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Headaches and Cervical Spine Conditions Related to Temporomandibular Disorders

Original Editor - Ewa Jaraczewska based on the course by Micaela Weinberg

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Around two-thirds of people with temporomandibular disorders (TMD) experience headaches, most commonly migraine.[1][2] Additionally, 85% of people with TMD have cervical spine dysfunction.[3] A multidisciplinary approach that integrates TMD, headache, and cervical spine assessment and management can improve outcomes for patients with these related conditions.

Identifying Headache Type

The ability to accurately differentiate between primary headache types enables proper diagnosis, appropriate referral when necessary, and targeted treatment interventions.

Migraine Characteristics

Migraine headaches are predominantly unilateral. They may switch sides during an attack or between episodes. The pain is throbbing or pulsating, with severity ranging from moderate to severe. Episodes last from 4 to 72 hours. Some migraines occur with aura (temporary neurological symptoms occurring before the headache).[4][5] They can occur with or without photophobia, phonophobia, nausea, or vomiting.[1] The prevalence is approximately 18% in females and 6% in males.[6]

Tension-Type Headaches

Tension-type headaches are bilateral and non-throbbing. Patients report pressure or tightness, often describing the pain as a tight band around the head. Severity typically ranges from mild to moderate, and duration varies from 30 minutes to a week.[7] Stress commonly triggers tension-type headaches, and patients are generally able to continue with their usual activities during attacks.[1] These headaches affect between 30% and 78% of the population, depending on the study.[8] [9]

Cluster Headaches

Cluster headaches (trigeminal autonomic cephalgia) present with severe, unilateral, sharp, or stabbing pain.[6][10] Accompanying symptoms include conjunctival injection (eye redness), lacrimation (watering eyes), nasal congestion, rhinorrhoea (runny nose), forehead and facial sweating, miosis (constricted pupils), ptosis (upper eyelid drooping), and eyelid oedema.[11] Individuals with cluster headaches often experience restlessness or agitation.[12] These headaches are the most severe type of primary headache, often incapacitating patients during episodes.[1] Episodes last from 15 minutes to three hours. The prevalence of cluster headaches is low, around 0.9%.[1]

Migraine, tension-type, and cluster headaches are all primary headaches. This optional video explains the difference between primary and secondary headaches.

[13]

Clinical Red Flags

The following presentations warrant immediate referral to rule out severe pathology:[14][1]

  • thunderclap headache, characterised by the sudden onset of severe pain
  • new onset of headaches in individuals over 50 or under 10 years of age
  • progressive headaches over several weeks
  • new headaches in patients with HIV or a history of cancer
  • waking with a headache accompanied by nausea

The Connection Between Temporomandibular Disorders and Headaches

Research demonstrates a bidirectional relationship between TMD and primary headaches.[1][15] A systematic review found that 61% of people with TMD experience headaches, with migraine being the most common (40%), followed by tension-type headaches (18%). People with primary headaches are also at increased risk of TMD; 59% of those with migraines and 55% of those with tension-type headaches have TMD.[2]

Treatment studies support integrated management approaches. A randomised controlled study conducted by Choi et al.[16] found that incorporating TMJ treatments into therapy for patients with chronic tension-type headaches and pericranial tenderness produced greater reductions in pain, neck disability, and headache impact compared to treating the cervical spine alone.

How TMD Contributes to Migraines

The trigeminal nerve provides a neuroanatomical and neurochemical pathway linking temporomandibular dysfunction and migraine pathophysiology.

Trigeminal Anatomy

The trigeminal nerve has three branches: ophthalmic, maxillary, and mandibular. The sensory cell bodies of these branches are located in the trigeminal ganglion.

The CGRP Pathway

Irritation along the mandibular branch—for example, from masseter hypertrophy or injury—triggers an increase in the release of calcitonin gene-related peptide (CGRP) and CGRP receptors at the trigeminal ganglion.[17] This causes increased CGRP along the entire trigeminal pathway. As with the other branches, the ophthalmic branch, which supplies the meningeal vessels, will exhibit elevated CGRP levels, which promote inflammation and vasodilation. Increased CGRP at the level of meninges is recognised as a key mechanism in migraine generation.[1]

Treatment Implications

Treatment aims to influence the mandibular branch of the trigeminal nerve and, subsequently, decrease CGRP at a meningeal level. While genetics, stress, dehydration, and hormonal changes contribute to migraine threshold, removing jaw pathology as an additional trigger can lower the cumulative burden.[1]

The Connection Between Temporomandibular Disorders and the Cervical Spine

The jaw and neck are connected through biomechanical, anatomical, and neurophysiological mechanisms.[18][19]

Biomechanical Connections

Mouth opening couples with upper cervical extension, and mouth closing with upper cervical flexion. This creates a compensatory relationship where restriction in one region leads to adaptation in the other.[20] For example, patients with significant capsular restriction, muscular hypertrophy, and tissue thickening may present with normal jaw range of motion because their upper cervical spine can compensate by increasing mobility at a local level to compensate for the loss of movement at the TMJ. [1] [20] Treatment focused solely on the upper cervical spine may not resolve chronic headaches or migraines if the underlying jaw restriction remains unaddressed.[1]

Anatomical Connections

The proximity of the TMJ and upper cervical spine means that these regions naturally influence each other.[21] Multiple muscles create anatomical connections between these regions. For example, the sternocleidomastoid (SCM) muscle runs past the mandible, inserting at the mastoid process. Overwork or overuse of the SCM can influence the myofascial system of the TMJ muscles. Similarly, the digastric muscle connects the mastoid process to the hyoid bone, creating another anatomical link between the TMJ and cervical spine.[1]

Neurophysiological Connections

The nerve roots of C1, C2, and C3 overlap with the trigeminal afferent fibres at the trigeminocervical nucleus. This overlap means that nociceptive information from one region can be perceived as originating from the other.[21] For example, pain localised at the jaw may originate from cervical structures, and neck pain may arise from TMJ pathology.

Clinical Application

The TMJ and cervical spine should be assessed in patients presenting with symptoms in either region, though not all patients require treatment of both. When patients present with acute neck pain, initial treatment should address the cervical spine. However, persistent or recurrent symptoms warrant jaw assessment, as the jaw restriction may be driving the cervical presentation. Understanding the anatomical, biomechanical, and neurophysiological connections allows clinicians to identify the drivers of symptoms.[22]

Patients are typically more aware of their neck than their jaw, and are more likely to present with neck complaints even when jaw dysfunction is the underlying cause. The term "cervicogenic headache" itself may be incomplete, as many of these cases involve TMD pathology. A more accurate classification might be "trigeminocervicogenic", which acknowledges the contribution of both systems. -- Dr. Micaela Weinberg[1]

Resources

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Weinberg M. Temporomandibular Related Disorders Course. Physiopedia Plus, 2026.
  2. ↑ 2.0 2.1 Yakkaphan P, Smith JG, Chana P, Renton T, Lambru G. Temporomandibular disorder and headache prevalence: A systematic review and meta-analysis. Cephalalgia Reports. 2022 May 16;5:25158163221097352.
  3. ↑ Odzimek M, Brola W. Occurrence of cervical spine pain and its intensity in young people with temporomandibular disorders. J Clin Med. 2024 Mar 27;13(7):1941.
  4. ↑ Grodzka O, Dzagoevi K, Rees T, Cabral G, Chądzyński P, Di Antonio S, et al. [https://link.springer.com/article/10.1186/s10194-025-01998-1 Migraine with and without aura-two distinct entities? A narrative review. J Headache Pain. 2025 Apr 14;26(1):77.
  5. ↑ Joppeková Ľ, Pinto MJ, da Costa MD, Boček R, Berman G, Salim Y, et al. What does a migraine aura look like?-A systematic review. J Headache Pain. 2025 Jul 1;26(1):149.
  6. ↑ 6.0 6.1 Khan L, Shahreen M, Qazi A, Jamil Ahmed Shah S, Hussain S, Chang HT. Migraine headache (MH) classification using machine learning methods with data augmentation. Scientific Reports. 2024 Mar 2;14(1):5180.
  7. ↑ Ashina S, Mitsikostas DD, Lee MJ, Yamani N, Wang SJ, Messina R, Ashina H, Buse DC, Pozo-Rosich P, Jensen RH, Diener HC. Tension-type headache. Nature reviews Disease primers. 2021 Mar 25;7(1):24.
  8. ↑ Ferrante T, Manzoni GC, Russo M, Camarda C, Taga A, Veronesi L, Pasquarella C, Sansebastiano G, Torelli P. Prevalence of tension-type headache in adult general population: the PACE study and review of the literature. Neurological Sciences. 2013 May;34(Suppl 1):137-8.
  9. ↑ Li XY, Yang CH, Lv JJ, Liu H, Zhang LY, Yin MY, Guo ZL, Zhang RH. Global, regional, and national epidemiology of migraine and tension-type headache in youths and young adults aged 15–39 years from 1990 to 2019: findings from the global burden of disease study 2019. The journal of headache and pain. 2023 Sep 18;24(1):126.
  10. ↑ Petersen AS, Lund N, Goadsby PJ, Belin AC, Wang SJ, Fronczek R, Burish M, Cho SJ, Peres MF, Jensen RH. Recent advances in diagnosing, managing, and understanding the pathophysiology of cluster headache. The Lancet Neurology. 2024 Jul 1;23(7):712-24.
  11. ↑ Malu OO, Bailey J, Hawks MK. Cluster Headache: Rapid Evidence Review. Am Fam Physician. 2022 Jan 1;105(1):24-32. PMID: 35029932.
  12. ↑ Kim SA, Choi SY, Youn MS, Pozo-Rosich P, Lee MJ. Epidemiology, burden and clinical spectrum of cluster headache: a global update. Cephalalgia. 2023 Sep;43(9):03331024231201577.
  13. ↑ Rhesus Medicine. Primary v Secondary Headache (with Red Flags) | Tension Type Headache, Migraine & Cluster Headache. Available from: https://www.youtube.com/watch?jHok_WFyijM [last accessed 21/01/2026]
  14. ↑ Pohl H. Red flags in headache care. Headache. 2022 Apr;62(4):534-535.
  15. ↑ Bizzarri P, Manfredini D, Koutris M, Bartolini M, Buzzatti L, Bagnoli C, Scafoglieri A. Temporomandibular disorders in migraine and tension-type headache patients: a systematic review with meta-analysis. J Oral Facial Pain Headache. 2024 Jun;38(2):11-24.
  16. ↑ Choi W, Woo J, Lee S, Lee S. Effects of treatment of temporomandibular disorders on headache, quality of life, and neck function in patients with tension-type headaches: a randomised controlled study. Physical Therapy Rehabilitation Science. 2020;9(4):215-21
  17. ↑ Sangalli L, Eli B, Mehrotra S, Sabagh S, Fricton J. Calcitonin Gene-Related Peptide-Mediated Trigeminal Ganglionitis: The Biomolecular Link between Temporomandibular Disorders and Chronic Headaches. Int J Mol Sci. 2023 Jul 30;24(15):12200.
  18. ↑ Barzaghideanu GB, Jighirgiu AA, Duceac M, Francu L, Ilie A, Scutariu MM. From jaw to spine: a narrative review on oral health, tmj function, and postural rehabilitation strategies. Romanian Journal of Medical and Dental Education. 2025 Jul;14(4).
  19. ↑ Petronis Z, Pliatkute I, Janovskiene A, Leketas M. The Relationship Between Cervical Spine Abnormalities and Temporomandibular Joint Internal Disorders: A Systematic Review of Literature. Annals of Dental Speciality. 2023;11(4-2023):20-8.
  20. ↑ 20.0 20.1 Kaczmarek B, Kaczmarek L, Mysliwiec A, Lipowicz A, Dowgierd K. Kinematic Relationship Between Temporomandibular and Cervical Spine Joints. Journal of Oral Rehabilitation. 2025 May 9.
  21. ↑ 21.0 21.1 Barzaghideanu GB, Jighirgiu AA, Duceac M, Francu L, Constantin V, Ilie A, Cojocaru C, Scutariu MM.Temporomandibular disorders and cervical spine pathology: a narratvie review on functional interrelations and oral health implications. Romanian Journal of Medical and Dental Education. 2025 Jul;14(4).
  22. ↑ Crăciun MD, Geman O, Leuciuc FV, Holubiac IŞ, Gheorghiţă D, Filip F. Effectiveness of physiotherapy in the treatment of temporomandibular joint dysfunction and the relationship with cervical spine. Biomedicines. 2022 Nov 17;10(11):2962.
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