Hello fellow TMD Therapists,

I was asked a great question at my last TMD course recently at Concordia University by one of the participants. What are some of the “red flags” aside from heart attack or angina that could mimic jaw pain? Admittedly, not something I cover during my 2 day course, as at some point, you have to draw a line on what you can and or cannot cover, so I thought, what better way then to put together a more lengthy blog, to present some things to consider or be aware of that might contribute to head neck or face pain. In no way is this meant to be a complete, exhaustive list, but a great starting point. I very much appreciate the question that was asked, as I never stop learning and it was a great reminder to revisit these red flags. Since so many of us work in states with direct access, having some knowledge on how to screen for medical disease is very important! 

Each patient should be screened for the presence of red flags. Important findings may include but are not limited to a history of emotional or psychological stress, medication usage, symptoms of vertebrobasilar insufficiency, upper cervical spine instability, cardiac dysfunction, central nervous system dysfunction, cranial nerve dysfunction, infection, and unexpected weight loss or gain. Some clinicians may choose to accomplish screening by means of intake questionnaire but verbally reviewing the information is advisable.

The American Headache Society has a handy mnemonic device for remembering headache warning signs — reasons to call your doctor right away. All you have to do is remember the mnemonic “SNOOP.”

S — Systemic Symptoms

This refers to any symptoms, in addition to your headache, that affect the body as a whole. Some systemic symptoms include fevers, muscle pain, and weight loss. This “S” can also refer to secondary risk factors, like HIV or cancer. For instance, if a person has cancer, a new headache could be a sign that the cancer has spread to the brain. 

N — Neurological Signs or Symptoms

Any headaches associated with changes in cognition, mental functioning, or personality or deficits in one or more areas of the body, like weakness or loss of sensation requires immediate medical attention. This could be an indication of a stroke, mass in the brain, or other vascular or autoimmune process in the nervous system. Look for signs of confusion, clumsiness, weakness, aphasia or visual problems.

O — Onset

Onset refers to how fast a headache sets in. Headache reaches peak intensity in <1 minute. Headaches that hit suddenly and severely, without warning, also called thunderclap headaches a sudden (extraordinarily severe and explosive onset of head pain), can be a sign of a stroke, especially a bleed in the brain known as a subarachnoid hemorrhage. If straining, coughing, or sexual activity causes a headache to appear, you should also discuss this with your healthcare provider. 

O — Older Age of Onset

If you are a bit older when you first start to experience headaches, you may actually have a more significant problem than simple migraines. This is especially true if you are age 50 or older — one type of headache that can newly develop in middle-aged people is giant cell arteritis.

P – Pattern Change

Compare a current headache with headaches you have experienced in the past. If your headache pattern has changed, like become more severe in intensity, more frequent, or associated with new symptoms like fatigue, than please seek medical attention. Likewise, if you are experiencing the first or worst headache of your life, seek medical attention right away, as this could indicate bleeding within the brain. Low pressure headache syndromes, cervicogenic headaches, intracranial hypertension, POTS. 

Aside from being painful and annoying, headaches are often just that — headaches. They do not indicate that you absolutely have a more significant illness or condition. That being said, taking the time to assess your headaches using the SNOOP mnemonic can give you peace of mind and a more organized way to classify your headaches.

Red flags that may mimic TMDs, face, head or neck symptoms:

  • History of malignancy—potential for a new primary, recurrence, or metastases
  • Presence of lymphadenopathy or neck masses—consider a neoplastic, infective, or autoimmune cause
  • Sensory or motor function changes (specifically focusing on cranial nerves V, VII, and VIII)—consider intracranial causes, or malignancy affecting the nerve’s peripheral branches
  • Recurrent epistaxis, purulent nasal drainage, or anosmia—consider nasopharyngeal carcinoma or chronic sinusitis
  • Trismus especially if history of using paan or betel nut—consider oral malignancy as part of differential diagnoses and think about employing the “Trismus checklist”.
  • Unexplained pyrexia or weight loss—consider malignant tumors, immunosuppression, and infective causes as part of differential diagnoses
  • First episode in over 50s, unilateral headache accompanied by jaw claudication (pain in the jaw associated with chewing), and general malaise—consider Temporal Arteritis or Giant-cell arteritis (GCA)
  • Facial asymmetry or masses (uncommon in TMD unless there is masseteric hypertrophy)—consider neoplastic, infective, or inflammatory causes
  • Occlusal changes (bite of teeth changes) as determined by dentist that do not predate the start of the TMD—consider growth disturbance of condyle, neoplasia, rheumatoid arthritis, and traumatic causes as part of differential diagnoses
  • Ipsilateral objective change in hearing—consider acoustic neuroma, or other ear disease as part of differential diagnoses
  • Persisting or worsening symptoms despite treatment—consider a misdiagnosis or more complex case
  • History of recent head and neck trauma
  • Paroxysmal unilateral lancinating pain with or without autonomic features—more likely to be associated with trigeminal neuralgia or one of the trigeminal autonomic cephalagias
  • Pain that is cardiac in origin is referred to as angina pectoris. Angina is usually described as pressure not necessarily as pain. Atypical angina may occur in the face, jaw, teeth among other areas.
  • Please feel free to add or share any patient stories in which you identified a “red flag” and made the appropriate referral to a medical professional. As you have heard me say and I continue to say, treating TMD, head, neck and face pain does require a multidisciplinary approach.

    Thanks, and Happy Holidays and New Year.




    Durham J. Acute presentations of chronic orofacial pain conditions. In: Greenwood M,Corbett I, eds. Dental emergencies. Wiley-Blackwell, 2012.

    Epstein JB, Jones CK. Presenting signs and symptoms of nasopharyngeal carcinoma. Oral Surg Oral Med     Oral Pathol 1993;75:32-6.

    Siccoli MM, Bassetti CL, Sandor PS. Facial pain: clinical differential diagnosis. Lancet Neurol 2006;5:257-67.

    Durham J, Aggarwal VA, Davies SJ, Harrison SD, Jagger RG, Leeson R, et al. Temporomandibular Disorders (TMDs): an update and management guidance for primary care from the UK Specialist Interest Group in Orofacial Pain and TMDs (USOT). 2013. https://www.rcseng.ac.uk/-/media/files/rcs/fds/publications/temporomandibular-disorders-2013.pdf

    Orofacial Pain, Guidelines for Assessment, Diagnosis, and Management 6th edition by the American Academy of Orofacial Pain.

Michael Karegeannes
Latest posts by Michael Karegeannes (see all)