernandes, DDS. MSc

; Daniela Gonçalves, AG. DDS. MSc. PhD

;

Cinara Camparis, M. DDS. MSc. PhD

; Richard Ohrbach, DDS. PhD.

Post Graduate student;

Professor - Discipline of Temporomandibular Disorders and Orofacial Pain,

Department of Dental Materials and Prosthodontics, Faculdade de Odontologia de Araraquara, Unesp - Univ

Estadual Paulista.

Associate Professor - Department of Oral Diagnostic Sciences, University at Buffalo, NY

Franco AL, Fernandes G, Gonçalves D, Camparis C, Ohrbach R. Headache complaints increase the risk for

temporomandibular disorder among brazilian adolescents: A population-based study.

Headache Medicine. 2012;3(4):217-20

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INTRODUCTION

Headaches (HA) are one of the most frequent

symptoms observed in children and adolescents diagnosed

with temporomandibular disorders (TMD).

(1)

A Brazilian

research with adolescents from a tertiary care center found

a significant increase in signs and symptoms of TMD in

those with HA,

(2)

similarly to what was recently observed in

adults.

(3)

Although the association between HA and TMD has

been studied in adolescents, results are not yet conclusive,

in part because of methodological design. Indeed, there is

a lack of studies in population-based samples, and in most

cases, TMD pain characteristics are not explored deeply.

AIM

The aim of the present study was to verify if headache

complaints (HAc) are associated to TMD diagnosis and

pain characteristics, by using standardized methods of

sampling and data collection in a population-based

sample of adolescents.

224 Headache Medicine, v.3, n.4, p.198-235, Oct./Nov./Dec. 2012

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MATERIALS AND METHODS

The sample consisted of public school students, 12

to 14 years age, from Araraquara - SP, Brazil. Overall,

24 public schools were visited and 3,117 adolescents

were invited to participate of the present study.

This study received full approval of the Research

Ethic Committee of Faculdade de Odontologia de

Araraquara, UNESP – Universidade Estadual Paulista

(process # 70/10).

The Research Diagnostic Criteria for Temporo-

mandibular Disorders (RDC/TMD)

(4)

Axis I (intra-

examiner kappa values 0.529-0.884) and questions #3

(Have you had pain in the face, jaw, temple, in front of

the ear or in your ear in the past month?), #4 (How

many time did your facial pain begin for the first time?),

#14 (Have you ever had your jaw lock or catch so that

it won´t open all the way) and #18 (During the last six

months have you had a problem with headaches or

migraines? - kappa= 0.688) of Axis II questionnaire

were used to collect data.

RESULTS

The sample consisted of 1,307 individuals, 56.8%

(n=742) girls. Among them, 80.7% (n=599) already

presented menarche, mean age was 12.72 years. Overall,

397 (30.4%) adolescents were diagnosed with TMD and

595 (45.5%) presented HAc.

Comparing to boys, girls showed higher risks for

presenting both, TMD and HAc (Relative Risk (RR) = 1.39;

95% Confidence Interval (CI) = 1.15-1.67), significantly

those with menarche (1.38; 1.16-1.66) (Table 1).

Individuals reporting HAc presented higher risks for

TMD (1.88; 1.62-2.17). The risk was particularly

significant for painful TMD diagnosis (1.51; 1.40-1.62)

(Table 2).

Regarding TMD painful subtypes, risks were higher

for combined (muscle and joint) painful TMD (1.24; 1.18-

1.31), followed for muscle TMD (1.23; 1.16-1.30) and

joint TMD (1.04; 1.01-1.07) (Table 3).

Considering chronicity, not only HAc slightly increased

the risk for acute TMD pain (1.09; 1.05-1.14), but also

Headache Medicine, v.3, n.4, p.198-235, Oct./Nov./Dec. 2012 225

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increased the risk in higher magnitude for chronic TMD

pain (1.41; 1.32-1.51) (Table 4).

DISCUSSION

The first finding of the present study refers to the high

prevalence rates of HAc and TMD. According to literature,

headache prevalence are up to 51% in children/

adolescents,

(5)

although mostly rates are of 2% to 5%.

(6)

Brazilian data about TMD and HAc in adolescents agree

with international rates for headaches prevalence but not

for TMD, which was surprisingly very high (about 30%).

However, a recent study with adolescents from Mexico

demonstrated similar prevalence of TMD, with 33.2%.

(7)

The reasons which may underlie this higher prevalence

should be further explored.

The second finding of this study refers to gender

differences. After stratifying adolescents by gender, females

demonstrated significant risks for the presence of HAc but

not for TMD, as similar previously observed in adults.

(3)

However, in the presence of both conditions, higher risks

were observed for girls with menarche. Based on this find,

we suggest that the hormonal related pain changes should

be explored in the future. It would be important to verify

how these changes affect the relationship between

headache and TMD, since most of researches exploring

gender differences in pain never consider these conditions

together.

Although a strong association between headaches

and TMD has been demonstrated, this relationship is still

poorly explored in adolescents. Considering TMD and

HA pain characteristics, it becomes also evident that the

relationship between them is complex, from both

pathophysiological and clinical perspectives. Basically,

there are two hypotheses to justify the association.

Clinically, TMD pain can characterize a "secondary

headache", since the temporalis is a masticatory muscle

located in the head. Considering pathophysiology, the

comorbidity of these two chronic pain conditions seems

to be related to central sensitization,

(8)

especially in

trigeminal subnucleus caudalis.

When interpreting the results, some points deserve

attention. First, HAc are based on adolescents responses

to one question, and consequently, no headache

diagnosis could be attributed. Second, a cross sectional

study allows the detection of association, but no causal

226 Headache Medicine, v.3, n.4, p.198-235, Oct./Nov./Dec. 2012

relationship can be established. Strengths include the

standardized methodology for epidemiology and for TMD

classification.

It could be concluded that HAc increased the risk for

TMD in adolescents, especially in girls with menarche.

The risk was particular higher for painful and chronic TMD.

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