Effects on temporomandibular disorder in the treatment of tension-type headache with acupuncture and therapeutic exercises. A secondary analysis from a randomized controlled trial
Schiller et al. · Clinical Rehabilitation · 2024
Evidence Level
MODERATEOBJECTIVE
To examine the effects of acupuncture and therapeutic exercises on temporomandibular joint symptoms in patients with tension-type headache
WHO
96 participants with frequent episodic or chronic tension-type headache
DURATION
6 weeks of treatment with follow-up at 3 and 6 months
POINTS
Standard points including Baihui (GV-20), Taiyang (EX-HN5), Fengchi (GB-20), Hegu (LI-4), plus individualized points
🔬 Study Design
Usual Care
n=24
standard care without additional intervention
Acupuncture
n=24
12 sessions of traditional Chinese acupuncture
Exercises
n=24
12 sessions of therapeutic exercises
Combination
n=24
acupuncture + therapeutic exercises
📊 Results in numbers
Improvement in temporomandibular dysfunction (acupuncture, 3 months)
Improvement in temporomandibular dysfunction (acupuncture, 6 months)
Significant improvement at 3 months
Improvement sustained only with acupuncture at 6 months
📊 Outcome Comparison
Temporomandibular Dysfunction Score (reduction at 6 months)
This study shows that acupuncture can help not only tension-type headache but also problems with the jaw joint. Among the treatments tested, only acupuncture maintained durable benefits at 6 months for temporomandibular symptoms. Patients with significant dental problems may have a smaller response to treatment.
Article summary
Plain-language narrative summary
Tension-type headache is one of the most common forms of headache, affecting millions of people worldwide. In addition to the characteristic pain, many patients with this type of headache also have symptoms involving the temporomandibular joint, which connects the jaw to the skull. This connection between the jaw joint and headache exists because both conditions share similar nerve structures and pain modulation systems. Therefore, it is common for people with tension-type headache to also report discomfort when chewing, opening their mouth, or moving their jaw.
Treatment of these conditions has evolved to include nonpharmacological approaches such as acupuncture and therapeutic exercises, which have shown promising results for both headache and temporomandibular joint problems.
The primary objective of this study was to investigate how different treatments for tension-type headache may affect symptoms related to the temporomandibular joint. The investigators analyzed data from a randomized controlled trial conducted at a German university hospital, involving 96 participants who had been suffering from frequent episodic or chronic tension-type headache for more than six months. Participants were randomly assigned into four treatment groups: acupuncture alone, therapeutic exercises alone, a combination of both treatments, and usual care as a control group. Treatment lasted six weeks, with 12 sessions distributed at decreasing frequency, and participants were followed for six months from the start of the intervention.
To evaluate temporomandibular joint symptoms, a validated questionnaire was used that assesses difficulties with chewing, opening the mouth, speaking, and other jaw-related functions. In addition, all participants underwent a detailed dental examination to identify structural problems in the joint and dentition.
Results showed that all active treatments produced significant improvements in temporomandibular joint symptoms at three months, compared with the usual care group. In the acupuncture group, there was a 5-point reduction on the dysfunction scale; in the therapeutic exercise group the reduction was 4 points; and in the combination group it was 3 points, while the control group showed no significant improvement. However, when investigators evaluated the effects at six months, only the acupuncture group maintained significant and durable benefits, with a 6-point reduction on the symptom scale. This finding suggests that acupuncture may have longer-lasting mechanisms of action, possibly related to modulation of central pain control systems and release of the body's natural analgesic substances.
An important finding was that participants with more severe dental problems, identified at the initial dental examination, had a smaller response to acupuncture treatment for their headaches, suggesting that significant structural changes in the joint may interfere with treatment efficacy.
For patients suffering from both tension-type headache and temporomandibular joint symptoms, this study brings valuable information. First, it shows that headache treatment can simultaneously improve jaw-related discomfort, which is excellent news for those living with both problems. Acupuncture proved particularly effective for durable benefits, sustaining its positive effects even six months after treatment. For clinicians, the findings highlight the importance of an interdisciplinary evaluation, especially when there is treatment resistance.
Patients with significant structural dental problems may need a specialized dental approach before or during headache treatment to optimize therapeutic results. This suggests that dentists and headache specialists should collaborate to deliver more comprehensive and effective care.
The study has some important limitations to consider. The inability to blind participants to the type of treatment received may have influenced the results, although the investigators tried to control for this bias. There was a higher dropout rate in the therapeutic exercise group, possibly due to the greater physical demand of this type of intervention. In addition, session duration differed between acupuncture and exercises, which may have contributed to the differences in results.
Despite these limitations, the study offers valuable evidence on the efficacy of integrative treatments for tension-type headache and their additional beneficial effects on temporomandibular joint symptoms. The results suggest that acupuncture may be especially beneficial for patients presenting with both conditions, but that careful dental evaluation should be considered in cases of treatment resistance, allowing a more personalized and effective therapeutic approach.
Strengths
- 1Randomized controlled design with four comparison groups
- 2Extended 6-month follow-up
- 3Comprehensive analysis including objective dental examination
- 4Standardized, evidence-based interventions
Limitations
- 1Open-label study due to the nature of the interventions
- 2Higher dropout rate in the therapeutic exercise group
- 3Secondary analysis, not primary outcome of the original study
- 4Possible participant preference bias toward acupuncture
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
The overlap between tension-type headache and temporomandibular disorder (TMD) is something any physiatrist experienced in craniofacial pain recognizes day to day — and this work by Schiller and colleagues directly addresses this phenomenon with a four-arm controlled design. The finding that acupuncture maintained significant reduction in TMD scores at 6 months, while therapeutic exercises alone did not sustain benefit beyond 3 months, has direct practical implications for therapeutic planning. In outpatient pain practice, the patient who arrives with chronic tension-type headache frequently also carries complaints of chewing difficulty and limited mouth opening — and the conventional tendency is to refer them in fragmented fashion between neurology and dentistry. This study supports a unified approach in which acupuncture can act as a therapeutic anchor for both conditions simultaneously, especially in patients without severe structural dental compromise.
▸ Notable Findings
The most noteworthy finding in this work is not simply the efficacy of acupuncture, but the temporal dissociation between the groups: at 3 months, acupuncture, exercises, and combination produced comparable reductions in TMD symptoms relative to usual care; at 6 months, only acupuncture sustained significant gain, with a 6-point reduction on the dysfunction scale and p < 0.01. It is also striking that the combination group did not exceed acupuncture alone in durability — suggesting that the addition of therapeutic exercises did not potentiate, and may even have diluted, the long-lasting analgesic effect of acupuncture on the trigeminal system. Another relevant finding is the association between structural dental compromise assessed at the initial dental examination and lower response to headache treatment, indicating that structural peripheral changes in the temporomandibular joint act as modulators of the central response — data that informs pretreatment screening.
▸ From My Experience
In my outpatient pain practice, I usually observe perceptible response of TMD associated with tension-type headache by the first 4 to 5 acupuncture sessions, typically expressed as reduction in reported nighttime clenching and subjective improvement in mouth opening range. What Schiller and colleagues confirm is what we had already perceived empirically: durability of benefit is differentiated relative to exercises alone. I usually conduct 12 to 16 sessions until stabilization, with maintenance return every 6 to 8 weeks for patients with chronic patterns. I make a habit of requesting dental evaluation before starting the protocol when there are signs of severe bruxism or mouth opening below 35 mm — precisely because patients with relevant structural dysfunction have a slower response curve and frustrate expectations if there is no concurrent occlusal adjustment. The profile that responds best, in my experience, is the woman between 30 and 50 years old with frequent episodic tension-type headache, without advanced degenerative joint pathology and with a predominant myofascial component in the masseters and temporalis muscles.
Full original article
Read the full scientific study
Clinical Rehabilitation · 2024
DOI: 10.1177/02692155241229282
Access original articleThis study underpins the editorial content of the site.
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Scientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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