Current pain and headache reports
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Clinicians currently base decisions regarding the use of intrathecal drug therapy for chronic pain on reports from uncontrolled and retrospective studies that fail to rely on standardized outcome measures. In this article, we summarize what is known about currently administered intrathecal therapies, including opioids, gamma-aminobutyric acid agonists, alpha-2 adrenoreceptor agonists, local anesthetics (sodium channel antagonists), calcium channel antagonists, miscellaneous agents, and drug combination therapy. In addition, we offer a brief look at novel approaches that may revolutionize intrathecal drug delivery.
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Although possessing a long history of use, the therapeutic use of epidural steroid injections still needs substantiation. Refinements in our understanding of the pathophysiology of radicular pain and in the techniques used to deliver depo-steroids to the target tissue will lead to improved clinical outcomes and fewer technique and drug-related side effects. Administration of epidural steroids at lumbar spine sites is more common than at cervical spine levels, although the same pain management concepts are applicable. Comparative studies are necessary to clearly define the advantages and disadvantages of the use of fluoroscopy and the transforaminal technique.
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With an increased knowledge of neural anatomy and technologic improvement, radiofrequency ablation (RFA) became an often-used technique for the pain control over an extended time period. Today, RFA is used safely for spinal pains of facet or discogenic origin, sympathetically maintained pain, and other pains of neural origin.
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Chronic daily headache (CDH), an almost continual headache in the absence of organic pathology, is an exceptionally challenging type of headache to treat in children and adolescents. CDH has different expressions in children and adults; the different expressions may reflect several different etiologies or a developmental continuum. Although a positive family history predisposes children to develop headache, many environmental, biological, and psychological processes may share a role in the etiology. ⋯ Although many drug and nondrug therapies are available for treating children's headache, we lack data about which therapies are best for children with CDH or its subtypes. The current principles guiding our management of CDH in children and adolescents are extrapolated from the existing literature on childhood headache, CDH in adults, and our clinical experience. A child-centered focus is particularly important in the treatment of CDH because it is not caused by an underlying disease or disorder.