A 40-year-old woman comes to the office due to daily headaches and facial pain for the past several months. The pain involves the temporal and periorbital region, affects the right side more than the left, is dull, and waxes and wanes. It is often worse toward the end of the day, and the patient gets a heavy and tired feeling in her jaws while eating dinner. Current medications are a multivitamin daily and ibuprofen as needed. She is a research professor and describes her work as stressful. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination shows normal pupils and no facial droop. Facial sensation is normal bilaterally and there is mild tenderness in the right masseter muscle. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?

Question

A 40-year-old woman comes to the office due to daily headaches and facial pain for the past several months.  The pain involves the temporal and periorbital region, affects the right side more than the left, is dull, and waxes and wanes.  It is often worse toward the end of the day, and the patient gets a heavy and tired feeling in her jaws while eating dinner.  Current medications are a multivitamin daily and ibuprofen as needed.  She is a research professor and describes her work as stressful.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  Physical examination shows normal pupils and no facial droop.  Facial sensation is normal bilaterally and there is mild tenderness in the right masseter muscle.  The remainder of the examination shows no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d54b_4740_bc81_2d1859ddbfd7_MD0003_00 This patient with headaches, facial pain, an achy jaw, and masseter muscle tenderness likely has temporomandibular joint disorder (TMD). The most recognizable findings are pain exacerbated by jaw motion, tenderness of the temporomandibular joint, and neck symptoms. However, TMD can also present primarily with headaches, muscle spasms, and jaw fatigue, as in this patient. Patients with anxiety may be at increased risk. The diagnosis of TMD is typically clinical. Palpation of the temporomandibular joint during jaw opening and closing often elicits pain, crepitus, and/or audible clicks. Tenderness of the muscles of mastication (eg, masseter, temporalis) is often present. Initial management of TMD should consist of education, a soft diet, warm compresses, and avoidance of triggers. Nonsteroidal anti-inflammatory drugs are the first-line medication. Muscle relaxants (eg, cyclobenzaprine) can be added for patients with associated muscle spasm. (Choice A) Fibromyalgia can cause pain and muscle tenderness in young or middle-aged women. However, pain is typically widespread, and physical examination shows tenderness at specific trigger points (eg, midtrapezius, lateral epicondyle). (Choice B) Giant cell arteritis can present with headaches and jaw pain when chewing (ie, jaw claudication). However, it very rarely occurs in patients age <50. (Choice C) Myasthenia gravis can present with fluctuating, fatigable bulbar muscle weakness (eg, dysarthria, dysphagia) that is worse at the end of the day. However, pain and focal muscle tenderness are uncommon. (Choice E) Tension headaches can present with pressure and muscle tenderness in the head and neck, especially during times of stress. However, the headaches are symmetric and do not typically cause focal (eg, masseter muscle) tenderness or jaw heaviness. (Choice F) Trigeminal neuralgia can present with unilateral facial pain. However, the pain is typically recurrent, severe, and shocklike rather than dull, heavy, and waxing and waning. Educational objective: Temporomandibular joint disorder can present with headaches, muscle spasms, jaw fatigue, and facial pain. Physical examination can reveal tenderness of the muscles of mastication, as well as pain, crepitus, and/or audible clicks from the joint. References: Diagnosis and treatment of temporomandibular disorders. (http://www.ncbi.nlm.nih.gov/pubmed/25822556)

A 40-Year-Old Woman Comes to the Office Due to Daily