Tension-type headache and teeth clenching: is the pain from a tooth or a muscle?

The NHS describes tension-type headache as pain on both sides of the head, face or neck, a feeling as if something is pressing on top of the head or squeezing around it, and tenderness that gets worse when touched. You can carry on with your daily activities with this pain, and movement does not make it worse. The pain lasts at least 30 minutes and sometimes goes on for several days. MSD Manuals separates pain occurring on fewer than 15 days a month as episodic, and on 15 or more days as chronic. According to the NHS, tension-type headache is not a sign of an underlying illness.

The common causes the NHS lists are stress, sleep problems and caffeine; it writes that taking painkillers too often or for too long also causes headaches, which are called medication overuse or rebound headaches. MSD lists sleep disorders, neck pain and jaw joint disorder among the triggers. According to the NHS, the symptoms of a jaw joint disorder are pain around the jaw, ear and temple, clicking or popping when the jaw moves, headaches around the temples, not being able to open the mouth fully and the jaw locking; the pain gets worse when chewing and at stressful times.

The link between teeth clenching and headache has been examined in two systematic reviews, and the result shows an interesting distinction. In a 2021 review of observational studies in adults, the three studies that examined tension-type headache found a significant link only with clenching while awake, that is, during the day; in those who clench during the day, the probability of tension-type headache was found to be about 5 times higher; the authors write that between studies this difference rose to as much as 17 times. No link came out between grinding during sleep and tension-type headache. The certainty of the evidence was rated as low and very low; because the studies are observational, it is not known whether clenching causes the headache or both are linked to a common cause.

The sleep side is more mixed. In a 2014 review examining sleep grinding and headache, there were only two adult studies that met the criteria; in both, the probability of headache was higher in those who grind in their sleep, but the studies looked at different types of headache. The authors write that in children there is not enough evidence either to confirm or to refute the link. The effect of a night guard on tension-type headache was not examined in these two reviews; the NHS recommends a guard to protect the teeth from damage. If you notice that you clench your teeth during the day, talk to your doctor about this too rather than relying on a night guard alone.

There is a measured way to tell headache from the jaw muscles apart. A diagnostic study in 373 people with headache and a jaw joint disorder proposed two criteria for headache linked to the jaw joint: the pain being in the temple and changing with jaw movement or habits such as chewing or clenching; and the same headache appearing when the muscle in the temple is pressed or with jaw movement. Applied through a doctor's examination, these criteria told headache from the jaw apart in people with headache and a jaw joint disorder with 89 percent sensitivity and 87 percent specificity; there is no such value for a test done at home. In other words, if the headache you know appears when you press gently on your temple or clench your teeth, this is a clue that deserves a conversation with a doctor about the muscle and jaw side; the diagnosis, however, is made by the examination.

This is where the confusion with the teeth begins. The NHS clearly lists teeth clenching and grinding among the causes of toothache; among the symptoms of clenching it gives jaw pain, worn or broken teeth, sensitivity, headaches and earache. Pain spreading from the jaw muscles can be felt not in a particular tooth but over an area, often the upper or lower back teeth, and as a dull ache. In a published case, pain coming from the jaw muscles was mistaken for toothache and the patient had dental procedures that cannot be reversed; the authors stress that if the source of the pain is not clear, a thorough examination is needed before any treatment that cannot be reversed.

The reverse is also true: a real dental problem can also come with a headache. Pain from decay, an abscess, a cracked tooth or an inflamed wisdom tooth can spread to one side of the face and the temple. In this situation, the pain is usually one-sided, triggered in a particular tooth by heat, cold, sweet things or biting, and often does not go away with painkillers. The NHS says to see a dentist with toothache that lasts more than 2 days, does not go away with painkillers, or comes with a high temperature, pain when biting, red gums or a bad taste in the mouth. The pressure-type tension pain on both sides, on the other hand, does not point to a single tooth.

A last warning concerns painkillers. MSD writes that overuse of painkillers or caffeine, whether the caffeine in headache medicines or in drinks, can lead to daily headaches. Suppressing a headache linked to clenching with painkillers every day can, over time, add a second headache that comes from the medicine itself. If you get headaches several times a week or your need for painkillers is growing, talk to your GP (family doctor).

The first list is signs that make it more likely the headache is tension-type and linked to the jaw muscles. The second list shows that the pain may be due to another cause; if an item from there applies to you, do not wait.

The sequence deliberately starts with dangerous headache signs, then moves on to the type of headache and to telling the jaw and the teeth apart.

1. 1

   First, emergency signs

   If there is a sudden and very severe onset, neurological symptoms, loss of vision, a very high temperature, a stiff neck or severe discomfort from light, or a blow to the head in the last 3 months, the assessment is done in A&E; call 112.

2. 2

   Headache diary

   The NHS writes that with regular tension-type headaches it may recommend a headache diary recording how often the pain comes and how long it lasts. Add the time of the pain, the medicine you took and the day, whether there was morning jaw tiredness, and the moments during the day when you noticed you were clenching.

3. 3

   Checking for clenching during the day

   Set a few reminders on your phone during the day and each time check whether your teeth are touching. The NHS writes that apart from when eating, your teeth should be apart; if your teeth are often in contact, tell your doctor.

4. 4

   Identifying the type of headache

   Your GP asks about where the pain is, what it is like, the symptoms that come with it and how often you take painkillers; migraine, cluster headache and headache caused by medication overuse are told apart at this stage.

5. 5

   Examination of the jaw muscles and joint

   The dentist presses on the chewing muscles in the temple and cheek to see whether the pain you know appears, and looks at how wide the mouth opens, jaw joint noises and signs of wear on the teeth. The criteria in the diagnostic study rest on this examination.

6. 6

   Testing the teeth

   If there is pain in the teeth, cold, tapping and bite tests and an X-ray show whether there is a tooth that explains the pain. If no tooth reproduces the pain, the possibility of pain from the muscles should be discussed before any dental procedure that cannot be reversed.

Treatment for tension-type headache and teeth clenching is often planned together; the GP and the dentist look at two ends of the same picture.

Below are the wrong decisions often seen with tension-type headache and teeth clenching, and what they cost.

The course of tension-type headache varies from person to person. The sequence below is the description given by the NHS and MSD; the plan of the doctor who follows you up comes first.

1. A single headache

   The NHS and MSD write that tension-type headache lasts at least 30 minutes and sometimes goes on for several days.

2. The first weeks

   Track how often the headaches come in your diary, along with checking for clenching during the day, a regular sleep pattern, cutting down on caffeine and relaxing activities.

3. Several times a week, or severe

   The NHS says to see your GP with headaches that come several times a week or are severe, and when painkillers and relaxation do not help.

4. 15 or more days a month

   MSD defines pain at this frequency as chronic. At this point, preventive treatment and an assessment for medication overuse come up.

We do not give a single figure here, because the assessment of tension-type headache and teeth clenching can vary greatly in scope from person to person. These are the items that determine the scope:

Type of headache

Simple tension pain is managed by the GP, while chronic or mixed pictures may need a neurology assessment.

Damage caused by clenching

Repairing worn, broken or sensitive teeth widens the scope.

Guard and jaw treatment

A mouth guard, physiotherapy or psychological support are separate items.

Avoiding unnecessary procedures

Putting pain from the muscles down to a tooth can lead to ineffective dental treatment that cannot be reversed.