Tension-type headache, temporomandibular disorders and burning mouth

Tension-type headache, temporomandibular disorders and burning mouth syndrome are common primary head and face pains treated mainly with education, behavioral and exercise therapy; amitriptyline prevents chronic tension-type headache, and burning mouth treatments have weak evidence.

1. Chronic tension-type headache: 15 or more days a month. Headache on at least 15 days/month for more than 3 months, with at least two of bilateral, pressing, mild-to-moderate and not aggravated by routine activity ¹.
2. Few associated features. Attacks last hours to days or are unremitting, with no more than one of photophobia, phonophobia or mild nausea, and neither moderate or severe nausea nor vomiting ¹.
3. Nondrug care, then amitriptyline. EMG biofeedback has documented effect and CBT and relaxation are likely effective; amitriptyline is first-choice prophylaxis, with mirtazapine and venlafaxine second ².
4. Treat episodes simply. Simple analgesics and NSAIDs are recommended for episodic tension-type headache, caffeine-containing combinations are drugs of second choice, and triptans, muscle relaxants and opioids should not be used ².
5. TMD: behavioral and exercise therapy first. For pain lasting 3 months or more, a 2023 guideline strongly recommends CBT, supervised jaw exercise and stretching, therapist-assisted mobilisation, manual trigger point therapy, supervised postural exercise and usual care such as reassurance ³.
6. Burning mouth evidence is weak. A Cochrane review found very low-quality evidence of short-term benefit from topical benzodiazepines, electromagnetic radiation, physical barriers and one anticonvulsant, and insufficient or contradictory evidence for dietary supplements ⁴.

Frequent analgesic use for tension-type headache risks medication-overuse headache; frequent and excessive use should be avoided ².

• Temporomandibular disorders are the second most common chronic musculoskeletal pain condition after low back pain, affecting 6–9% of adults ³.
• The TMD guideline strongly recommends against irreversible oral splints, discectomy and NSAIDs combined with opioids ³.
• It conditionally recommends against reversible occlusal splints, botulinum toxin, gabapentin and benzodiazepines for chronic TMD pain ³.
• Burning mouth syndrome is oral burning pain without an identifiable cause, with a prevalence of 0.1% to 3.9% ⁴.
• In one trial, sucking a 1-mg clonazepam tablet, holding saliva near painful sites for 3 minutes and spitting cut pain by 2.4 versus 0.6 points ⁵.
• Physical therapy and acupuncture may help frequent tension-type headache but lack robust evidence ².
• The TMD guideline conditionally favors manipulation, acupuncture, and CBT combined with NSAIDs ³.

• Prescribing a muscle relaxant or triptan for tension-type headache ².
• Offering an irreversible splint or bite change for chronic TMD pain ³.
• Expecting strong evidence for any burning mouth treatment; all evidence is very low quality ⁴.