Periodic migrainous neuralgia: A cause of dental pain

oral medicine Editor:

JAMES W. LITTLE, D.M.D., M.S.D. Department University Lexington,

of Oral Diagnosis

and Oral Medicine

of Kentucky Kentucky

40506

Periodic migrainous neuralgia: A cause of dental pain Ralph 1. Brooke, B.Ch.D., L.D.S., F.D.S.R.C.S., F.R.C.D.(C), London, Ontario, Canada THE UNIVERSITY

OF WESTERN

The clinical findings in thirty-five

ONTARIO

AND

M.R.C.S.,

UNIVERSITY

cases of periodic migrainous

neuralgia

L.R.C.P.,

HOSPITAL

(PMN) are given. Typical

case histories are used to illustrate the fact that the condition may mimic dental pain. The nomenclature and association of the condition with migraine are briefly discussed, and a plea is made that the condition always be considered in cases of facial pain, when other clinical features of the disease are present, in order to save needless loss of teeth and delay in treatment.

Pain in the teeth or jaws may have a cause which lies outside these structures. Whereas most of us are aware of such conditions as maxillary sinusitis or trigeminal neuralgia mimicking toothache, a less well-known entity-periodic migrainous neuralgia-does not appear to be so well recognized as a cause of “dental” pain. The purpose of this article is to review the clinical findings in thirty-five patients with periodic migrainous neuralgia which presented as dental or oral pain. All the patients were seen in the Department of Oral Medicine Clinic at The University of Western Ontario between August, 1972, and January, 1978. CLINICAL MATERIAL

Table I sets out clinical details of the patients. Twenty (57 percent) were women and fifteen (43 percent) were men. The age at onset of symptoms is shown in Fig. 1; it will be noticed that most cases showed an onset in the second and third decades. There was a personal history of migraine in eighteen cases (5 1 percent) and a family history in eight cases (23 percent). Four patients had both family and personal history of migraine. *Professor and Chairman, University Hospital.

Department

0030-4220/78/ 100511+06$00.60/0

@

of Oral Medicine, The University of Western Ontario; Chief of Dentistry,

1978 The C. V. Mosby Co.

511

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Oral Surg.

Brooke

October, 1978

Table I. Clinical features of thirty-five cases of periodic migrainous neuralgia presenting as dental or jaw pain Features of pain

Patient

Age

Sex

H. A. J. A. J. B. R. B. J. B. D. B. K. C. M. C. B. C. H. C. M. c. D. F. M. G. L. G. G. G. P. G. J. H. J. H. L. H. K. H. E. H. S. J. D. J. L. K. R. L. K. M. D. M. P. 0. B. P. A. P. J. R. K. S. D. T. J. T. M. T.

31 31 41 46 32 37 23 28 37 44 34 34 33 36 46 39 27 39 37 46 25 40 23 41 25 34 25 22 41 53 30 19 36 44 30

F M F M F F F F F M F M F M M M F F F F M F F F M F M F F M M M M F M

Duration of symptoms (mo.)

Nocturnal in onset

48 4 6 8 9 36

Presents as jaw pain

X X

9 24 12 18 36 4 12 60 48 6 84 8 6 36 48 24 12 24 180 60 18 12 6 6 24 48

Presents as toothache

Pain inlor around eye X X

X X X X

X X X

X X

X

X X X

X X X X

X

X X X X X X

X X X X X

X X X X X X

X X X X X X X X X X X X X X X X X

The duration of symptoms ranged from 1 month to 15 years. It must be remembered, however, that all these patients were referred from other practitioners and many had had numerous dental and medical consultations prior to being seen. Pain was described as “toothache” in twenty cases (57 percent) and as jaw pain, (in maxilla, mandible, or temporomandibular joint region) in fifteen cases (43 percent). It occurred in the early hours of the morning in 80 percent of the patients and involved the region of the eye in 77 percent. In addition to the pain, 60 percent of patients complained of blockage of the nostril on the same side as the pain and 60 percent developed a

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Periodic migrainous neuralgia

Additional clinical features Bloodshot eye X X X

Epiphora

Congested nose

Family history of migraine

X X

X X X X

X

X

X X X X X X X

X

X X X X

X X X X X X

X X X X X

X X X X

X X

Extraction, endodontic treatment, etc. carried out in attempt to relieve pain X X

X

X

X X X

Personal histories of migraine

5 13

X X

X X

X

X X X X

X X X X X

X

X X X

X X

X X X X

X X

X

X

X X X

X X X

X

bloodshot eye, also on the ipsilateral side. Nine patients had epiphora. Sixteen patients (46 percent) had had extractions or root canal therapy in one or more teeth in an attempt to alleviate the pain. Most of the patients had periods of pain lasting 3 weeks to 3 months, occurring as frequently as every 3 or 4 months. Some patients had pain-free intervals as long as 4 years. The pain occurred as many as ten times per day and lasted from 20 minutes to 2 hours. Two typical histories will be given to illustrate difficulties in diagnosis in these cases.

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Oral Surg. October. 1978

Fii. 1. Histogram showing ages of thirty-five patients with periodic migrainous neuralgia. CASE 16 A 39-year-old man complained of intermittent facial pain of 4 years’ duration. The pain usually came in the middle of the night, when it would wake the patient. The pain started in the region of the upper right first premolar and over the next 20 minutes spread to involve the side of the nose, the right eye, and the whole upper jaw. The right eye watered, and blockage of the right nostril occurred. The right eye became bloodshot. The attack never lasted more than 1 hour. The pain was not relieved by the patient’s standing. Attacks occurred daily for about 3 weeks, and then the patient remained pain-free a variable length of time, sometimes as long as 6 months. In an attempt to relieve the pain, the upper right canine and first and second premolars had initially been restored, then treated endodontically, and finally extracted. It was not possible to determine what dental findings had prompted this treatment. There was no family or personal history of migraine. No other features of the history or examination were relevant. CASE 12 A 34-year-old man had a 7-year history of dental pain. He was of Greek origin and worked as a cook on one of the Great Lakes tankers. The pain usually began in the right lower jaw and radiated into the cheek and right temple, this order sometimes being reversed. The pain came on slowly, becoming very severe and “pounding” in quality, and lasting from 20 minutes to 4 hours; its average duration was 90 minutes. The patient was often nauseated when the pain occurred. The pain was accompanied by watering of the right eye and stuffiness of the right nostril. There was also drooping of the right eyelid. The pain would usually waken him in the middle of the night. Pressing the side of the face eased the pain temporarily. Three lower right molars had been removed in an attempt to relieve the pain, with no success. Other findings in the history and examination were noncontributory. DISCUSSION

Unfortunately, many names have been given to this condition and, as Gayford and Haskell have stated, they should all be regarded as periodic migrainous neuralgia’; the various names include Horton’s headache or syndrome, Sluder’s neuralgia or syndrome, histamine encephalalgia or headache, cluster headache, hemifacial migrainous neuralgia, sphenopalatine syndrome, Harris’ headache or neuralgia, ciliary ganglion syndrome, and alarm clock headache.

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Recently Lance and Anthony2 have argued that periodic migrainous neuralgia differs from migraine, both clinically and biochemically, and have stated that it is neither migrainous nor neuralgic. Even if this is the case, we believe that the term is so widely acceptedthat it should be retained, at least until the etiology of this condition has been fully established. Whatever its etiology or association with migraine, PMN is seen to be a wellrecognized clinical entity. It is a disease of young adults in which periodic bouts of unilateral facial pain, often nocturnal in onset, are associatedwith vascular phenomena, such as nasal blockage, bloodshot eye, erythema, and sweating of the face. The attacks last a variable length of time and recur every 3 weeks to 3 months, there being frequent remissionslasting up to 4 years. Most clinicians describea male/female ratio of 85 to 15, although in our series only 43 percent of the patients were male. The dental aspectsof this condition are extremely important. As will be seen from Table I, many of the patients had had dental treatment in the form of extraction or endodontic therapy administered in an attempt to relieve the symptoms. When the pain was located in the teeth or had been presentfor sometime, there was a greater likelihood that dental treatmentwould have beencarried out. It is thus important to rule out PMN asa course of “dental” pain. PMN may also’ masqueradeas myofascial pain dysfunction syndrome,3and its recognition in these caseswill avoid delay in treatment. It will be evident from an examination of Table I that not all the associatedclinical featuresoccur with every case.It should be stressed,however, that if one or two of these phenomenaoccur in association with unilateral facial pain, the diagnosis of PMN should be considered, in order to prevent needlessloss of teeth and delay in correct treatment leading to alleviation of symptoms. TREATMENT

This is usually in the handsof the patient’s physician, who may not have beenaware of the patient’s condition. Frequently, a neurologist’s opinion should be sought. Many different regimens, using a variety of drugs, are in use. They are all directed to preventing the onset of the pain. The most commonly used drugs are the ergot derivatives, given in the form of ergotamine tartrate tablets (1 mg. twice a day) or cafergot suppositories (2 mg.). Ergotamine may also be given by injection (0.25 mg) twice a day, if the previous methods have failed. If the attacks are occurring in the early hours of the morning, one doseis given at night. Dosesshould be omitted in order to detectremissions, and if attacks do not occur on these occasionsthe drug is gradually discontinued. The patient should be made aware of the adverseeffects of the drug, such as vascular spasm(tingling or cold fingers or toes), nausea,and vomiting. The drug should not be administeredif the patient is pregnant or if hypertension is present. Another drug (methysergide) has been used but has been associatedwith untoward side effects, such as retroperitoneal fibrosis. Antihistamines, as well as sedatives and tranquilizers, have been used for the condition, but if the patient fails to respond to ergotamine it is better for a neurologist or someonewith special knowledge of the care of this group of patients to select the most appropriate drug therapy. All patients in this series respondedto prophylactic therapy, this in itself being evidencethat the diagnosis of PMN was correct. Relapsesoccur-tedin severalcasesand were treated by combinations of the drugs referred to above. It was sometimesnecessaryto

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hospitalize the patients in an attempt to investigate and stabilize their condition, especially if they were resistant to therapy. The author wishes to thank Mrs. Lorna Brooke for assistance in collating and checking data. REFERENCES

1. Gayford, J. J., and Haskel, R.: Clinical Oral Medicine, London, 1971, Staples Press,p. 220. 2. Lance, J. W., and Anthony, M.: Clinical and Biochemical Distinctions Between Migraine and Migrainous Neuralgia (Cluster headache),in Cummings, J. N. (editor): Background to Migraine, Fifth Migraine Symposium, New York, 1973, Springer Verlag. 3. Brooke, R. I., Stenn, P. G., and Mothersill, K. J.: The Diagnosis and Conservative Management of Myofascial Pain Dysfunction Syndrome, ORAL SURG. 44: 844-852, 1977. Reprint requests to:

Dr. Ralph I. Brooke Department of Oral Medicine Faculty of Dentistry University of WesternOntario London, Ontario, Canada

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