Headache and Oral Parafunctional Behaviors

Headache and Oral Parafunctional Behaviors

Alan G. Glaros • Anne H. Hanson •

Chris C. Ryen

Published online: 12 February 2014

� Springer Science+Business Media New York 2014

Abstract This study tested the hypotheses that individ-

uals with headaches would show significantly more oral

parafunctional behaviors than non-headache controls, be

diagnosed with one or more temporomandibular disorders

(TMD) significantly more frequently than controls, and

would report significantly less pain and other symptoms of

headache after participating in a habit reversal treatment to

reduce oral parafunctional behaviors, compared to a wait

list control. In Phase I, individuals with and without self-

reported headaches were examined by a blinded examiner

and participated in a week-long experience sampling pro-

tocol (ESM) to assess oral parafunctional behaviors, pain,

and emotional states. In Phase II, those with headaches

were randomly assigned to either a habit reversal treatment

or to a wait list control group. In the last, sixth week of the

program, participants again completed an ESM protocol.

Results showed that headache patients were significantly

more likely to report oral parafunctional behaviors than

non-headache controls and to receive a Research Diag-

nostic Criteria/TMD diagnosis. Results from Phase II

showed general improvement in both groups on pain and

parafunctions. Individuals with headaches engage in sig-

nificantly higher rates and intensities of oral parafunctional

behaviors. Treatment of these behaviors using habit

reversal techniques appears to have the same effect on pain

as waiting.

Keywords Headache � Oral parafunctions � Pain �Experience sampling � Habit reversal

Introduction

Patients diagnosed with headaches and temporomandibular

disorders (TMD) share a similar set of symptoms. Both

report pain in the face, head, and cervical areas. The

headaches reported by TMD patients are similar to those

reported by patients diagnosed with tension-type or

migraine headaches. Both disorders are relatively common,

and women are disproportionately represented among both

headache and TMD patients.

Individuals who complain of TMD have high rates of

headaches. One study surveying 1,511 individuals with

TMD (Hoffmann et al. 2011) reported a higher likelihood

of headache in the TMD patients compared to case con-

trols. Among 502 TMD patients who were also diagnosed

using ICHD-II criteria, nearly half were diagnosed with

tension-type headache, with additional patients diagnosed

with some type of migraine (Kang et al. 2010). Pro-

spective studies show that those who develop TMD are

also likely to report increases in headaches and other

pains (Lim et al. 2010). Similarly, headache patients

(typically those with tension-type and migraine head-

aches) have a significantly higher likelihood of being

diagnosed as having a temporomandibular disorder (i.e.,

myofascial pain) (Ballegaard et al. 2008; Stuginski-

Barbosa et al. 2010).

The reasons for the diagnostic overlap between the two

conditions are unclear. Several studies have suggested that

both disorders have neurological underpinnings, including

increased functional connectivity between the left anterior

insular cortex and the anterior cingulate cortex, central

A. G. Glaros (&) � A. H. Hanson � C. C. Ryen

Division of Basic Medical Sciences, Kansas City University of

Medicine and Biosciences, 1750 Independence Ave,

Kansas City, MO 64106, USA

e-mail: [email protected]

123

Appl Psychophysiol Biofeedback (2014) 39:59–66

DOI 10.1007/s10484-014-9242-0

facilitation of nociceptive inputs, peripheral and central

sensitization, and cutaneous allodynia and aftersensations

(Anderson et al. 2011; Bevilaqua Grossi et al. 2009,

Goncalves et al. 2011; Ichesco et al. 2012; Sato et al.

2012). Some investigators have suggested there is a shared

genetic risk between the two conditions (Plesh et al. 2012),

while others have proposed an important role for occlusion

(Troeltzsch et al. 2011).

The role of oral parafunctional behaviors in headache is

a relatively unexplored area. One study used experience

sampling methods to assess oral parafunctions in groups of

headache and non-headache controls. It reported that

headache patients had significantly more frequent and

intense tooth contact, more masticatory muscle tension,

and more stress than non-pain controls (Glaros et al.

2007c). A focus on tooth contact may be relevant for

understanding the role of oral parafunctions in headache,

since experimental tooth contact can increase pain in

otherwise pain-free individuals and can lead to a diagnosis

of the myofascial form of TMD by a blinded examiner

(e.g., Glaros and Burton 2004).

Multiple studies suggest that habit reversal can suc-

cessfully reduce TMJD-related pain (Glaros et al. 2007a;

Gramling et al. 1996; Townsen et al. 2001). One successful

habit reversal strategy uses a ‘‘DTMD’’ procedure (Peter-

son et al. 1993). The DTMD procedure teaches patients to

reduce tooth contact and muscle tension by dropping their

jaws slightly (D), separating their teeth about the width of a

pencil (T), relaxing the muscles in the jaw and face area

(M), and performing a simple deep breathing activity (D).

Success in reducing tooth contact is associated with greater

reduction in self-reported pain (Glaros et al. 2007b).

However, the utility of a habit reversal strategy focusing on

tooth contact and masticatory and facial muscle activity in

headache patients has not been widely reported.

This study was carried out in two phases. The first phase

addressed two specific aims: (1) to determine the incidence

with which headache patients are diagnosed with myofas-

cial pain using validated physical examination techniques,

and (2) to compare oral parafunctional behaviors, pain,

emotional distress, and stress in headache versus non-

headache individuals using experience sampling method-

ology. We hypothesized that headache subjects would be

diagnosed with myofascial pain with or without arthralgia

more often than non-headache controls and that these

headache subjects would report greater oral parafunctional

activity, pain, emotional distress, and stress.

The second phase aimed to test the effectiveness of a

habit reversal strategy focusing on oral parafunctional

behaviors and facial/masticatory muscle tension on pain

reported by headache patients. We hypothesized that

individuals in the habit reversal group would report less

pain than those in a wait list control group.

Materials and Methods

Phase I

Subjects

Participants between the ages of 18 and 65 years of age

were selected from the KCUMB Clinical Research Center

and the general population. All participants signed an

informed consent formed approved by the Institutional

Review Board. Participants were pre-screened for prior

history of major trauma to the head or neck, any trauma to

the head or neck in the past 6 weeks, current diagnosis of

temporomandibular disorder (TMD) or any other chronic

pain condition (excluding headache), as well as psychi-

atric and chronic health disorders. Individuals taking

analgesic and anti-migraine medications were permitted

to participate as long as no medication adjustments were

made during the length of the study. Self-report was used

to assign participants to Headache (H) or Non-Pain

Control (C) groups. Groups were balanced for age and

gender..

Interviews and Questionnaires

All participants completed two questionnaires: (1) Head-

ache Screening Questionnaire, a 54-item instrument pub-

lished by the National Headache Foundation. Responses to

questionnaire items generated subscale scores for tension,

migraine, cluster, and other headaches; and (2) RDC/TMD

Questionnaire, a 31-item instrument that is a component of

the Research Diagnostic Criteria (RDC) for TMD (Dwor-

kin and LeResche 1992). The RDC/TMD Questionnaire

was used to obtain information on health status, emotional

distress, facial and jaw injury, pain, limitations, and general

demographics. Headache patients were interviewed

according to the diagnostic criteria developed by the

International Headache Society described in the ICHD-2

(Olesen 2006). Headache patients were questioned on

duration, frequency, location, quality, and intensity of their

headaches and on the impact of physical activity on their

headaches.

RDC Examinations for TMD

Blinded-examiner physical evaluations were performed on

participants according to the RDC/TMD. All three inves-

tigators performed the RDC/TMD examination. Two (AH

and CR) were trained by the lead investigator (AG) until

they could correctly and reliably perform the examination.

The examiner asked specific questions about a participant’s

60 Appl Psychophysiol Biofeedback (2014) 39:59–66

123

pain and then examined opening and closing of the mouth,

vertical range of motion, and location of pain during

opening. Joint sounds were assessed by palpation of the

temporomandibular joint (TMJ), as participants opened,

closed, and protruded their jaws. The extent of travel for

left and right excursions and for protrusions were mea-

sured. Sixteen extraoral muscle sites and four intraoral

muscle sites were palpated to assess muscle pain as well

two extraoral sites to assess TMJ pain. Participants repor-

ted their pain on a 0–3 point scale with 3 being severe pain.

To increase the consistency of applied palpation pressures,

examiners calibrated themselves prior to each examination

using a digital scale. The RDC/TMD has good reliability

and validity for diagnosing myofascial pain/muscle ten-

derness (Look et al. 2010).

Experience Sampling Methodology

Experience sampling methodology (ESM) was used to

obtain information about tooth contact, muscle activity,

pain, mood, and stress from participants in their natural

environments. This technique was used to reduce recall

bias in participant reporting and facilitate responding from

normal surroundings. To collect information, pre-printed

30 9 50 question cards were provided to the participants to

fill out each time a pager provided to participants sounded

or vibrated. Participants reported on pain and tension in the

jaw, face or head; the presence and intensity of tooth

contact; mood, and stress. All measures except tooth con-

tact were recorded on a 0 to 10 numerical scale. The two

mood scales were reversed-scored to assess response

validity.

A custom program placed calls to the pagers. The

average time between calls was 120 min. Calls to the

pagers could vary up to 40 min from a fixed schedule; i.e.,

the pager could activate up to 20 min prior to the

‘‘expected’’ time or up to 20 min later. This procedure

reduced the likelihood that a participant adjusted his or her

activities in anticipation of a page.

Participants provided their waking and sleeping sched-

ules, and the call schedule was customized so as to not

disturb sleep. Participants were given permission to turn off

the pager if they were in a situation where responding to a

call would be dangerous or disruptive. They were also

instructed to turn off the pager if they chose to sleep late or

go to bed early. Participants were instructed on use of the

pagers following a written script. All participants were

asked to demonstrate adequate understanding and compe-

tency in the use of the pager before starting the study.

The first day of paging varied for each participant and

was randomly assigned from Monday through Sunday.

Paging continued for a week. After 1 week, participants

turned in completed questionnaire cards.

Phase II

Subjects

Only headache patients who participated in Phase I were

permitted to enroll in Phase II of the study. To enter Phase

II, patients signed a second informed consent form

approved by the Institutional Review Board.

Treatments

Headache patients who accepted the invitation to partici-

pate in Phase II (N = 20) were randomly assigned to either

a Habit Reversal (HR) or Wait List (WL) control group.

The habit reversal treatment was delivered in a one-hour

session. During this session, patients were given informa-

tion about (1) facial pain and headaches, (2) the role of oral

behaviors in headaches, and (3) possible treatments for

reducing headaches. Patients were shown (4) how tooth

contact can affect the activity of the masticatory muscles

(using biofeedback in the form of a computer display of

EMG activity) and (5) how to reduce masticatory muscle

activity, using the feedback display. Subjects were taught

the ‘‘DTMD’’ treatment approach described earlier to

facilitate the learning and practice of the alternative

behavior.

Participants assigned to the HR group carried pagers that

contacted them approximately every two hours during their

awake time. The signal from the pager was a cue to use the

DTMD technique. Participants were also instructed to use

the DTMD technique when they detected tooth contact or

when they detected internal states suggestive of mastica-

tory and facial muscle tension.

Participants assigned to the WL group were told that the

supply of pagers was limited and that they would be

enrolled in the active treatment phase in approximately

6 weeks. At that point, they would return to the clinic to

obtain a pager, take part in a 1-week monitoring activity

similar to Phase I, and start treatment. Three individuals

from the WL group elected to take part in active treatment

at the end of Phase II.

Experience sampling techniques were used to collect

data from all Phase II participants on tooth contact, pain,

and other variables during the last week of this 6-week

phase. Subjects returned their pagers and cards to the clinic

and had a RDC/TMD examination performed by a blinded

examiner.

Data Management and Statistical Analysis

Information collected during Phase I consisted of quanti-

tative and categorical data. For quantitative data, one-way

between-subjects analyses of variance were used to analyze

Appl Psychophysiol Biofeedback (2014) 39:59–66 61

123

the data. Categorical data were analyzed via Chi-square

tests or Fisher’s exact tests for 2 9 2 tables.

ESM data collected from headache subjects in Phase I

were used as pre-treatment values, and ESM data collected

at the end of the 6-week treatment period were used as

post-treatment values. RDC/TMD examination findings

obtained at the end of the 6-week treatment period were

analyzed by one-way analyses of variance for qualitative

variables or Fisher’s exact tests or Chi-square tests for

categorical data.

Results

Phase I

Thirty-seven individuals began Phase I, 23 with headaches

and 14 without. Demographic information on these par-

ticipants is presented in Table 1. Groups did not differ in

age, education, gender composition, or race. Responses to

the questionnaires are presented in Table 2. Participants in

the Headache group endorsed significantly more items on

the Migraine and Tension subscales of the Headache

Screening Questionnaire. Participants in the Headache

group also reported significantly higher levels of charac-

teristic pain, greater disability, and more disability points.

Individuals in the Headache group also reported signifi-

cantly higher levels of depression and general somatiza-

tion, as assessed in the RDC/TMD questionnaire.

Of the 23 individuals assigned to the Headache group,

all met the criteria for at least one headache type as defined

in the ICHD-II; migraines and tension-type headaches were

present in 52.1 and 82.6 % respectively of the Headache

group participants. Significantly more individuals in the

headache group (15 of 23) were diagnosed with the myo-

fascial pain of TMD than non-headache control partici-

pants (0 of 14), v2 (1, N = 37) = 15.36, p \ 0.001.

Participants in the Headache group reported significantly

more muscles that were painful to palpation than individ-

uals in the Control group (Table 2).

Three individuals, all from the headache group, dropped

out before completing Phase I, leaving 20 in the headache

group. Table 3 shows the results from the pager question-

naires. Participants responded to 59.8 % of prompts from

the pager to complete data collection forms. Many of the

non-responses occurred early or late in the day (i.e., about

the time for awakening or the time for sleep).

Participants in the headache group reported significantly

more head and facial pain but not more pain elsewhere in the

body. They reported significantly more frequent tooth con-

tact, more intense tooth contact, more ‘‘effort’’ (a composite

measure combining tooth contact intensity and time in tooth

Table 1 Phase I: Demographic characteristics and RDC diagnosis of

participants

Headache Control

Age 28.87 (8.11) 25.79 (1.98)

Education 16.65 (1.87) 17.07 (1.82)

Gender (% male/% female) 26.1/73.9 28.6/71.4

Race (% white/% other) 87.0/13.0 85.7/14.3

Myofascial pain diagnosis (%) 65.2 0.0

Values in parentheses are standard deviations

Table 2 Phase I: Self-Report Questionnaire and RDC/TMD examination data, by group

Headache Control p Partial g2

Mean SD Mean SD

Headache Screening Questionnaire

Migraine (34) 16.62 5.53 3.64 3.90 0.001 0.81

Tension (10) 3.62 2.27 0.79 1.31 0.001 0.35

Cluster (7) 0.81 0.98 0.29 0.47 0.073 0.09

Other (3) 0.14 0.36 0.07 0.27 0.529 0.01

RDC Questionnaire

Characteristic Pain Intensity (100) 36.30 24.83 4.05 15.14 0.001 0.35

Disability Score 23.77 27.79 0.00 0.00 0.003 0.22

SCL depression 0.42 0.46 0.09 0.10 0.014 0.16

SCL somatization 0.63 0.49 0.13 0.17 0.001 0.28

Muscles sites tender to palpation

Externally accessible sites (4) 2.83 3.11 0.14 0.36 0.003 0.23

Intraorally accessible sites (16) 2.65 1.23 1.00 1.04 0.001 0.34

Total tender sites (20) 5.48 3.94 1.14 1.23 0.001 0.31

Values in parentheses are maximums possible for item


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contact), and more head and facial muscle tension. They also

reported significantly more emotional distress on one of the

mood scales (Mood 2) and more stress.

Phase II

Of the 20 individuals who began this phase, four individ-

uals, all from the wait list control group, completed the

assigned tasks for this phase except for the second expe-

rience sampling assessment. Groups did not differ signifi-

cantly (p [ 0.05) on any outcome measure at the start of

Phase II.

On the Headache Screening Questionnaire, there were

no significant group, time, or group 9 time interaction

effects (Table 4). On the RDC History Questionnaire,

overall Characteristic Pain Intensity and Disability Scores

decreased significantly, F(1,18) = 12.85, p \ 0.01, partial

g2 = 0.42 and F(1,18) = 9.25, p \ 0.01, partial g2 =

0.34, respectively. There were no significant changes in the

number of externally accessible muscles that were tender to

palpation, but the overall number of internally accessible

and total muscle sites tender to palpation was significantly

lower at post-treatment, F(1,18) = 12.37, p \ 0.01, partial

g2 = 0.41 and F(1,18) = 6.80, p \ 0.05, partial g2 =

0.27, respectively. Of the seven participants in the habit

reversal group with an initial diagnosis of myofascial pain,

three retained that diagnosis at post treatment; for the wait

list control group, the comparable figures were seven and

two, a significant (p \ 0.05) change for both groups, as

determined by a binomial test.

Table 3 Phase I: Behavioral and emotional outcomes obtained by experience sampling methodology

Headache Control p Partial g2

Mean SD Mean SD

Jaw, face and head pain (0–10) 1.91 1.81 0.26 0.42 0.002 0.258

Pain elsewhere in the body (0–10) 1.27 1.60 0.36 0.63 0.053 0.112

Percentage of time in tooth contact 54.17 23.84 30.10 27.63 0.011 0.187

Intensity of tooth contact (1–4) 1.80 0.46 1.37 0.33 0.005 0.222

Effort (arbitrary units) 180.98 46.04 137.02 33.20 0.005 0.226

Muscle tension (0–10) 2.66 1.75 1.34 1.15 0.019 0.161

Mood 1 (10–0) 6.21 1.32 6.96 1.17 0.095 0.084

Mood 2 (0–10) 3.11 1.17 2.28 1.02 0.039 0.126

Stress (0–10) 2.72 1.67 1.62 0.88 0.031 0.137

Numbers in parentheses show range of possible values. Except for the Mood 1 scale, larger values indicate more pain, contact, tension, effort,

emotional distress, and stress

Table 4 Phase II: Pre- and

post-treatments means (and

standard deviations) of Self-

Report Questionnaires and

RDC/TMD examination data

Habit reversal Wait list

Pre-treatment Post-treatment Pre-treatment Post-treatment

Headache Screening Questionnaire

Migraine (34) 15.89 (6.86) 13.11 (7.15) 18.00 (3.53) 15.6 (6.20)

Tension (10) 4.11 (2.71) 3.00 (2.35) 3.40 (2.07) 2.90 (2.47)

Cluster (7) 0.89 (0.93) 0.56 (0.88) 0.80 (1.14) 0.50 (0.71)

Other (3) 0.22 (0.44) 0.11 (0.33) 0.10 (0.32) 0.20 (0.63)

RDC Questionnaire

Characteristic Pain Intensity (100) 35.17 (26.22) 23.00 (25.50) 39.67 (25.41) 17.33 (22.98)

Disability Score 22.67 (29.93) 13.33 (20.79) 29.00 (29.65) 9.33 (21.71)

SCL depression 0.43 (0.44) 0.43 (0.62) 0.28 (0.32) 0.34 (0.35)

SCL somatization 0.45 (0.40) 0.52 (0.64) 0.54 (0.26) 0.63 (0.28)

Muscle sites tender to palpation

Externally accessible sites (4) 3.70 (3.74) 1.40 (1.65) 2.20 (2.57) 1.90 (3.32)

Intraorally accessible sites (10) 3.00 (1.16) 1.20 (1.48) 2.50 (1.35) 1.70 (1.64)

Total tender sites (20) 6.70 (4.47) 2.60 (2.88) 4.70 (3.50) 3.60 (4.50)


123

Data collected via experience sampling techniques

(Table 5) showed that groups responded to 91.4 % of

prompts to complete data forms. The HR group significant

reduced the intensity of contact compared to the wait list

control group, F(1,14) = 6.66, p \ 0.05, partial g2 =

0.32. The overall proportion of time spent in tooth contact

was significantly less at post-treatment, F(1,14) = 6.61,

p \ 0.05, partial g2 = 0.32. The amount of ‘‘effort’’ was

significantly less in the HR group, F(1,14) = 4.85,

p \ 0.05, partial g2 = 0.26. Overall, jaw, face, and head

pain was significantly lower at post-treatment, F(1,14) =

4.84, p \ 0.05, partial g2 = 0.26. There were no signifi-

cant time, group, and time 9 group interactions for pain

elsewhere in the body, muscle tension, mood, or stress.

Three individuals in the WL group took part in treat-

ment at the end of Phase II. There were no changes from

baseline on self-reported pain or in the number of masti-

catory muscles that were tender to palpation.

Discussion

The results from Phase I generally replicate the results

reported by Glaros et al. (2007c). Individuals complaining

of headache were significantly more likely to receive a

diagnosis of myofascial pain than non-headache controls.

According to the RDC, the diagnosis of myofascial pain

requires at least three of the 20 muscle sites to be tender to

palpation. It is therefore not surprising that the number of

muscles tender to palpation was significantly higher in the

headache group. On self-report measures associated with

the RDC, those complaining of headache reported more

pain, greater disability, more depression, and higher

somatization than non-headache controls.

As assessed by experience sampling methods, individ-

uals in the headache group reported significantly higher

levels of facial/head/jaw pain, more tooth contact, more

intense tooth contact, greater ‘‘effort,’’ more tension the

face/head/jaw, more emotional distress, and greater stress.

In the earlier study, the proportion of time in tooth contact

was 49 and 30 % for the headache and non-headache

control groups, respectively. These values correspond

closely to the values obtained in this study. Similarly the

values for effort were 163 and 134 for the headache and

non-headache control groups, respectively. The values for

the non-headache control group correspond well to the

earlier study, while the values for the headache group in

this study are considerably higher.

Earlier studies have shown that those with TMD, espe-

cially those with myofascial pain (with or without

arthralgia) also report more pain, more frequent and intense

tooth contact, more muscle tension, greater emotional

distress, and more stress than non-TMD controls (Chen

et al. 2007; Glaros et al. 2005). Taken as a whole, the

findings show not only diagnostic but also behavioral

overlap between those complaining of TMD and those

complaining of headache. Both types of patients engage in

higher levels of oral parafunctional behaviors, shown in

experimental studies to increase pain and results in TMD

diagnoses (Glaros and Burton 2004).

In Phase II, both groups reported less pain and disability.

The total number of muscle tender to palpation, and more

specifically muscles accessible to palpation intraorally,

decreased significantly. Scores on the Headache Screening

Questionnaire did not change significantly, suggesting that

the mix of headache symptoms did not change over the

6-week trial period.

Data obtained by experience sampling showed that the

HR group significantly reduced the intensity of tooth

contact, compared to the WL group. In general, the percent

of time spent in tooth contact decreased significantly from

pre- to post-treatment, as did measures of face/head/jaw

pain and ‘‘effort.’’ The other measures obtained by expe-

rience sampling showed no change.

The results from Phase II can be interpreted in multiple

ways. The data may indicate that a habit reversal approach

to headaches using the ‘‘DTMD’’ procedure is not suffi-

ciently powerful to produce significant changes in pain and

Table 5 Phase II: Pre- and

post-treatment means (and

standard deviations) obtained by

experience sampling

methodology

Except for the Mood 1 scale,

larger values indicate more

pain, contact, tension, effort,

emotional distress, and stress.

Smaller values in the Mood 2

scale indicate more emotional

distress

Habit reversal Wait list control

Pre-treatment Post-treatment Pre-treatment Post-treatment

Jaw, face and head pain (0–10) 1.32 (1.08) 1.09 (1.22) 1.78 (1.19) 1.20 (0.65)

Pain elsewhere in the body (0–10) 0.88 (0.83) 1.13 (1.38) 0.67 (0.92) 0.93 (1.21)

Percentage of time in tooth contact 57.98 (15.45) 45.33 (20.33) 46.32 (32.96) 44.28 (33.42)

Intensity of tooth contact (1–4) 1.81 (0.34) 1.53 (0.24) 1.69 (0.57) 1.74 (0.81)

Effort (arbitrary units) 181.24 (33.86) 153.14 (23.90) 172.05 (59.39) 173.95 (80.89)

Muscle tension (0–10) 2.02 (1.22) 1.93 (1.22) 2.57 (0.99) 2.88 (1.64)

Mood 1 (0–10) 6.72 (1.33) 6.51 (1.42) 5.92 (1.50) 5.84 (1.72)

Mood 2 (10–10) 2.87 (1.32) 2.78 (1.35) 3.14 (1.21) 3.53 (1.62)

Stress (0–10) 2.27 (1.22) 2.79 (2.15) 2.25 (1.38) 2.44 (2.10)


123

oral parafunctions, at least in a brief, 6-week trial. Perhaps

a longer trial with more post-treatment monitoring would

reveal more powerful effects.

A related interpretation focuses on the percent time in

tooth contact and ‘‘effort’’ measures. Although these

measures showed significant decreases from pre- to post-

treatment, the amount of decrease was not sufficient to

bring the values into a range that is more typical of non-

headache controls.

It is likely that many individuals with chronic pain

choose to participate in a research study when their pain

levels are relatively higher than usual or their own levels

of frustration with their pain has increased. For indi-

viduals whose pain is not severely debilitating, waiting

will often result in positive therapeutic change, inde-

pendent of the type of treatment offered. Such regression

to the mean may account for the results seen here and

elsewhere in patients with TMD and headache (Doepel

et al. 2011).

The Phase II data may also suggest that oral parafunc-

tions and headache pain are not causally related. While oral

parafunctions may be a significant correlate of headache,

the mechanisms responsible for the two conditions may be

different. Alternatively, other investigators have shown

that a diagnosis of TMD is often related to the presence of

other painful conditions, not just headache (Lim et al.

2010). Perhaps a more general process such as emotional

and physiological reactivity (Schmidt and Carlson 2009) or

genetic vulnerabilities underlie the likelihood of having a

chronically painful condition.

The size of the sample, especially in Phase II, was small.

There was also greater drop-out from the wait list group

than from the habit reversal group. Subjects may have left

the wait list group because they were expecting to receive

treatment, despite the disclosures provided in their

informed consent documents. The investigators also did not

provide any monetary incentive for subjects to remain in

the study. Development of a credible non-therapeutic

alternative to the wait list group would be very desirable.

Although the results from the habit reversal trail were

disappointing, it may still be valuable to consider the

potential role that oral parafunctions play in TMD and

headache. In the present sample, the correlation between

‘‘effort’’ and facial/head/jaw pain was 0.45 (p \ 0.01), and

the correlation between ‘‘effort’’ and pain in other parts of

the body was 0.35 (p \ 0.05). The role that oral para-

functions play in TMD and in headache remains to be

determined. However, there may still be value in clinicians

bringing patients’ attention to oral parafunctions, other

unwanted muscle activity, and general physiological

arousal. Bringing a patient’s attention to these behaviors,

teaching alternatives (e.g., muscle relaxation) to these

behaviors, and providing a simple means for patients to

practice these alternatives in their everyday lives should

result in considerable relief from pain.

Acknowledgments We thank Dr. James Guillory and the KCUMB

Summer Fellowship program for their support of this project. We’re

grateful for the assistance provided by the staff of the Clinical

Research Center.

References

Anderson, G. C., John, M. T., Ohrbach, R., Nixdorf, D. R., Schiffman,

E. L., Truelove, E. S., et al. (2011). Influence of headache

frequency on clinical signs and symptoms of TMD in subjects

with temple headache and TMD pain. Pain, 152, 765–771.

Ballegaard, V., Thede-Schmidt-Hansen, P., Svensson, P., & Jensen,

R. (2008). Are headache and temporomandibular disorders

related? A blinded study. Cephalalgia, 28, 832–841.

Bevilaqua Grossi, D., Lipton, R. B., & Bigal, M. E. (2009).

Temporomandibular disorders and migraine chronification.

Current Pain and Headache Reports, 13, 314–318.

Chen, C. Y., Palla, S., Erni, S., Sieber, M., & Gallo, L. M. (2007).

Nonfunctional tooth contact in healthy controls and patients with

myogenous facial pain. Journal of Orofacial Pain, 21, 185–193.

Doepel, M., Nilner, M., Ekberg, E., Vahlberg, T., & Bell, Y. (2011).

Headache: Short- and long-term effectiveness of a prefabricated

appliance compared to a stabilization appliance. Acta Odonto-

logica Scandinavica, 69, 129–136.

Dworkin, S. F., & LeResche, L. (1992). Research diagnostic criteria

for temporomandibular disorder: Review, criteria, exams and

specification, critique. Journal of Craniomandibular Disorders,

6, 301–355.

Glaros, A. G., & Burton, E. (2004). Parafunctional clenching, pain,

and effort in temporomandibular disorders. Journal of Behav-

ioral Medicine, 27, 91–100.

Glaros, A. G., Kim-Weroha, N., Lausten, L., & Franklin, K.-L.

(2007a). Comparison of habit reversal and a behaviorally-

modified dental treatment for temporomandibular disorders: A

pilot investigation. Applied Psychophysiology & Biofeedback,

32, 149–154.

Glaros, A. G., Owais, Z., & Lausten, L. (2007b). Parafunctional

activity and TMD pain: A potential mechanism for the effec-

tiveness of splint therapy. Journal of Oral Rehabilitation, 34,

97–104. doi:10.1111/j.1365-2842.2006.01660.x.

Glaros, A. G., Urban, D., & Locke, J. (2007c). Temporomandibular

disorders and headache: Evidence for diagnostic and behavioural

overlap. Cephalalgia, 27, 542–549.

Glaros, A. G., Williams, K., & Lausten, L. (2005). The role of

parafunctions, emotions and stress in predicting facial pain.

Journal of the American Dental Association, 136, 451–458.

Goncalves, D. A., Camparis, C. M., Speciali, J. G., Franco, A. L.,

Castanharo, S. M., & Bigal, M. E. (2011). Temporomandibular

disorders are differentially associated with headache diagnoses:

A controlled study. Clinical Journal of Pain, 27, 611–615.

Gramling, S. E., Neblett, J., Grayson, R., & Townsend, D. (1996).

Temporomandibular disorder: Efficacy of an oral habit reversal

treatment program. Journal of Behavior Therapy and Experi-

mental Psychiatry, 27, 245–255.

Hoffmann, R. G., Kotchen, J. M., Kotchen, T. A., Cowley, T.,

Dasgupta, M., & Cowley, A. W, Jr. (2011). Temporomandibular

disorders and associated clinical comorbidities. Clinical Journal

of Pain, 27, 268–274.

Ichesco, E., Quintero, A., Clauw, D. J., Peltier, S., Sundgren, P. M.,

Gerstner, G. E., et al. (2012). Altered functional connectivity


123

http://dx.doi.org/10.1111/j.1365-2842.2006.01660.x

between the insula and the cingulate cortex in patients with

temporomandibular disorder: A pilot study. Headache, 52,

441–454.

Kang, J. K., Ryu, J. W., Choi, J. H., Merrill, R. L., & Kim, S. T.

(2010). Application of ICHD-II criteria for headaches in a TMJ

and orofacial pain clinic. Cephalalgia, 30, 37–41.

Lim, P. F., Smith, S., Bhalang, K., Slade, G. D., & Maixner, W.

(2010). Development of temporomandibular disorders is associ-

ated with greater bodily pain experience. Clinical Journal of

Pain, 26, 116–120.

Look, J. O., Schiffman, E. L., Truelove, E. L., & Ahmad, M. (2010).

Reliability and validity of axis I of the research diagnostic

criteria for temporomandibular disorders (RDC/TMD) with

proposed revisions. Journal of Oral Rehabilitation, 37, 744–759.

Olesen, J. (2006). International classification of headache disorders,

second edition (ICHD-2): Current status and future revisions.

Cephalalgia, 26, 1409–1410.

Peterson, A. L., Dixon, D. C., Talcott, G. W., & Kelleher, W. J.

(1993). Habit reversal treatment of temporomandibular disor-

ders: A pilot investigation. Journal of Behavior Therapy and

Experimental Psychiatry, 24, 49–55.

Plesh, O., Noonan, C., Buchwald, D. S., Goldberg, J., & Afari, N.

(2012). Temporomandibular disorder-type pain and migraine

headache in women: A preliminary twin study. Journal of

Orofacial Pain, 26, 91–98.

Sato, H., Saisu, H., Muraoka, W., Nakagawa, T., Svensson, P., &

Wajima, K. (2012). Lack of temporal summation but distinct

aftersensations to thermal stimulation in patients with combined

tension-type headache and myofascial temporomandibular dis-

order. Journal of Orofacial Pain, 26, 288–295.

Schmidt, J. E., & Carlson, C. R. (2009). A controlled comparison of

emotional reactivity and physiological response in masticatory

muscle pain patients. Journal of Orofacial Pain, 23, 230–242.

Stuginski-Barbosa, J., Macedo, H. R., Bigal, M. E., & Speciali, J. G.

(2010). Signs of temporomandibular disorders in migraine

patients: A prospective, controlled study. Clinical Journal of

Pain, 26, 418–421.

Townsen, D., Nicholson, R. A., Buenaver, L., Bush, F., & Gramling,

S. (2001). Use of a habit reversal treatment for temporoman-

dibular pain in a minimal therapist contact format. Journal of

Behavior Therapy and Experimental Psychiatry, 32, 221–239.

Troeltzsch, M., Troeltzsch, M., Cronin, R. J., Brodine, A. H.,

Frankenberger, R., & Messlinger, K. (2011). Prevalence and

association of headaches, temporomandibular joint disorders,

and occlusal interferences. Journal of Prosthetic Dentistry, 105,

410–417.


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