Temple and alternating eye pain that persisted after medical care and a reported normal MRI

This de-identified pediatric-adolescent case involved irregular severe pain in both temples and pressure-like eye pain alternating between left and right after medical evaluation and a reported normal MRI had not identified a clear cause.

The patient first mentioned left TMJ discomfort, but detailed history showed that temple and eye pain, each rated VAS 7–8, caused greater distress to the patient and caregiver.

No injection was used. A soft oral appliance based on a digital design and conservative TMJ care were provided. At visit 2, both the patient and caregiver reported no headache or eye pain.

Symptoms later varied by site, and appliance damage was recorded. At visit 6, the patient reported no discomfort and good sleep, so care ended after six visits. This course does not prove that the TMJ was the sole cause or guarantee long-term nonrecurrence.

Medical history and privacy boundary

The patient and caregiver said they had attended several medical services, including pediatric care at a university hospital, and were told the MRI was normal, but the recurring headache had not received a clear diagnosis.

They traveled a long distance by express bus from Gyeongsangnam-do. The specific city, route, prior facility names, exact age, and sex are not disclosed.

A reported normal MRI is important, but it does not exclude every headache, eye, muscular, or functional condition. New or changing warning signs still require renewed medical evaluation, and a normal MRI does not make the remaining symptoms a jaw diagnosis.

Initial jaw symptoms

The patient initially said the left TMJ had been uncomfortable for perhaps one to two years, without remembering an exact onset.

On further questioning, the jaw was not clearly painful at that moment; instead there was a sound and a feeling of force or tension, rated VAS 3–4. The initial word pain and later description of nonpainful discomfort were retained rather than treated as contradictory.

Opening was adequate, but the jaw made a sound. Sound without pain or locking does not alone establish severe joint damage or a need for treatment; movement path, timing, catching, and opening range were considered together.

Radiographs cannot establish the cause of headache or eye pain

The TMJ radiograph can show bone structure and condylar position, but one image cannot determine the cause of joint sounds, temple headache, eye pressure, or posterior neck pain.

Muscle tension, actual jaw movement, headache type, and ocular status require symptom history, movement and opening examination, palpation, and ophthalmic or neurologic evaluation when indicated.

Severe irregular bilateral temple pain

The patient described irregular pain in both temples at VAS 7–8. The temporalis muscle moves the jaw, but temple location alone does not establish headache attributed to TMD.

Assessment should distinguish sudden onset, episode duration, light or sound sensitivity, nausea, and change with chewing, yawning, clenching, or prolonged talking, and whether familiar pain is reproduced by temporalis palpation or jaw movement.

Alternating pressure-like eye pain

Eye pain was described as a pressing feeling, irregularly alternating between left and right, also rated VAS 7–8.

Subjective pressure is not the same as elevated intraocular pressure. Recurrent severe eye pain may require visual acuity, visual field, intraocular pressure, and other ophthalmic evaluation; the source record did not include those results.

Eye and neurologic warning signs

Sudden vision loss or field change, severe redness with abrupt eye pain, double vision, difficulty looking at light, marked pain on eye movement, severe eye pain with headache, nausea or vomiting, facial or limb sensory change or weakness, slurred speech, or altered consciousness requires ophthalmic, neurologic, or emergency assessment first.

Neck and shoulder discomfort

Irregular pain in both posterior neck areas was rated VAS 4, with shoulder discomfort. The patient was unsure whether it related to the jaw or headache, and co-occurrence alone was not used to assign one cause.

Posture, muscle fatigue, cervical conditions, clenching, sleep, stress, and prolonged sitting may be relevant. Arm numbness, weakness, gait change, or severe post-traumatic neck pain requires separate medical evaluation.

Soft oral appliance without injection treatment

No injection was performed. After TMJ assessment, a soft oral appliance was made as the first treatment step and followed by conservative TMJ care. This was an individualized plan, not a general rule for pediatric-adolescent pain.

Several appliances from one digital design

Because frequent long-distance travel was difficult, stored digital oral data and one verified design were used with 3D printing to prepare several soft appliances of the same shape as backups for tearing or deformation.

The value of the digital workflow here was reproducibility and reduced interruption, not a claim that a digitally made appliance is inherently superior. Growth, tooth change, pain, sores, occlusal change, or a differently fitting backup requires stopping use and reassessment.

Improvement after appliance delivery can be recorded, but timing alone cannot prove that the appliance directly treated or prevented headache and eye pain. Clenching, sleep, natural variation, and other factors remain relevant.

Visit 2: no headache or eye pain

The caregiver said, “It is so good that for a week there was no talk of pain.” The patient also reported no head or eye pain at visit 2.

Caregiver observations about pain expression, sleep, eating, school, and daily activity can be useful in pediatric follow-up, but absence of verbal complaints does not objectively prove complete disappearance.

Posterior neck pain remained irregular at VAS 4, and the feeling of force in the jaw was unchanged. Thus headache and eye pain followed a different course from neck and jaw discomfort.

Jaw sound disappeared briefly and returned

The sound was absent Monday through Wednesday and returned Thursday evening. This did not prove that the joint improved and worsened again or that appliance use caused the timing; movement, food, clenching, posture, and fatigue can alter perceived sound.

Visit 3: left jaw sound and force sensation without pain

The patient localized the sound and force sensation to the left and said it was not pain. Persistent sound did not prove deterioration, while lack of pain did not make the functional sensation irrelevant.

The record did not state the status of headache, eye pain, or neck pain at visit 3, so continuation of earlier improvement was not assumed.

Visit 4: afternoon temple aching and appliance damage

About one month later, the patient still felt force in the jaw and developed bilateral temple aching around the afternoon at VAS 4. This was recorded separately from the irregular VAS 7–8 headache at the first visit.

The soft appliance had torn. On nights when it could not be worn, the patient sometimes experienced eye and temple pain. When a backup made from the same digital design was worn again, those symptoms disappeared.

The nonwear-recurrence and rewear-improvement pattern is clinically relevant, but it does not prove that the appliance was the sole preventive cause. Sleep clenching, sleep quality, fatigue, stress, and activity may also vary.

Handling a torn or deformed appliance

A damaged appliance can irritate teeth or gums or alter contacts. It should not be glued or used despite poor fit. A backup may be substituted only if it fits as expected; pain, sores, growth-related change, or occlusal change requires stopping use and contacting the clinic.

Visits 5 and 6

At visit 5, the patient simply said, “It does not hurt.” The body area was not specified, so the statement was not expanded to mean that every jaw, temple, eye, and neck symptom or appliance issue had resolved.

At visit 6, the patient reported no discomfort and good sleep. With current daily function stable, care ended after six visits, while recurrence of sounds, force sensation, temple, eye, or neck pain and sleep difficulty remained for observation.

Ending care meant active treatment was no longer judged necessary at that time; it did not mean cure or guaranteed long-term nonrecurrence.

When spinal alignment may also be assessed

In a young person with persistent neck, shoulder, or back pain that is not well explained, visible shoulder or waist asymmetry, one prominent scapula or rib area, or trunk lean can justify assessment for scoliosis and other alignment conditions.

Difficult-to-explain pain does not make scoliosis likely. Adolescent idiopathic scoliosis is often found without pain, while common muscle fatigue, activity, and posture can also produce neck and back pain.

How scoliosis is assessed

Standing examination compares head and trunk center, shoulders, scapulae, waist and pelvis, and forward bending for rib or back prominence.

When suspected, pediatric or orthopedic assessment may include growth and neurologic examination and a standing whole-spine radiograph with Cobb-angle measurement.

The attached image was not used here to make an arbitrary angle measurement or diagnosis. Night-waking or rapidly worsening pain, fever, weight loss, leg weakness or sensory change, gait change, or bowel-bladder change requires prompt medical evaluation.

Mandibular deviation and scoliosis: association is not causation

Observational studies have reported statistical associations between facial or mandibular asymmetry and spinal alignment, but results vary by population, asymmetry threshold, imaging method, and whether cervical deviation, thoracic midline deviation, or Cobb-defined scoliosis is measured.

Lee 2020 doctoral study

The Seoul National University study analyzed 171 mostly adult orthognathic-surgery patients, mean age 25.8 years, using facial CT, standing whole-spine AP radiographs, and cephalograms. It was not a general-population or pediatric pain cohort.

CT comparison used menton deviation over 3 degrees for asymmetry and under 1.5 degrees for nonasymmetry, excluding the intermediate group. Scoliosis was Cobb angle over 10 degrees.

Among 171 people, 30 had scoliosis (17.54%). CT-defined asymmetry groups differed in scoliosis prevalence, 24.56% (14/57) versus 11.11% (8/71), P=0.04, and mean Cobb angle 8.01 versus 6.62 degrees, P=0.03; both means were below 10 degrees.

Cephalogram-defined groups did not show significant differences: scoliosis 20.93% versus 10.53%, P=0.10, and mean Cobb 7.52 versus 7.09 degrees, P=0.49. CT menton deviation and Cobb angle had only a small correlation, R=0.169, P=0.02.

Because this was an observational, selected surgical cohort with intermediate groups excluded and method-dependent findings, it cannot show that mandibular deviation causes scoliosis or explain this patient's pain.

Other studies

A 2015 Seoul National University thesis of 326 cephalograms found significance using a 4-degree angular asymmetry threshold (P=0.026) but not a 4-mm distance threshold (P=0.638); thoracic Cobb angle was measured on chest radiographs, so lumbar curvature was unavailable.

Two Japanese retrospective studies in 2025 also diverged: facial asymmetry was associated with greater thoracic midline deviation but not a significant Cobb-angle difference in one study, while another found a positive association with cervical deviation.

These are different outcomes and should not be merged as scoliosis.

Visible facial, shoulder, or trunk asymmetry may justify standardized dental measurement and separate pediatric or orthopedic standing whole-spine assessment; the research does not replace diagnosis of the attached image.

Scoliosis cannot explain all headache and eye pain

Even when temple headache, eye pressure, neck and shoulder pain coexist, one spinal diagnosis cannot explain them all. VAS 7–8 head and eye pain still requires separate headache, ophthalmic, and neurologic assessment.

TMJ, eye, headache, neck, and spine assessments are complementary scopes, not substitutes for one another.

How jaw-related contribution was assessed

The question was not whether all head, eye, and neck pain came from the jaw, but whether symptoms changed reproducibly with jaw-use conditions after urgent and alternative causes were considered.

Assessment can include opening range and deviation, sound timing and locking, left joint and masseter-temporalis-neck tenderness, reproduction of temple pain, clenching and sleep habits, and symptom timelines by site.

Summary

The young patient traveled a long distance after medical evaluation and a reported normal MRI had not clarified severe bilateral temple pain and alternating eye pressure. Left jaw sound and force sensation were milder than the VAS 7–8 head and eye symptoms.

No injection was used. A soft digitally designed appliance and conservative care were provided, with several same-design backups prepared because frequent travel was difficult.

Headache and eye pain were absent at visit 2 while neck pain and jaw force sensation remained. Visit 4 documented temple pain with nonwear after appliance damage and improvement after backup use, without claiming proof.

Visits 5 and 6 recorded no pain or discomfort, and care ended after six visits.

The case supports careful symptom-by-symptom tracking and practical digital continuity, while preserving ophthalmic, neurologic, headache, neck, and spine boundaries and avoiding causal claims from treatment timing.

References and guidance

TMJ and headache references included DC/TMD (Schiffman et al., 2014; DOI 10.11607/jop.1151), NIDCR TMD guidance, the American Academy of Pediatric Dentistry policy on acquired TMD, and NHS eye-pain guidance.

Scoliosis guidance included AAOS information on idiopathic scoliosis and Scoliosis Research Society diagnostic guidance. Observational references were presented as association evidence only.

Additional facial-asymmetry and posture studies included Lee's 2020 SNU thesis, Park's 2015 SNU thesis, and studies on trunk, cervical, thoracic, and Cobb-angle relationships. Their differing methods and outcomes preclude a single causal conclusion.

Frequently asked questions

Did improvement after TMJ care prove the cause?

No. The timing supports considering a relationship, but cannot establish the TMJ as the sole cause. New warning signs or a different headache still require medical reassessment.

Does pressure around the eye mean high intraocular pressure?

Not necessarily. Subjective pressure and measured intraocular pressure are different; recurrent or severe eye pain should be assessed ophthalmically.

Why make several same-design soft appliances?

Long-distance travel made frequent replacement visits difficult. Verified digital data enabled backups to reduce interruption, but every backup still requires expected fit and reassessment if growth, tooth change, pain, sores, or occlusal change occurs.

Does pain on a night without the appliance prove it is essential?

No. The repeated timing is useful, especially with improvement after backup use, but sleep clenching, sleep quality, fatigue, stress, and other conditions must also be tracked.