Pain referral patterns

Anatomical Region	Possible Muscle referral	Other possibilities
Maxillary anterior	Anterior temporalis	Odontogenic Neuropathic pain
Maxillary canine/pre-molar	Middle temporalis	Odontogenic Neuropathic pain Sinusitis Mid face Migraine
Upper molars	Superficial masseter (superior portion) Posterior temporalis	Odontogenic Sinusitis Facial Migraine
Lower anterior Gingival pain	Anterior belly digastric	Odontogenic
Lower jaw/molars	Superficial masseter (lower portion) Trapezius Posterior belly digastric Platysma (very diffuse) (VII)	Odontogenic CV
TMJ/Ear	Medial pterygoid Lateral pterygoid (inferior head) (pain increases with protrusive resistance) Both SCM Deep masseter	Odontogenic Ramsay Hunt Pain in TMJ: Ligaments (with function, common to have muscle co-contraction) Retrodiscitis (with ipsilateral excursion and loading – open bite might be present. Co-contraction not common) Capsular (inflammatory condition, continuous, with secondary co-contraction, increases with function, tender at palpation, possible changes in occlusion for increase in intra-articular fluids) Arthritis (dull-achy pain aggravated by function) Eagle syndrome: difficulty swallowing and pain with neck movement.
Ear	Deep masseter SCM	Otitis externa (pain increases with ear pulling) Otitis media TMJ pain Tympanic plexus neuralgia Nervus intermedius neuralgia or geniculate neuralgia (VII cranial nerve) Foreign body Barotrauma Mastoiditis Ramsey Hunt syndrome
Tinnitus	Deep masseter	Vascular disease Neoplasms Vertigo
Angle of mandible	SCM Masseter Medial Pterygoid Upper Trapezius Posterior Digastric	Mastoiditis Pain from styloid C2, C3
Top of head	Splenius capitis SCM	Nummular headache
Forehead	Both SCM Anterior temporalis Occipito-frontalis (VII)	Eagle syndrome: difficulty swallowing and pain with neck movement will refer to ophthalmic region if carotid artery is involved by encroaching.
Occipital region	cervical muscles	Cervical strain Occipital neuralgia
Eye	Trapezius SCM Occipitofrontalis Zygomaticus major (inner canthus) Splenius cervicis	Tolosa Hunt (pain with eye movements) Painful Horner = carotid dissection or tumor in lungs Pain with eye movements: consider optic neuritis, sinusitis. Eagle syndrome: difficulty swallowing and pain with neck movement will refer to ophthalmic region if carotid artery is involved by encroaching. TAC (itchy eyes usually HC). Bell’s Palsy Temporal arteritis Tumors Glaucoma Ocular inflammation Corneal disease Referred vascular pain Red eye: consider cervical problems (C3)
Temple	Temporalis Trapezius Sternal head of SCM	Temporal arteritis
Cheek / zygomatic area	Temporalis Deep masseter Superficial masseter Medial pterygoid Lateral pterygoid (superior head) pain increases with biting. Sternal head of SCM	Temporal tendinitis (usually unilateral, throbbing, burning, lancinating, mild to severe)
Nose Paranasal sinus	Anterior temporalis Orbicularis oculi (also refers to upper lip) (VII)	Nasal mucosal pain (might refer to upper teeth, zygomatic area, temple, inner canthus of the eye) Rhinosinusitis Vestibulitis Nasal polyps Infections
Chin	Sternal head of SCM	Malignancy numb chin Trauma surgery Brain ischemia
Neck	Both SCM Splenius capitis Trapezius Medial pterygoid Suboccipital muscles	ANTERIOR: Thyroid disease TOS Carotydinia (could be associated with hemicrania continua) Glossopharyngeal neuralgia LATERAL Eagle POSTERIOR: Occipital neuralgia Arthropathies
Throat	Medial Pterygoid	Eagle syndrome: also, difficulty swallowing and pain with neck movement, will refer to ophthalmic region if carotid artery is involved by encroaching. Glossopharyngeal neuralgia Superior Laryngeal neuralgia Pharyngeal pain, Pharyngitis, tonsillitis. Neoplasia
Dry cough	Sternal head of SCM	Pulmonary disease Allergic reaction
Behind the ear	Both SCM (clavicular and sternal) Upper Trapezius Posterior temporalis Medial Pterygoid	Mastoid process Psoriasis
Intraoral	Medial pterygoid	Dental pain Soft tissue pain BMS
Cross midline	Anterior belly digastric Clavicular head of SCM	Psychogenic pain