Current pain and headache reports
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This review is intended to help the headache physician think through and plan for management issues concerning the use of opioids. We ask the headache physician to consider if there are instances where prescribing or continuing prescriptions of opiates is plausible, and if so, how can the physician proceed as safely as possible. Our goal is to start a conversation regarding the inevitable encounter with a patient on opiates or requesting opiates. ⋯ The use of opiates in our society has reached a crisis in staggering death and addiction rates. Recent guideline published by the CDC can assist us in developing an algorithmic approach towards opiate use. Recent advances in addiction medicine can also assist us in protecting our patients. Every headache physician will undoubtedly encounter patients on opiates. There still are appropriate reasons to treat patients with opiates. Every headache physician may need to prescribe opiates and they may be indicated. It is important to learn the correct way to approach, manage, and treat patients on opiates.
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External nasal neuralgia is a rare syndrome of atypical facial pain for which there is limited reports in the scientific literature. We aim to review diagnosis and provide an update on treatments for this rare condition. ⋯ Etiology has been documented as post-traumatic due to direct trauma to the nose area and in few case reports, idiopathic. Sensory innervation of the nose arises from the ophthalmic and maxillary divisions of the trigeminal nerve. Direct injury to the nerve appears to be the etiology of post-traumatic external nasal neuralgia. Pathophysiology for idiopathic nasal neuralgia is poorly understood but it appears to be of a central etiology given lack of response to intranasal anesthetics. Pain can be episodic with episodes of tingling sensation lasting up to 30 min, two to three times per day, but for some patients it can be constant bruised sensation of mild to moderate pain. Diagnostic workup including magnetic resonance imaging of brain and computerized tomography of the sinuses are usually negative, but there have been few cases of a nasal contact point. Routine blood work including erythrocyte sedimentation rate is negative. Treatment for this rare condition is varied with very few patients responding to tricyclic antidepressants, specifically amitriptyline. Another medication used as prevention is pregabalin with good results as well. Most patients respond to nerve blockade with local anesthetic to the external nasal nerve and sphenopalatine ganglion block and radiofrequency ablation. More reports of this condition need to be published in the scientific literature to assist with proper diagnosis and treatment of this condition.