Temporo-mandibular headache: a cracking case

18. October 2013

Patients with undefined headaches often suffer from a temporo-mandibular dysfunction. If the jaw joint does not function properly, cervicogenic pain can be considerable. Researchers are in dispute over the forms of therapy. According to one study orofacial therapies are able to help.

There are few randomised controlled studies on the topic “manual therapy for cranio-mandibular dysfunction (CMD)”. Brazilian scientists working under Betania Mara Franco Alves (University of Minas Gerais) scoured medical databases such as PubMed, EMBASE, The Cochrane Library and the physiotherapy evidence database PEDro and came to a sobering conclusion: only two studies of moderate quality were in the eyes of the researchers worthy of use in an evaluation process. The authors found no sufficient evidence for the effectiveness of manual therapy in cases of CMD.

Harry von Piekartz, University of Osnabrück, and Tony Hall, Curtin University of Technology, Australia, formed their own picture. They conducted a randomised controlled trial with 43 patients in which they wanted to find out whether a particular orofacial manual therapy could help with CMD.

The researchers found their study participants in Dutch physiotherapy clinics. With all patients, a neurologist had previously diagnosed cervicogenic headache. They demonstrated on average a measure on the Neck-Disability Index (NDI) of about 15 and had been suffering from their headaches for over 4 years. The authors found in their study that the patients each showed at least one sign of CMD.


About a third of patients even had all four symptoms of CMD, i.e. joint noises, asymmetries of > 2 mm with opening the mouth, passive freedom of movement of less than 53 mm with passive mouth opening and pain during passive mouth opening (> 32 mm on the visual analogue scale). The patients complained most frequently of pain when opening the mouth.

The researchers randomised patients into two treatment groups: 21 patients received ordinary manual therapy used as standard treatment. 22 patients were additionally treated with orofacial manual therapy. These also include techniques that aim to desensitise the cranial nervous system. The treatment took place over a period of 3-6 weeks. All patients were treated in 6 sessions of 30 minutes each. In addition the patients were issued exercises as “homework”.

The orofacial group benefited significantly

During treatment, the range of motion (ROM) of patients treated using orofacial therapy increased considerably, as the researchers established in the follow-up after 3 months. In particular, greater degrees of motion were achieved in the extension and rotation of the head. These improvements were not found in the standard group. However over the period up until the follow-up occurring 6 months after study start no further improvement in the ROM was shown in the orofacial group, indicating that the improvements occur only during the period of active intervention.

These results confirmed the review results of the Brazilian researchers therefore only in part: Regular manual therapy used against CMD does not help. However, what apparently has great effect is in particular orofacial manual therapy.

Studies indicate that cervicogenic headaches and CMD are mutually dependent. The study done by Harry von Piekartz and Toby Hall therefore allows the patient to hope: Cervicogenic headaches may improve when a – possibly previously undetected – CMD is treated via orofacial manual therapy.

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