Pressure-Pain Threshold Variation in Temporomandibular Disorder Myalgia over the Course of the Menstrual Cycle

Aims: To evaluate the influence of the menstrual cycle on pressure-pain thresholds (PPTs) in patients with masticatory myalgia. Methods: Fluctuations in pain sensitivity during 2 consecutive menstrual cycles were assessed in 15 normally menstruating patients with a myogenous temporomandibular disorder (TMD). Muscle pain was measured by the use of pressure algometry and a visual analog scale (VAS). The McGill Pain Questionnaire was used to assess the sensory, affective, and evaluative dimensions of the pain. Results: Since 5 patients dropped out of the study due to pregnancy, unexpected menstrual cycle irregularities, or personal problems, statistical analysis was performed on 10 patients. Time had a significant influence on the pain condition. The PPTs of all muscle sites increased significantly and progressively over time by 16% to 42% in the follicular and luteal phases. PPTs remained low in the perimenstrual phase. The VAS pain rating did not correspond well with the PPTs, and the statistical analysis showed that the VAS ratings could not be used as predictors for the PPT measurements or detect the differences between cycle phases. The sensory, affective, and evaluative dimensions of the pain were significantly lower at the end of the trial. Conclusion: These data suggest a significant influence of the menstrual cycle on pain report and a nonspecific improvement of the chronic myogenous TMD.

pain threshold; menstrual cycle; masticatory muscle; myofascial pain

1. Simons DG. Myofascial pain syndromes of the head, neck and low back pain. In: Dubner R, Gebhart GF, Bond MR (eds). Proceedings from the Fifth World Congress on Pain. Amsterdam: Elsevier, 1988:186–200.

2. Dworkin SF, Huggins KH, LeResche L, Von Korff M, Howard J, Truelove E, et al. Epidemiology of signs and symptoms in temporomandibular disorders: Clinical signs in cases and controls. J Am Dent Assoc 1990;121:11–23.

3. Helkimo M. Epidemiological surveys of dysfunction of the masticatory system. Oral Sci Rev 1976;7:54–69.

4. Schiffman E, Fricton JR. Epidemiology of TMJ and craniofacial pain. In: Fricton JR, Kroening RJ, Hathaway KM (eds). TMJ and Craniofacial Pain: Diagnosis and Management. St. Louis: Ishiyaku Euro America, 1988:1–10.

5. Von Korff M, Dworkin SF, LeResche L, Kruger A. An epidemiologic comparison of pain complaints. Pain 1988;32:173–183.

6. Goulet J-P, Lavigne GJ, Lund JP. Jaw pain prevalence among French-speaking Canadians and related symptoms of temporomandibular disorders. J Dent Res 1995;74:1738–1744.

7. Carlsson GE, LeResche L. Epidemiology of temporomandibular disorders. In: Sessle BJ, Bryant PS, Dionne RA (eds). Progress in Pain Research and Management. Vol 4: Temporomandibular Disorders and Related Pain Conditions. Seattle: IASP Press, 1995:211–226.

8. Dao TT, Lavigne GJ, Charbonneau A, Feine JS, Lund JP. The efficacy of oral splints in the treatment of myofascial pain of the jaw muscles: A controlled clinical trial. Pain 1994;56:85–94.

9. Berkley KJ. Sex differences in pain. Behav Brain Sci 1997;20:371–380.

10. Berkley KJ, Holdcroft A. Sex and gender differences in pain. In: Wall PD, Melzack R (eds). Textbook of Pain, ed

4. Edinburgh: Churchill-Livingstone, 1999:951–965.

11. Dao TTT, LeResche L. Gender differences in pain. J Orofac Pain 2000;14:169–184.

12. Da Silva JA, Hall GM. The effect of gender and sex hormones on outcome in rheumatoid arthritis. Baillieres Clin Rheumatol1992;6:196–219.

13. Anderberg UM, Liu Z, Berglund L, Nyberg F. Elevated plasma levels of neuropeptide Y in female fibromyalgia patients. Eur J Pain 1999;3:19–30.

14. Marcus D. Interrelationships of neurochemicals, estrogen and recurring headache. Pain 1995;62:129–139.

15. Lokken C, Holm JE, Cook Myers T. The menstrual cycle and migraine: A time series analysis of 20 women migraineurs. Headache 1997;37:235–239.

16. Case AM, Reid RL. Effects of the menstrual cycle on medical disorders. Arch Intern Med 1998;158:1405–1412.

17. Hapidou EG, Rollman GB. Menstrual cycle modulation of tender points. Pain 1998;77:151–161.

18. Riley JL, Robinson ME, Wise EA, Price D. A meta-analytic review of pain perception across the menstrual cycle. Pain 1999;81:225–235.

19. Mc Ewan BS. Ovarian steroids have diverse effects on brain structure and function. In: Berg G, Hammar M (eds). The modern management of menopause. New York: Panthenon, 1994:269–278.

20. Kayser V, Berkley KJ, Keita H, Gautron M, Guilbaud G. Estrous and sex variations in vocalization thresholds to hindpaw and tail pressure stimulation in the rat. Brain Res 1996;742:352–354.

21. Mc Ewan BS, Alves SE, Bulloch K, Weiland NG. Clinically relevant basic science studies of gender differences and sex hormones. Psychopharmacol Bull 1998;34:251–259.

22. Bradshaw H, Miller J, Ling Q, Malsnee K, Ruda MA. Sex differences and phases of the estrous cycle alter the response of spinal cord dynorphin neurons to peripheral inflammation and hyperalgesia. Pain 2000;85:93–99.

23. LeResche L, Saunders K, Von Korff MR, Barlow W, Dworkin SF. Use of exogenous hormones and risk factors of temporomandibular disorder pain. Pain 1997;69: 153–160.

24. Dao TTT, Knight K, Ton-That V. Modulation of myofascial pain by the reproductive hormones: A preliminary report. J Prosthet Dent 1998;79:663–670.

25. Goulet J-P, Clark GT, Flack VF, Liu C. The reproducibility of muscle and joint tenderness detection methods and maximum mandibular movement measurement for the temporomandibular system. J Orofac Pain 1998;12: 17–26.

26. Ohrbach R, Gale EN. Pressure pain thresholds, clinical assessment and differential diagnosis: Reliability of validity in patients with myogenic pain. Pain 1989;37:157–169.

27. Reid KI, Gracely RH, Dubner RA. The influence of time, facial side and location on pain-pressure thresholds in chronic myogenous temporomandibular disorder. J Orofac Pain 1994;8:258–265.

28. Isselée H, De Laat A, Bogaerts K, Lysens R. Long-term fluctuations of pressure pain thresholds in normally menstruating women, users of oral contraceptives and men. Eur J Pain 2001;5:27–37.

29. Isselée H, De Laat A, De Mot B, Bogaerts K, Lysens R. Pressure pain thresholds during menstrual cycle in myofascial pain patients [abstract]. J Dent Res 1999;78(special issue):3596.

30. Dworkin SF, LeResche L. Research Diagnostic Criteria for Temporomandibular Disorders: Review, Criteria, Examinations andSpecifications, Critique. J Craniomandib Disord Facial Oral Pain 1992;6:301–355.

31. Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain 1994;56:217–226.

32. Vanderiet K, Adriaensen H, Carton H, Vertommen H. The McGill Pain Questionnaire constructed for the Dutch language (MPQ-DV). Preliminary data concerning reliability and validity. Pain 1987;30:395–408.

33. Van Der Kloot WA, Oostendorp RAB, Van Der Meij J, Van Den Heuvel J. The Dutch version of the McGill pain questionnaire: A reliable instrument. Ned Tijdschr Geneeskd 1995;139:669–673.

34. Stegenga B, de Bont LGM, de Leeuw R, Boering G. Assessment of mandibular function impairment associated with temporomandibular joint osteoarthrosis and internal derangement. J Orofac Pain 1993;7:183–195.

35. Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–149.

36. Isselée H, De Laat A, Lesaffre E, Lysens R. Short-term reproducibility of pressure pain thresholds in masseter and temporalis muscles of symptom-free subjects. Eur J Oral Sci 1997;105:583–587.

37. Isselée H, De Laat A, Bogaerts K, Lysens R. Short-term reproducibility of pressure pain thresholds in masticatory muscles measured with a new algometer. J Orofac Pain 1998;12:203–209.

38. Ohrbach R, Gale EN. Pressure pain thresholds in normal muscles: Reliability, measurement effects, and topographic differences. Pain 1989;37:257–263.

39. Feine JS, Lund JP. An assessment of the efficacy of physical therapy and physical modalities for the control of chronic musculoskeletal pain. Pain 1997;71:5–23.

40. Laskin DM, Greene CS. Influence of the doctor-patient relationship on placebo therapy for patients with myofascial pain-dysfunction syndrome. J Am Dent Assoc 1972;85:892–894.

41. Greene CS, Laskin DM. Long-term evaluation of conservative treatment for myofascial pain-dysfunction syndrome. J Am Dent Assoc 1974;89:1365–1368.

42. Goodman P, Greene CS, Laskin DM. Response of patients with myofascial pain-dysfunction syndrome to mock equilibration. J Am Dent Assoc 1976;92:755–758.

43. Greene CS, Laskin DM. Meprobamate therapy for the myofascial pain-dysfunction (MPD) syndrome: A double blind evaluation. J Am Dent Assoc 1971;82:587–590.

44. De Boever JA, Van Wormhoudt K, De Boever EH. Reasons that patients do not return for appointments in the initial phase of treament of temporomandibular disorders. J Orofac Pain 1996;10:66–72.

45. Jensen K, Andersen HO, Olesen J, Lindblom U. Pressure pain threshold in human temporal region. Evaluation of a new pressure algometer. Pain 1986;25:313–323.

46. Baird DD, McConnaughey DR, Weinberg CR, Musey PI, Collins DC, Kesner JS, et al. Application of a method for estimating day of ovulation using urinary estrogen and progesterone metabolites. Epidemiology 1995;6:547–550.

47. Johannes CB, Linet MS, Stewart WF, Celentano DD, Lipton RB, Szklo M. Relationship of headache to phase of the menstrual cycle among young women: A daily diary study. Neurology 1995;45:1076–1082.

48. Rollman GB. Measurement of pain in fibromyalgia in the clinic and laboratory. J Rheumatol 1989;16(suppl 19):113–119.

49. Bennett RM. Fibromyalgia and the facts. Sense or nonsense. Rheum Dis Clin North Am 1993;19:45–59.

50. McDermid AJ, Rollman GB, McCain GA. Generalized hypervigilance in fibromyalgia: Evidence of perceptual amplification. Pain 1996;66:133–144.

51. Giamberardino MA, Berkley KJ, Iezzi S, De Bigontina P, Vecchiet L. Pain threshold variations in somatic wall tissues as a function of menstrual cycle, segmental site and tissue depth in non-dysmenorrheic women, dysmenorrheic women and men. Pain 1997;71:187–197.

52. Yaksh TL, Malmberg AB. Central pharmacology of nociceptive transmission. In: Wall PD, Melzack R (eds). Textbook of Pain, ed 3. Edinburgh: Churchill Livingstone, 1994:165–200.

53. Bush FM, Harkins SW, Harrington WG, Price DD. Analysis of gender effects on pain perception and symptom presentation in temporomandibular pain. Pain 1993;53:73–80.

54. Linton SJ, Melin L. The accuracy of remembering chronic pain. Pain 1982;13:281–285.

55. Feine JS, Lavigne GJ, Dao TTT, Morin C, Lund JP. Memories of chronic pain and perceptions of relief. Pain 1998;77:137–141.

56. Peters ML, Sorbi MJ, Kruise DA, Kerssens JJ, Verhaak PF, Bensing JM. Electronic diary assessment of pain, disability and psychological adaptation in patients differing in duration of pain. Pain 2000;84:181–192.

57. Madland G, Feinmann C, Newman S. Factors associated with anxiety and depression in facial arthromyalgia. Pain 2000;84:225–232.

58. Stroud MW, Thorn BE, Jensen MP, Boothby JL. The relation between pain beliefs, negative thoughts, and psychosocial functioning in chronic pain patients. Pain 2000;84:347–352.

59. Dubner R. Hyperalgesia and expanded receptive fields. Pain 1992;48:3–4.

60. Mense S. Nociception from skeletal muscle in relation to clinical muscle pain. Pain 1993;54:241–289.

61. Sessle BJ. Masticatory muscle disorders: Basic science perspectives. In: Sessle BL, Bryant PS, Dionnne RA (eds). Progress in Pain Research and Management. Vol 4: Temporomandibular disorders and related pain conditions. Seattle: IASP Press, 1995:47–61.

62. Svensson P, Graven-Nielsen T, Arendt-Nielsen L. Mechanical hyperesthesia of human facial skin induced by tonic painful stimulation of jaw muscles. Pain 1998;74:93–100.

63. Woda A, Pionchon P. A unified concept of idiopathic orofacial pain: Pathophysiologic features. J Orofac Pain 2000;14:196–212.

64. Stohler CS, Zarb GA. On the management of temporomandibular disorders: A plea for low-tech, high prudence therapeutic approach. J Orofac Pain 1999;13:255–261.