Unraveling the challenge of head and face pain

The differential diagnosis and treatment of headache and craniofacial pain has long been a subject of debate. Historically, much has been written on the topic, extending back into ancient times,¹ yet the clinical decision making process with these patients remains challenging.^2,3 A 2007 study suggested that the percentage of the global adult population with an active headache disorder was as high as 46%.² Although reportedly less prevalent, orofacial pain, including tempromandibular joint pain, has a substantial negative impact on patients who suffer with it.³ Accordingly, the International Association for the Study of Pain (IASP) has recently launched the 2013–2014 Global Year Against Orofacial Pain campaign, highlighting the fact that this common form of pain is often poorly recognized and inadequately treated.

To launch this special issue on headache and craniofacial pain, we present a two part series by Shaffer and colleagues^4,5 which discusses the evaluation and physical therapy management of tempromandibular (TMD) dysfunction. These papers draw from an expanding research literature, and provide an evidence-based review of the biomechanical and clinical features of TMD, as well as valuable guidelines for management. von Piekartz and Mohr⁶ discuss the unique neurophysiological effects of facial pain. Importantly, this work highlights how facial pain may impede the ability to express emotions, and as a consequence, the ability to perceive emotions in others. This altered affective state, i.e., the inability to express and recognize emotions, painful or otherwise, may predispose the individual to chronic pain.⁷ This may be a paradigm shift for some clinicians; specifically, that dysfunction in affect may be both a cause and effect of chronic pain.

While recent interest has focused on the cognitive sequellae of traumatic brain injury, Defrin⁸ draws attention to a major adverse outcome that may occur following brain trauma: post-concussive headache. An incredibly high number of individuals experience chronic headache following traumatic head injury.⁹ Both the contributions by Defrin,⁸ as well as Fernández-de-las-Peñas and Courtney¹⁰ address the complex pathophysiology and the importance of multimodal treatment plans for individuals with headache. This complexity is demonstrated by Stuhr and colleagues,¹¹ who describe a successful outcome in a young patient with both headache and TMD complaints.

As guest editors, we postulate that the topic of headache and craniofacial pain is likely under-addressed in many professional and post-graduate education programs. If this is the case, we challenge educators, clinicians, and researchers to turn their attention to this group of chronic pain conditions, which affects such a large proportion of our society.