Headache - 2022 - Silva - Association Among Headache Temporomandibular Disorder and Awake Bruxism A Cross Sectional

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Received: 14 October 2021 Accepted: 4 April 2022
DOI: 10.1111/head.14322
RESEARCH SUBMISSIONS
Association among headache, temporomandibular disorder,

and awake bruxism: A cross-sectional study
Tatiana B. Silva DDS, MSc, PhD1 | Fernanda R. Ortiz DDS, MSc, PhD2 |
Lucas M. Maracci DDS3 | Gabriela B. P. Silva4 | Rafaela S. Salbego DDS5 |
Gabriela S. Liedke DDS, MSc, PhD6 | Mariana Marquezan DDS, MSc, PhD6
1
Department of Restorative Dentistry,
Universidade Federal de Santa Maria, Abstract
Santa Maria, Brazil
Objective: To evaluate the association between headache, myofascial temporoman-
2
Faculdade Meridional -IMED/Passo
Fundo, Passo Fundo, Brazil
dibular disorder (TMD), and awake bruxism (AB).
3
Graduate Program in Dental Sciences, Background: Bruxism seems to act as a risk factor for TMD and its associated comor-
Universidade Federal de Santa Maria, bidities, such as headaches.
Santa Maria, Brazil
4 Methods: In total, 406 medical records of individuals who sought care at a university
Dental School, Universidade Federal de
Santa Maria, Santa Maria, Brazil dental clinic were screened. The Research Diagnostic Criteria for Temporomandibular
5
Graduate Program in Dental Sciences, Disorders was used to assess and diagnose TMD, as well as to obtain self-reports of
Universidade de São Paulo, São Paulo,
Brazil AB and headache.
6
Department of Stomatology, Results: The sample consisted of 307 medical records. About 72.5% (221/305) of the
Universidade Federal de Santa Maria,
sample reported having headaches, and 67.4% (180/267) and 68.4% (210/307) were
Santa Maria, Brazil
diagnosed with AB and TMD, respectively. Individuals who reported having AB (odds
Correspondence
ratio [OR], 2.28; 95% confidence interval [CI], 1.09–4.7) and who were diagnosed with
Tatiana B. Silva, Department of
Restorative Dentistry, Universidade myofascial TMD (OR, 2.53; 95% CI, 1.15–5.5) were more likely to have had head-
Federal de Santa Maria, Av. Roraima nº
aches in the past 6 months when compared with patients without myofascial TMD
1000, 26F-2111, 97105-900, Santa Maria-
RS, Brazil. and bruxism. Also, individuals who self-reported headache were 2.27 times (95% CI,
Email: tabernardon@hotmail.com
1.09–4.7) more likely to have AB and 2.45 times (95% CI, 1.13–5.34) more likely to
have myofascial pain than individuals without headaches.
Conclusions: Individuals with myofascial TMD, headaches, or AB were more likely to
have at least one of the other conditions.
KEYWORDS
awake bruxism, headache, temporomandibular disorders
I NTRO D U C TI O N or articular origin. 2 Myofascial pain, a condition of muscular origin,

is characterized by localized muscle tenderness and regional muscle
The American Academy of Orofacial Pain defines temporomandib- pain3 and may be associated with mouth-opening limitation,4 being
ular disorders (TMD) as a group of disorders involving masticatory the most prevalent diagnosis among those affected by TMD.5
muscles, temporomandibular jpoint (TMJ), and associated struc- Although the literature could not properly clarify the relationship
1
tures that have a multifactorial cause. TMD may have a muscular between TMD and bruxism, the latter seems to act as a risk factor
Abbreviations: AB, awake bruxism; CI, confidence interval; OR, odds ratio; RDC/TMD, research diagnostic criteria for temporomandibular disorders; TMD, temporomandibular disorder;
TMJ, temporomandibular joint.
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748 © 2022 American Headache Society wileyonlinelibrary.com/journal/head Headache. 2022;62:748–754.
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HEADACHE 749
for TMD and its associated comorbidities, such as headaches.6,7 statistical power calculation was conducted prior to the study, and the
8
Bruxism had its definition updated in 2018, which encompasses the sample size was based on the available data of the Occlusion Clinic.
2 types of bruxism: sleep bruxism and awake bruxism (AB), whose
diagnoses can be considered as possible, probable, or definitive.9
Sleep bruxism is defined as a masticatory muscle activity that oc- Data collection
curs during sleep, characterized as rhythmic (phasic) or nonrhythmic
(tonic), and is not considered a movement or sleep disorder. AB is Patients were evaluated through the RDC/TMD, which was applied
defined as masticatory muscle activity during wakefulness, charac- by trained examiners. Complementary examinations such as pano-
terized by repetitive or continuous tooth contact and/or bracing and ramic radiography, cone beam computed tomography, or magnetic
thrusting of the mandible, and is not considered a movement dis- resonance imaging were requested to complement the clinical diag-
order.8 Emotional stress; substances such as alcohol, tobacco, and nosis when necessary.
coffee; sleep disorders; certain medications; anxiety; and headaches The RDC/TMD21 was created to standardize the diagnosis
8,10
are predisposing factors for this habit in adults. of TMD. It is divided into 2 axes. Axis I provides the diagnosis for
Headaches seem to play an important role in the clinical setting of 3 groups of TMD: group 1 (G1)—myofascial TMD (myofascial pain,
patients with TMD or bruxism.11–13 Headaches are categorized into 2 myofascial pain with mouth-opening limitation, or without a diagno-
types: primary and secondary. Primary headaches can be classified as sis); group 2 (G2)—disk displacements (disk displacement with reduc-
episodic or continuous and have an unknown cause. Scientific litera- tion, disk displacement without reduction and with mouth-opening
ture shows the coexistence of primary headache and TMD in the same limitation, disk displacement without reduction and without mouth-
individuals, and such conditions may act as perpetuating and aggravat- opening limitation, or without a diagnosis); and group 3 (G3)—other
ing factors for each other.14–16 Secondary headaches can be diagnosed joint conditions (arthralgia, TMJ osteoarthritis, TMJ osteoarthrosis,
by clinical or laboratory tests and can be caused by pre-existing disor- or without a diagnosis) that are assessed separately for each joint.
13,17,18
ders, for example, TMD of muscular origin. The RDC/TMD allows multiple diagnoses for the same individual.
Although the literature considers AB as a predisposing factor for For this study, the G1 diagnoses (myofascial TMD) of both sides were
TMD,19 especially myofascial pain, 20 the relationship among these unified; that is, the individual who presented with a positive diagno-
conditions and headaches still needs to be clarified. Therefore, the sis for either side on axis I was classified as sick (with TMD); if there
aim of this study was to evaluate the association between headache, was no diagnosis, it was classified as normal (without TMD).
myofascial TMD, and AB in a population from southern Brazil. The Diagnosis of AB was based on patients' self-reporting during the
conceptual hypothesis is that these three clinical conditions are as- RDC/TMD anamnesis. Patients answered “yes” or “no” to the fol-
sociated, possibly in a comorbid relationship with each other. lowing question: “During the day, do you grind or clench your teeth?”
A positive response was considered as self-reported AB. Self-report
is an indicated method for identifying possible cases of AB.9
M E TH O D S Diagnosis of headache was based on question 18 of the RDC/
TMD: “During the past six months, have you had any problems with
Design and sample headaches or migraines?” Patients who answered “yes” to this ques-
tion were considered to have headaches.
This is a cross-
sectional observational study approved by the Demographic and socioeconomic variables were also collected:
Research Ethics Committee of the Federal University of Santa Maria sex (female or male), age (in years), and skin color (white person or
(UFSM) (protocol number: 4728.9415.0.000.5346). All participants person of color). Participants selected their marital status as single,
signed an informed consent form. widowed, divorced, married, or in common-law marriage. For sta-
The sample consisted of patients treated at the Occlusion Clinic tistical analysis, marital status was categorized as unmarried (single,
at UFSM dental school from March 2015 to December 2019, which widowed, and divorced) or married (married and common-law mar-
constituted a convenience sample. UFSM provides the benchmark riage). Monthly income was collected in Brazilian minimum wages
for dental appointments in the region of Santa Maria, a city located (BMWs; US $1.00 corresponded to R$3.94, based on the annual
in the south of Brazil with 263,403 inhabitants, according to the averages of the dollar exchange rate between 2015 and 2019) and
Brazilian Ministry of Health. later dichotomized into individuals who received up to 2 BMW (ap-
Four hundred and six medical records of patients who were proximately US $263.70) and those who received more than 2 BMW.
assessed for TMD using the Research Diagnostic Criteria for
Temporomandibular Disorders (RDC/TMD) Axis I21 were screened.
Patients between 18 and 60 years of age were included in the sam- Statistical analyses
ple. Those with neuropathic pain (such as trigeminal neuralgia), with a
history of facial and/or jaw trauma, and with rheumatic disease were The primary analysis of these data was performed using the STATA
excluded from the sample. Incomplete medical records, which made 14 software package (Stata Corporation, College Station, TX, USA).
it impossible to determine TMD diagnosis, were also excluded. No Descriptive analyses were expressed by frequency and percentage
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TA B L E 1 Clinical and sociodemographic characteristics of the

for categorical variables and means and standard deviation (SD) for
sample (n = 307)
continuous variables.
Logistic regressions were performed to verify the associations Variable No. (%)
between AB, headache, and TMD through unadjusted and adjusted Sex
analyses. Co-variables that could be confounding for the 3 outcomes Male 71 (23.1)
were included in the analysis, such as sex, age, skin color, monthly Female 236 (76.9)
income, and marital status. All models included the same variables Skin color
so that the results could be compared. The co-variables remained in
White 259 (84.9)
the final model as an adjustment. The associations were interpreted
Person of color 46 (15.1)
by odds ratio (OR) measure of effect, a significance level of 0.05,
Marital Status
and a 95% confidence interval (CI), including 2-tailed hypothesis
Single, widowed, or divorced 193 (63.1)
tests. Three different adjusted models were performed to verify
Married or in common-law marriage 113 (36.9)
the interrelationships between AB, headache, and TMD through the
behavior of the variables, sometimes as a predictor and sometimes Age, mean (SD), y 34.5 (12.9)
as an outcome. Hosmer–Lemeshow tests were used to examine the Monthly income
predicted and observed models. Covariance analyses were also per- ≤2 Brazilian minimum wages 88 (34.5)
formed prior to regression analyses; the results showed that the out- >2 Brazilian minimum wages 167 (65.5)
comes have positive and low values and that they do not interfere Awake bruxism
with multicollinear factors in the regression analysis. No 87 (32.6)
Yes 180 (67.4)
G1 diagnosis—myofascial TMD
R E S U LT S Without diagnosis 97 (31.6)
Myofascial TMD 210 (68.4)
A total of 406 medical records were screened for patients between
Headache
18 and 60 years of age who were assessed for TMD using the RDC/
No 84 (27.5)
TMD Axis I. 21 Seventy-eight patients did not meet the eligibility cri-
Yes 221 (72.5)
teria: 13 were younger than 18 years, 36 were older than 60 years,
26 had a history of trauma, and 3 were diagnosed with trigeminal Abbreviation: TMD, temporomandibular disorder.
neuralgia. Also, 20 medical records were incomplete, and 1 was
duplicated. Therefore, the sample consisted of 307 individuals as-
sessed for myofascial TMD, of whom 269 (68.4%) were positively headaches were 2.45 times more likely (95% CI, 1.13–5.34) to have
diagnosed for this condition. Moreover, 305 patients were assessed myofascial TMD when compared with individuals without head-
for headache and 267 were assessed for AB, of whom 221 (72.5%) aches. AB was not associated with TMD.
and 180 (67.4%) self-reported having these conditions, respectively.
Missing data were owing to incomplete RDC/TMD files, which
made it impossible to perform diagnosis for headache or AB. Also, DISCUSSION
most participants were female, White, unmarried, a mean age of
34.5 years (SD, 12.9), and received more than 2 BMW. The sample This study evaluated the association between headache, AB, and
characteristics are shown in Table 1. myofascial TMD. Its conceptual hypothesis was accepted, allowing
Table 2 shows the results of the unadjusted and adjusted analy- the inference that these three conditions are associated and often
ses for the headache outcome. Individuals who reported having AB coexist in the patients’ clinical condition. Although other studies
(OR, 2.28; 95% CI, 1.09–4.7) and who were diagnosed with myofas- have observed similar results,10,13 this was the first study to our
cial TMD (OR, 2.53; 95% CI, 1.15–5.5) were more likely to have had knowledge to evaluate these three conditions together and sug-
headaches in the past 6 months when compared with patients with- gest that myofascial TMD, headache, and AB might have a comorbid
out myofascial TMD and bruxism. In addition, age was also associ- relationship.
ated with headaches, showing that older individuals tended to be less The sample of this study was composed mostly of women
likely to report having headaches compared with younger individuals. (76.9%), which is commonly observed in studies on headaches and
Table 3 shows the results of the unadjusted and adjusted analysis TMD.22–25 This predominance can be explained by the fact that
for the AB outcome. Individuals who had headaches were 2.27 times women seek more professional help compared with men.1 Studies
more likely (95% CI, 1.09–4.7) to have AB when compared with indi- also suggest that this higher prevalence of TMD in women may be ex-
viduals who did not have headaches. plained by psychological changes, such as depression and anxiety.26–28
Finally, Table 4 shows the results of the unadjusted and ad- In the present study, most people were White, unmarried
justed analysis for the myofascial TMD outcome. Individuals with (single, widowed, or divorced), had a mean age of 34.5 years, and
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HEADACHE 751
TA B L E 2 Adjusted logistic regression analysis among predictors and headache
Headache
Unadjusted OR (95% CI) p value Adjusted OR (95% CI) p value
Sex <0.0001 0.062

Male 1 1
Female 4.3 (2.46–7.6) 2.25 (0.96–5.3)
Skin colora 0.028 0.919
White 1 1
Person of color 1.55 (1.05–2.29) 0.95 (0.361–2.50)
a
Marital status 0.165 0.063
Single, widowed, or divorced 1 1
Married or in common-law marriage 0.64 (0.347–1.19) 1.90 (0.96–3.75)
Age, mean (SD), y 1.00 (0.98–1.02) 0.652 0.95 (0.92–0.99) 0.019
a
Monthly income 0.165 0.674
≤2 BMW 1 1
>2 BMW 0.64 (0.347–1.19) 0.84 (0.377–1.87)
Awake bruxism 0.004 0.027
No 1 1
Yes 2.45 (1.33–4.5) 2.28 (1.09–4.7)
G1 diagnosis—myofascial TMD <0.0001 0.021
Without diagnosis 1 1
Myofascial TMD 4.62 (2.70–7.9) 2.53 (1.15–5.5)
Note: Hosmer–Lemeshow test: p = 0.396. Adjusted analysis includes all covariates shown in the table.
Abbreviations: BMW, Brazilian minimum wages; CI, confidence interval; OR, odds ratio; TMD, temporomandibular disorder.
a
Missing data.
earned a monthly income of less than 2 BMW. Low monthly in- Participants in the study sample who self-reported headaches
29
come may be related to limited housing and employment choices, in the past 6 months were more likely to report myofascial TMD
which are directly related to worse quality of life and general episodes. Also, patients with myofascial TMD were more likely
health. The mean age of the patients also corroborates the higher to have headaches. Gonçalves et al.12 also demonstrated this as-
30
incidence of TMD episodes in younger women. Furthermore, sociation, concluding that TMD can act as a trigger for the onset
the findings of this study show that older individuals tend to have or worsening of headache symptoms. Furthermore, the authors
fewer headaches. Other studies corroborate this information and reported that improvements in headache symptoms were only
show that there is a constant drop in episodes of headaches after achieved when treatment of TMD was carried out concomitantly.
30 years of age31,32; in cases of headache secondary to TMD, this Glaros et al.13 found that a large number of patients who had
can be explained by the decrease in the prevalence of TMD as age headaches were also diagnosed with myofascial pain, and that
increases. 30 treatment of TMD could improve both diseases. This association
Bruxism and headaches are among the factors that may con- among myofascial TMD (G1 diagnosis), headache, and AB found
tribute to predisposition, initiation, and/or maintenance of TMD, 20 in the present study corroborated the scientific literature on the
although in the present study AB was not found to be associated subject.10,16,18,33,34 However, other studies have also found an as-
with TMD. Participants who self-reported AB were more likely to sociation between headache and TMD of articular origin, as well as
report headaches, and vice versa, since participants who reported other joint conditions.13,31,35
headaches were more likely to have AB. Patients with headache re- In this study, data interpretation did not allow inferring whether
ported significantly more dental contact during wakefulness com- myofascial pain is secondary to headaches or vice versa, because
pared with individuals without a headache diagnosis.13 In a recent a cross-sectional study does not establish a cause-effect relation-
clinical trial, Haggiag and Speciali11 found a relationship between ship. However, the International Headache Society recognizes that
AB and chronic headache. After undergoing treatment of AB with secondary headaches can be attributed to TMJ problems, with this
an intraoral appliance designed for daytime use, they obtained an type of headache being related to pain in the skull, face, or cervical
improvement in the intensity of the patients' pain, which was main- structures.36 According to this classification, headache is considered
tained after 1 year. primary when there is no other disorder that justifies its cause. In
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752 HEADACHE
TA B L E 3 Adjusted logistic regression analysis among predictors and awake bruxism
Awake bruxism
Sex 0.017 0.233

Male 1 1
Female 2.09 (1.13–3.86) 1.59 (0.74–3.44)
White 1 1
Person of color 0.73 (0.359–1.47) 0.74 (0.320–1.69)
a
Age, mean (SD), y 0.99 (0.97–1.01) 0.819 1.00 (0.98–1.04) 0.560
a
≤2 BMW 1 1
>2 BMW 1.00 (0.56–1.80) 1.20 (0.63–2.29)
Headache 0.004 0.028
No 1 1
Yes 2.45 (1.33–4.49) 2.27 (1.09–4.7)
G1 diagnosis—myofascial TMD 0.029 0.144
Without diagnosis 1 1
Myofascial TMD 1.94 (1.07–3.53) 1.69 (0.83–3.44)
a
Missing data.
fact, primary headaches can interfere with the success of the treat- To our knowledge, this is the first study to assess the relationship
ment of TMD, and concomitant treatment of both conditions is rec- between myofascial TMD, AB, and headache. Its strengths include
ommended for better results.33 its large sample size and the use of the RDC/TMD for the diagnosis
The association between myofascial TMD and headache, and of myofascial TMD, which is a validated and globally used instru-
their possible association with bruxism, can be explained by the ment. Even though the RDC/TMD has also been used to consider
nonspecific activation of common pathways of the central nervous self-reports of AB and headaches, diagnosing a patient with such
system bidirectionally (caudal trigeminal nucleus), that is, pain in the conditions demands specific questionnaires and criteria, such as the
trigeminal distribution predisposes to other forms of facial pain or International Classification of Headache Disorders,39 to enable the
headache. This fact has pathophysiological and therapeutic impor- assessment of the type of headache as well as its characteristics in
tance, as one condition can contribute to the refractoriness of the terms of frequency, intensity, duration, and limitations of the par-
other.10 According to Gonçalves et al.,15 since nociceptive inputs ticipants' activities. Even when using diagnostic criteria, there is a
from the orofacial area can induce trigeminal sensitization, TMD can difficulty in diagnosing headaches because of the possibility of an
be a risk factor for headache progression. overlapping diagnosis of tension-type headache and headache at-
Although an association between AB and TMD has not been tributed to TMD arising from muscular tension, for example.39
verified in this study, other studies show that dental contact during However, the retrospective nature of this study did not allow adding
wakefulness is more frequent in patients with TMD when compared new questions or clinical examination for a more accurate diagnosis.
36,37
with asymptomatic patients. However, the real association Still, self-report is a method used by other studies in recent years
between AB and TMD is not well established in the literature, as for diagnosing possible AB,40–43 as well as for identifying individuals
there are few studies that have accurately assessed the relationship with headaches.9,43–46 Also, the use of a convenience sample can be
38
between these two conditions. Also, one study which sought to considered a limitation, as individuals were not selected using statis-
simulate AB events did not cause muscle or TMJ pain after 3 days, tical criteria. Thus, longitudinal studies with random and representa-
possibly because AB by itself is not capable of triggering TMD, as the tive samples of the population are suggested to confirm the findings
latter has a multifactorial cause.1 of the present study.
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TA B L E 4 Adjusted logistic regression analysis between predictors and myofascial TMD
Myofascial TMD (G1 diagnosis)
Sex 0.001 0.084

Male 1 1
Female 2.52 (1.46–4.36) 2.06 (0.91–4.66)
White 1 1
Person of color 0.71 (0.369–1.38) 0.54 (0.22–1.32)
a
Age, mean (SD), y 1.00 (0.99–1.02) 0.494 1.00 (0.97–1.03) 0.947
a
≤2 BMW 1 1
>2 BMW 0.73 (0.42–1.30) 0.91 (0.43–1.91)
Headache <0.0001 0.024
No 1 1
Yes 4.62 (2.70–7.90) 2.45 (1.13–5.34)
Awake bruxism 0.029 0.139
No 1 1
Yes 1.94 (1.07–3.53) 1.70 (0.84–3.46)
a
Missing data.
CO N C LU S I O N Lucas M. Maracci https://orcid.org/0000-0003-4668-8130

Gabriela B. P. Silva https://orcid.org/0000-0001-6591-9614
It was concluded that individuals who self-reported headaches in the Rafaela S. Salbego https://orcid.org/0000-0002-9143-7288
past 6 months are more likely to have AB and myofascial TMD, and Gabriela S. Liedke https://orcid.org/0000-0002-0967-9617
also that individuals with AB and myofascial TMD are more likely to Mariana Marquezan https://orcid.org/0000-0001-6078-5194
present with headache episodes, showing association among these
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Received: 14 October 2021 Accepted: 4 April 2022

Association among headache, temporomandibular disorder,

I NTRO D U C TI O N or articular origin. 2 Myofascial pain, a condition of muscular origin,

TA B L E 1 Clinical and sociodemographic characteristics of the

as an outcome. Hosmer–­Lemeshow tests were used to examine the Monthly income

TA B L E 2 Adjusted logistic regression analysis among predictors and headache

Unadjusted OR (95% CI) p value Adjusted OR (95% CI) p value

Sex <0.0001 0.062

TA B L E 3 Adjusted logistic regression analysis among predictors and awake bruxism

Unadjusted OR (95% CI) p value Adjusted OR (95% CI) p value

Sex 0.017 0.233

TA B L E 4 Adjusted logistic regression analysis between predictors and myofascial TMD

Myofascial TMD (G1 diagnosis)

Unadjusted OR (95% CI) p value Adjusted OR (95% CI) p value

Sex 0.001 0.084

CO N C LU S I O N Lucas M. Maracci https://orcid.org/0000-0003-4668-8130

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as an outcome. Hosmer–Lemeshow tests were used to examine the Monthly income