Current pain and headache reports
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The opioid crisis most likely is the most profound public health crisis our nation has faced. In 2015 alone, 52,000 people died of drug overdoses, with over 30,000 of those people dying from opioid drugs. A recent community forum led by the Cleveland Clinic contrasted this yearly death rate with the loss of 58,000 American lives in 4 years of the Vietnam War. The present review describes the origins of this opioid epidemic and provides context for our present circumstances. ⋯ Alarmingly, the overwhelming majority of opioid abusers begin their addiction with prescription medications, primarily for chronic pain. Chronic postoperative pain, which occurs in 10-50% of surgical patients, is a major concern in many types of surgery. Nationwide, the medical community has made it a priority to ensure that postsurgical analgesia is sufficient to control pain without increasing non-medically appropriate opioid use. The opioid epidemic remains a significant pressing issue and will not resolve easily. Numerous factors, including the inappropriate prescription of opioids, lack of understanding of the potential adverse effects of long-term therapy, opioid misuse, abuse, and dependence, have contributed to the current crisis.
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Headache phenotypes can differ between adults and children. While most headaches are due to primary headache disorders, in a small population, they can be an indication of a potentially life-threatening neurologic condition. The challenge lies in identifying warning signs that warrant further workup. This article reviews different types of pediatric headaches and headache evaluation in children and teens, and focuses on the approach for diagnosis of secondary headaches. ⋯ Common thought is that increased frequency and severity of headache may reflect secondary pathology; however, headache phenotype may not be fully developed and can evolve in adolescence or adulthood. Headache location, particularly occipital headache alone, does not necessarily signify secondary intracranial pathology. Certain warning signs warrant neuroimaging, but others only warrant imaging in certain clinical contexts. Brain MRI is the neuroimaging modality of choice, though there is a high rate of incidental findings and often does not change headache management. A stepwise approach is essential to avoid missing secondary headaches. There are several differences between adults and children in clinical manifestations of headache. Evaluation and diagnosis of pediatric headache starts with a thorough headache and medical history, family and social history, and identification of risk factors. A thorough physical and neurologic exam is important, with close attention to features that could suggest secondary headache pathology. Neuroimaging and other testing should only be performed if there is concern for secondary headache.
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Curr Pain Headache Rep · Feb 2018
ReviewMigraine and Autonomic Dysfunction: Which Is the Horse and Which Is the Jockey?
Symptoms of autonomic dysfunction are common in patients with migraine, both during and between migraine attacks. Studies evaluating objective autonomic testing in patients have found significant, though somewhat conflicting results. The purposes of this review are to summarize and interpret the key findings of these studies, including those evaluating heart rate variability, autonomic reflex testing, and functional imaging in patients with migraine. The neuroanatomy of the central autonomic network as it relates to migraine is also reviewed. ⋯ Several studies have evaluated autonomic balance in migraineurs, with conflicting results on the magnitude of sympathetic versus parasympathetic dysfunction. Most studies demonstrate sympathetic impairment, with a lesser degree of parasympathetic impairment. Three trends have emerged: (1) migraine with aura tends to produce more significant autonomic dysfunction than migraine without aura, (2) sympathetic impairment is more common than parasympathetic impairment, and (3) sympathetic impairment is common in the interictal period, with increased sympathetic responsiveness during the ictal period, suggesting adrenoreceptor hypersensitivity.
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Curr Pain Headache Rep · Feb 2018
ReviewChronification of Pain: Mechanisms, Current Understanding, and Clinical Implications.
The development of acute to chronic pain involves distinct pathophysiological changes in the peripheral and central nervous systems. This article reviews the mechanisms, etiologies, and management of chronic pain syndromes with updates from recent findings in the literature. ⋯ Chronic post-surgical pain (CPSP) is not limited to major surgeries and can develop after smaller procedures such as hernia repairs. While nerve injury has traditionally been thought to be the culprit for CPSP, it is evident that nerve-sparing surgical techniques are not completely preventative. Regional analgesia and agents such as ketamine, gabapentinoids, and COX-2 inhibitors have also been found to decrease the risks of developing chronic pain to varying degrees. Yet, given the correlation of central sensitization with the development of chronic pain, it is reasonable to utilize aggressive multimodal analgesia whenever possible. Development of chronic pain is typically a result of peripheral and central sensitization, with CPSP being one of the most common presentations. Using minimally invasive surgical techniques may reduce the risk of CPSP. Regional anesthetic techniques and preemptive analgesia should also be utilized when appropriate to reduce the intensity and duration of acute post-operative pain, which has been correlated with higher incidences of chronic pain.
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Curr Pain Headache Rep · Feb 2018
ReviewIntrathecal Drug Delivery and Spinal Cord Stimulation for the Treatment of Cancer Pain.
The purpose of the present investigation is to summarize the body and quality of evidence including the most recent studies in support of intrathecal drug delivery systems and spinal cord stimulation for the treatment of cancer-related pain. ⋯ In the past 3 years, a number of prospective studies have been published supporting intrathecal drug delivery systems for cancer pain. Additional investigation with adjuvants to morphine-based analgesia including dexmedetomidine and ziconotide support drug-induced benefits of patient-controlled intrathecal analgesia. A study has also been recently published regarding cost-savings for intrathecal drug delivery system compared to pharmacologic management, but an analysis in the Ontario, Canada healthcare system projects additional financial costs. Finally, the Polyanalgesic Consensus Committee has updated its recommendations regarding clinical guidelines for intrathecal drug delivery systems to include new information on dosing, trialing, safety, and systemic opioid reduction. There is still a paucity of clinical evidence for spinal cord stimulation in the treatment of cancer pain. There are new intrathecal drugs under investigation including various conopeptides and AYX1. Large, prospective, modern, randomized controlled studies are still needed to support the use of both intrathecal drug delivery systems as well as spinal cord stimulation for cancer pain populations. There are multiple prospective and small randomized controlled studies that highlight a potential promising future for these interventional modalities. Related to the challenge and urgency of cancer pain, the pain practitioner community is moving toward a multimodal approach that includes discussions regarding the role of intrathecal therapies and spinal cord stimulation to the individualized treatment of patients.