The Clinical journal of pain
-
In some forms of cerebrovascular disease, such as intracranial hemorrhage, headaches are well known as a prominent symptom and often are a valuable clue to diagnosis. There are difficulties, sometimes, in distinguishing between a small subarachnoid hemorrhage and a severe migraine headache, but these can be resolved using clinical observations, CT scan, and lumbar puncture. It seems less well known that headaches may accompany or precede cerebral thrombosis and embolism. When these headaches are recognized as a forerunner to stroke, they may allow an opportunity for preventive treatment.
-
Healing or successful intervention usually leads to the resolution of pain. However, in some patients biologic or psychologic symptoms associated with pain persist despite treatment or apparent healing. In cases in which the etiology is not known, persistent pain is categorized as a clinical syndrome known as "chronic pain." Organic, psychologic, and socioenvironmental factors contribute to the development of chronic pain. ⋯ Before successful management can begin, the major etiologic factors and sequelae of the chronic pain syndrome must be understood. Antidepressants, neuroleptics, anticonvulsants, nonsteroidal anti-inflammatory drugs, and hydroxyzine have been proven effective in the treatment of pain syndromes. The treatment of patients who present with chronic pain must be individualized based on a comprehensive understanding of the factors underlying the chronic pain syndrome of each patient.
-
A significant percentage of chronic headache sufferers use excessive quantities of substances for relief. Drug dependency is frequent in these patients. Patients have an impaired lifestyle, sustain organ system damage, may suffer a withdrawal syndrome, and continue to have headaches. ⋯ The mechanism of substance abuse may be related to repeated use of substances that reinforce behavior and stimulate brain reward systems. Treatment includes comprehensive diagnostic workup, withdrawal of the agent, and use of headache preventives. beta-Adrenergic blockers, tricyclic antidepressants, monoamine oxidase (MAO) inhibitors, and nonsteroidal anti-inflammatory agents may be of value. Behavior modification and dietary counseling are also helpful.
-
An updated review of patient-controlled analgesia (PCA) for acute pain relief in the postoperative period is presented. The technique, becoming more and more popular with patients, surgeons, and nurses, is undergoing numerous clinical trials under a variety of clinical protocols that are currently being reviewed. Benefits found with PCA include the fact that it is individualized therapy, allowing optimum drug titration; it decreases a patient's anxiety in the postoperative period; and it is a safer and more efficient technique of acute pain relief than conventional therapy. ⋯ Contraindications to the technique and most current equipment in use are listed herein. Clinical experience with PCA at Georgetown University Medical Center has provided, as has been the case elsewhere, data showing the superiority of the technique and its wide acceptance as part of the Acute Pain Service. The anesthesiologist plays a vital role in coordinating the various people and aspects involved in PCA for postoperative pain relief.