Pain 131 (2007) 106–111

www.elsevier.com/locate/pain

Muscle tenderness in different types of facial pain and its relation

to anxiety and depression: A cross-sectional study on 649 patients
a,*
Franco Mongini , Giovannino Ciccone b, Manuela Ceccarelli b,
Ileana Baldi b, Luca Ferrero a
a
Section Headache–Facial Pain, Department of Clinical Pathophysiology, University of Turin, 14 Corso Dogliotti, I-10126 Torino, Italy
b
Unit of Cancer Epidemiology, San Giovanni Battista Hospital, Turin, Italy

Received 8 May 2006; received in revised form 5 December 2006; accepted 19 December 2006

Abstract

To evaluate in patients with different types of facial pain the association between muscle tenderness and a set of characteristics,
649 consecutive outpatients with facial myogenous pain (MP), TMJ disorder, neuropathic pain (NP) and facial pain disorder (FPD)
(DSM-IV) were enrolled. For each patient a psychological assessment on the Axis 1 of the DSM-IV and standardized palpation of
pericranial and cervical muscles were carried out. A pericranial muscle tenderness score (PTS), a cervical muscle tenderness score
(CTS) and a cumulative tenderness score (CUM, range 0–6) were calculated. Univariate analyses (one-way analysis of variance
or v2 test) indicated that both age- and sex-distribution, tenderness scores and prevalence of psychiatric disorders markedly differed
between groups. The prevalence of depression was highest in FPD patients (44.9%). Both muscle tenderness scores (either PTS or
CTS) and prevalence of anxiety were higher in patients with MP than in those with TMJ or NP. To assess associations between
CUM score and patients’ demographic and clinical characteristics an ordered logit model was fit and interactions between psychi-
atric disorders and diagnostic groups were tested. The analysis showed that, regardless of the diagnostic group, anxiety and depres-
sion independently increase the likelihood of having one point higher muscle tenderness score (OR = 1.55, 95% CI: 1.13–2.12 and
OR = 1.56, 95% CI: 1.10–2.21, respectively). A careful screening for the presence of an underlying psychiatric disorder, either
anxiety or depression, should be part of the clinical evaluation in patients suffering from facial pain.
Ó 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Keywords: Facial pain; Anxiety; Depression; Muscle tenderness

1. Introduction importance in tension-type headache (Langemark and

Olesen, 1987; Hatch et al., 1992; Jensen et al., 1993;
Facial pain accounts for 40% of all chronic pain Jensen, 1996; Jensen and Rasmussen, 1996; Jensen
problems (Feinmann, 1999; LeResche, 2001; Korszun, et al., 1998) and, to some extent, in migraine (Jensen
2002). In different types of facial pain, multiple etiologic et al., 1988; Vernon et al., 1992; Anttila et al., 2002). More-
factors may be involved. over, it may lead to spontaneous myogenous pain in the
Muscle disorder is a frequent condition in the craniofa- craniofacial-cervical area (Mense, 1993; Vanderas, 1996).
cial, neck and shoulder areas. It includes tooth clenching, Psychiatric comorbidity is also considered a poten-
bruxism, tongue thrust, nail or lip biting and sustained tially important factor in several head pain conditions
muscle contraction. Muscle disorder may lead to (Merikangas et al., 1994; Cao et al., 2002; Bensenor
increased muscle tenderness at palpation and may be of et al., 2003; Breslau et al., 2003; Mongini et al., 2003;
Zwart et al., 2003).
* A high degree of comorbidity was found between
Corresponding author. Tel.: +39 11 6334041; fax: +39 11 6636489.
E-mail address: [email protected] (F. Mongini). chronic facial pain and depression (Vimpari et al.,

0304-3959/$32.00 Ó 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2006.12.017
 F. Mongini et al. / Pain 131 (2007) 106–111 107

1995; Korszun et al., 1996; Feinmann, 1999) and a sig- abuse or presence of a concurrent relevant medical condition,
nificant overlap between both depression and chronic such as endocrine, immune, blood, neurologic or circulatory
facial pain with other stress-related pain disorders such disorders.
as fibromyalgia and widespread pain was established The 649 included patients had: myogenous pain (MP, 462
patients), temporomandibular disorders (arthrogenous TMJ
(Stohler, 1995; Korszun et al., 1998; Sipila et al., 2006).
disorders, 70 patients), neuropathic pain (NP, 68 patients),
Facial pain in which the psychological factor plays a
facial pain disorder (FPD, 49 patients). The diagnoses were
unique or predominant role may be included within the made according to the guidelines of the International Classifi-
‘‘Somatoform Disorders’’ as described by the ‘‘Diagnos- cation of Headache Disorders (International Headache Socie-
tic and Statistical Manual of Mental Disorders’’ (DSM- ty, 2004), of the American Academy of Orofacial Pain (1996)
IV) (American Psychiatric Association, 1994). The main and, for FPD patients, of the DSM-IV (American Psychiatric
feature of such disorders is ‘‘the presence of physical Association, 1994). MP patients had pain in the projection
symptoms that suggest a general medical condition areas of one or more facial or masticatory muscle: pain was
(hence the term Somatoform) and are not fully explained spontaneous but could be exacerbated by muscle palpation.
by a general medical condition, by the direct effects of a Location of pain differed with the muscles mainly involved:
substance, or by another mental disorder’’. In particular pre-auricular and cheek areas for the lateral pterygoid and
masseter muscles; parietal, temporal, periorbital areas for the
these facial pain syndromes may be categorized accord-
temporal muscle. Pain could be aggravated by meteorological
ing to the DSM-IV as ‘‘Pain Disorder Associated with
changes or certain weather conditions (cold, dampness, wind)
Psychological Factors’’. In this, the pain is the ‘‘predom- or sports involving prolonged isometric contractions, while
inant focus of clinical attention’’ in which psychological mastication was not an overt aggravating factor.
factors seem ‘‘to have an important role in its onset, To be assigned to the arthrogenous TMJ group a patient
severity, exacerbation, or maintenance’’. had to show signs of TMJ internal derangement. Clinical signs
In a previous study (Mongini et al., 2004) on were joint noises, pain at joint palpation and jerky jaw move-
patients with different headache types the tenderness ments. Imaging techniques could reveal disc displacement with
of pericranial and cervical muscles and its relation or without reduction. Bony change in shape was also present in
to anxiety and depression was investigated. The data some cases. In these patients the TMJ was the sole or main
showed a significantly lower muscle tenderness in source of pain, and mastication was always an aggravating
factor.
migraine patients with respect to those with tension-
The neuropathic pain group included trigeminal neuralgia
type headache. Anxiety and depression were frequent
and persistent neuropathic pain (19 and 49 patients, respective-
comorbid disorders and their prevalence was highest ly). Patients with trigeminal neuralgia suffered from attacks of
in patients suffering from chronic migraine. The main lancinating facial pain lasting from a few seconds to less than
finding of this study was a positive relationship two minutes, distributed along one or more branches of the
between muscle tenderness and psychiatric disorders trigeminal nerve and precipitated from trigger areas, or by
in patients with migraine. certain daily activities such as eating, talking, face washing
Aim of this work was to analyze in patients suffering or tooth cleaning. The persistent neuropathic facial pain was
from facial pain of different types muscle tenderness, the less intense than neuralgic pain. It could be located in the gums
prevalence of psychiatric comorbidity and the relation and/or lips and cheek. Frequently it was described as a burning
between these two variables. Our more relevant hypoth- pain. Pain in these patients had stereotypical characteristics
and conformed to the region of innervation of a sensory nerve.
eses were the following:
According to the DSM-IV, patients with FPD were those in
whom pain was the predominant focus of attention and pain
(1) muscle tenderness varies with the type of pain and could not be explained by a medical condition. In these
is highest in patients with myogenous pain; patients the pain was usually constant or persistent for most
(2) psychiatric comorbidity varies with the type of of the day, and was troublesome but variable in intensity
pain and is highest in pain disorder associated and quality (sometimes described as burning, other times as
with psychological factors. a sense of swelling, strain, etc.). The site could be mutable:
(3) in different facial pain conditions a positive rela- the pain could start as a sense of localized burning or swelling
tionship may exist between muscle tenderness in the zygomatic region, uni- or bilaterally, and then spread to
and psychiatric disorders. a broader area of the face and/or neck. The site of pain was
not confined to the distribution of a cranial or cervical nerve
root, nor could a structural source of pain be identified.
2. Methods
2.2. Data collection
2.1. Patients
A complete medical history was taken, that included a
All patients with facial pain consecutively referred to the record of the pain characteristics, improvement or aggravating
Headache and Facial Pain Unit, Department for Clinical Path- factors and associated symptoms. A psychological assessment
ophysiology, University of Turin, between 1998 and 2005 were on the Axis 1 (Anxiety-, Mood- and Somatoform-Disorders)
enrolled. Exclusion criteria for the present analyses were drug of the DSM-IV was then carried out by the same expert
108 F. Mongini et al. / Pain 131 (2007) 106–111

neurologist who evaluated the possible presence of major

NP; MP vs FPD; TMJ vs FPD; NP vs FPD

Differences among groups tested by one-way analysis of variance or v2 test. Bonferroni adjustment for multiple comparisons. (MP, myogenous pain; TMJ, temporomandibular joint intracapsular
depression and/or anxiety disorder according to the criteria
of the DSM-IV with a structured interview (Mazzi et al., 2000).
Clinical examination included neurological and craniofacial
examination. Muscle palpation of pericranial and cervical

NP; TMJ vs NP; TMJ vs FPD

muscles was carried out by an expert clinician in a standard-
ized way, following the instructions given by Dworkin and
LeResche (1992). Pericranial muscles examined were: 1. masse-
ter, 2. lateral pterygoid, 3. medial pterygoid, temporal (4. man-

TMJ; MP vs NP;
NP; TMJ vs NP;

MP vs TMJ; MP vs NP
MP vs TMJ; MP vs NP
MP vs TMJ; MP vs NP
dibular and 5. cranial insertion). Cervical muscles were:
sternocleidomastoid (1. belly and 2. cranial insertion), 3. trap-
etius, 4. nuke muscles. Tenderness at palpation was scored in

p-value < 0.05

each location from 0 to 3, with 0 indicating normal tone, 1

Comparisons
mild, 2 moderate, and 3 severe tenderness. Pericranial and
nuke muscles were palpated with the second and third finger

vs
vs
vs
vs
performing small rotation movements with pressure. The other

MP
MP
MP
MP
cervical muscles were pinched delicately. Palpation of each site
lasted three to four seconds. Scores of pericranial muscles and
cervical muscles were summated separately and the totals
obtained were divided by the number of sites examined. Thus,

Overall
p-value

0.001

0.001
<0.001

<0.001

<0.001
<0.001
<0.001
for each patient a pericranial muscle tenderness score (PTS)
and a cervical muscle tenderness score (CTS) (range 0–3) were

disorder; NP, neuropathic pain; FPD, facial pain disorder; PTS, pericranial tenderness score; CTS, cervical tenderness score).
calculated. A cumulative tenderness score (CUM, range 0–6)

Distribution of patients’ characteristics (gender, age, psychiatric disorders, muscle tenderness score) by diagnostic groups
was also calculated by summing the PTS and CTS.

FPD (n = 49)

0.91 (±0.86)
1.11 (±1.12)
2.02 (±1.84)
2.3. Statistical analyses

(22.5)
(±13)
(30.6)
(44.9)
For each diagnostic group the following characteristics

11
46
15
22
were analyzed: gender, age, muscle tenderness, presence of
anxiety and/or depression. Continuous variables were
expressed as mean and standard deviation. Univariate analyses
were performed by one-way analysis of variance. Bonferroni

0.82 (±0.84)
0.82 (±0.99)
1.64 (±1.74)
NP (n = 68)

correction was used for multiple comparisons. Discrete vari-

(35.3)
(±14)
(16.2)
ables were summarised by frequency percentages and analyzed (10.3)
by v2 test.
24
50
11
7

Ordered logit regression models (one for each muscle ten-

derness score as dependent variable), stratified by diagnostic
group, were initially performed to assess associations with
age, gender and psychiatric disorders. As no relevant interac-
TMJ (n = 70)

0.61 (±0.76)
0.68 (±0.95)
1.29 (±1.61)

tions were found between psychiatric disorders and diagnostic

(14.3)
(±17)
(15.7)
(15.7)

groups, two ordered logit models including the diagnostic

group as a covariate (with MP group as reference category)
10
38
11
11

were fit. As PTS and CTS were associated with the same pre-
dictors and showed a quite high Pearson correlation coefficient
(R2 = 0.67, p-value < 0.0001), a final ordered logit model with
Diagnostic group

CUM as response was chosen.

MP (n = 462)

1.25 (±0.86)
1.31 (±0.97)
2.56 (±1.64)

Statistical analyses were performed using STATA statistical

(16.0)
(±15)
(33.5)
(22.3)

analysis software (STATA Corp., College Station, TX, v. 8.2).

155
103
74
43

3. Results

Univariate analyses indicate that both age and gender

distribution, tenderness scores and prevalence of psychi-
Age (years): mean (±SD)

Muscle tenderness scores

Major depression: n (%)
Anxiety disorder: n (%)

atric disorders markedly differ between groups (Table 1).

Gender (male): n (%)

CUM: mean (±SD)

Anxiety disorders were in 97% of the cases generalized

CTS: mean (±SD)
PTS: mean (±SD)

anxiety disorders (GAD) and in only 3% of the cases

characteristics

panic disorders or agoraphobia. Depressive disorders

were major depression in 85% of the cases and dysthy-
Patients’
Table 1

mic disorder in 15% of the cases. The ratio between

these two disorders was similar among the diagnostic
 F. Mongini et al. / Pain 131 (2007) 106–111 109

Table 2 positively evolve along time (Hiltunen et al., 2003;

Associations between patients’ characteristics and cumulative muscle Magnusson et al., 2005). Muscle tenderness was, not
tenderness score
surprisingly, more elevated in patients with myogenous
Patients’ Cumulative tenderness score pain than in TMJ and NP. This raw association is also
characteristics
OR (95% CI) p-value confirmed after adjusting by gender, age, and psychiat-
Male gender 0.40 (0.27–0.58) <0.001 ric symptoms in the multivariate analysis.
Age (years) 0.99 (0.98–1.00) 0.029 The presence of anxiety and depression was positively
Anxiety disorder 1.55 (1.13–2.12) 0.006 associated with higher muscle tenderness scores. It
Major depression 1.56 (1.10–2.21) 0.012
Diagnostic group*
should be noticed that no differences in this relationship
TMJ 0.18 (0.11–0.30) <0.001 across facial pain subtypes were found.
NP 0.46 (0.29–0.75) 0.002 The major strength of this study is that, to our
FPD 0.47 (0.26–0.84) 0.010 knowledge, it is the first pursuing a joint assessment
Odds ratios (OR) and 95% confidence intervals (95% CI) estimated of muscle tenderness and psychiatric comorbidity in
with ordered logit regression are adjusted for all variables listed in the groups of patients with different types of facial pain.
table. So far, such variables have been investigated separate-
*
Reference group: MP.
ly. Moreover, previous studies relating facial pain with
psychiatric disorders did not assess the strength of
groups. The low number or the absence of other specific these associations.
anxiety and mood disorders in our files may be attribut- Our study has some limitations. Since all information
ed to the fact that patients with these disorders are more was collected by the same examiner during the consulta-
frequently referred directly to a psychiatric institution. tion, some degree of association between symptoms,
The study sample includes a majority of women and comorbidity and diagnosis of facial pain is expected.
their prevalence (above 80%) is higher in MP and TMJ However, it seems quite unlikely that the strong associ-
than in NP. Mean age ranges from 38 (TMJ) to 50 years ations found could be completely explained by this
(NP). The prevalence of depression is highest in FPD potential bias. The absence of a pain-free control group
patients (44.9%). Both muscle tenderness scores (either limits the inference about the etiologic role of the factors
PTS or CTS) and prevalence of anxiety are higher in analyzed. Moreover, interpretation of the causal path-
patients with MP than in those with TMJ or NP but sta- way of some of the associations described in the cross-
tistically similar to FPD. sectional study is not obvious, since the temporal
Table 2 shows the results of the ordered logit regres- sequence of appearance of facial pain, muscle tenderness
sion assessing associations between CUM score and age, and psychiatric disorders is not clear. Only a well-
gender, psychiatric disorders, diagnostic group. The designed prospective cohort study could disentangle
analysis indicates that both anxiety and depression these complex relations.
increase the likelihood of having a higher muscle tender- A crucial problem is to understand the extent to
ness score (OR = 1.55, 95% CI: 1.13–2.12 and which a comorbid disorder, and depression in particu-
OR = 1.56, 95% CI: 1.10–2.21, respectively) while male lar, relates with a chronic pain condition in general or
gender and age are negatively associated with higher with a specific facial pain. Indeed, symptoms of
CUM score. Among diagnostic categories, NP and, depression and psychological distress are more com-
above all, TMJ show a decreased likelihood of having mon in persons with chronic pain than in pain-free
muscle tenderness with respect to MP. individuals (Croft et al., 1995). Extensive survey stud-
ies show that the rates of depression in individuals
4. Discussion with and without chronic pain may vary between
18–20% and 6–8%, respectively (Magni et al., 1990,
This study reports scores of head and neck muscle 1993; Currie and Wang, 2004). As mentioned, even
tenderness and a prevalence of anxiety and depression higher depression rates were found in patients suffer-
disorders that were higher in patients suffering from ing from a chronic facial pain not better specified
MP and FPD than from other facial pain types. This (Vimpari et al., 1995; Korszun et al., 1996; Feinmann,
datum suggests that these two groups, diagnostically dif- 1999). Stressful life events may precede the onset of
ferent on presence/absence of objective findings and pre- chronic facial pain (Feinmann, 1983, 1993; Lennon
sumed involvement of psychological factors, may be et al., 1990; Auerbach et al., 2001; Korszun, 2002)
more similar than is generally recognized. and depression (Brugha et al., 1997; Kessler, 1997;
The arthrogenous TMJ is more common among the Kendler et al., 1999; Riise and Lund, 2001; Kessing
younger women. This is in accordance with the widely et al., 2003; Chapman et al., 2004; Coyne et al.,
accepted notion that symptoms of TMJ derangement 2004; Arean and Reynolds, 2005). A diathesis-stress
are more frequent in women (Johansson et al., 2003; model has been put forward to explain why
Rutkiewicz et al., 2006; Winocur et al., 2006) and may under particular circumstances some subjects have a
110 F. Mongini et al. / Pain 131 (2007) 106–111

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