Current pain and headache reports
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The purpose of this review is to provide an overview and update on the common causes of headache attributed to arterial hypertension with a focus on secondary headache disorders. We will also highlight uncommon and recent findings in this area of research. ⋯ There is some controversy in the relationship between chronic hypertension and headache, particularly migraine; recent research suggests that there may be a link, but it is likely complex and multifactorial. Many recent studies and case reports demonstrate that the pathophysiology underlying the onset of headache as it relates to abrupt rises in blood pressure seems to lie at the cellular level and mechanically becomes an issue with disruption of the blood-brain barrier. Although not a formally defined headache entity, carotid revascularization syndrome demonstrates this phenomenon and also has a recent set of proposed criteria that include headache and elevated blood pressure. This paper reviews the various etiologies of hypertensive headaches, mostly in regard to headache as a secondary symptom of elevated blood pressure. We will also discuss trends of hypertensive headache in pregnancy. Finally, we will touch on controversy that exists in relation to chronic hypertension and its causal relationship to headache as well as the relationship between hypertension and migraine.
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Enhanced recovery after surgery (ERAS) has become a widespread topic in perioperative medicine over the past 20 years. The goals of ERAS are to improve patient outcomes and perioperative experience, reduce length of hospital stay, minimize complications, and reduce cost. Interventions and factors before, during, and after surgery all potentially play a role with the cumulative effect being superior quality of patient care. ⋯ Preoperatively, patient and family education, optimization of nutritional status, and antibiotic prophylaxis all improve outcomes. Recovery is also expedited by the use of multimodal analgesia, regional anesthesia, and opioid reducing approaches. Intraoperatively, the anesthesiologist can have an impact by using less-invasive monitors appropriately to guide fluid and hemodynamic management as well as maintaining normothermia. Postoperatively, early enteral feeding, mobilization, and removal of invasive lines support patient recovery. Implementation of ERAS protocol in cardiac surgery faces challenges by some unique perioperative perspectives in cardiac surgery, such as systemic anticoagulation, use of cardiopulmonary bypass, significantly more hemodynamic variations, larger volume replacement, postoperative intubation and mechanical ventilation and associated sedation, and potentially significantly more co-existing morbidities than other surgical procedures. ERAS in cardiac surgery may benefit patients more related to its high risk and high cost nature. This manuscript specifically reviews the unique aspects of enhanced recovery in cardiac surgery.
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Curr Pain Headache Rep · Mar 2019
ReviewCurrent Approach to Undifferentiated Headache Management in the Emergency Department.
To discuss pharmacological interventions in the emergency department (ED) setting for the management of acute primary headache. ⋯ Acute headache treatment in the ED has seen an expansion in terms of possible pharmacological interventions in recent years. After a thorough evaluation ruling out dangerous causes of headache, providers should take the patient's history, comorbidities, and prior therapy into consideration. Antidopaminergics have an established role in the management of acute, severe, headache with manageable side-effect profiles. However, recent studies suggest anesthetic and anti-epileptic drugs may play roles in headache treatment in the ED. Current literature also suggest steroids as a promising tool for emergency department clinicians combating the readmission of patients with recurrent headaches. Emergency medicine providers must be cognizant of these traditional and emerging therapies in order to optimize the care of headache patients.
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Curr Pain Headache Rep · Mar 2019
ReviewSpinal Cord Stimulation: Comparing Traditional Low-frequency Tonic Waveforms to Novel High Frequency and Burst Stimulation for the Treatment of Chronic Low Back Pain.
The purpose of the present investigation is to summarize supporting evidence for novel sub-perception spinal cord stimulation (SCS) therapy over traditional paresthesia inducing low-frequency waveforms for the treatment of chronic pain. The focus of this review is to summarize key studies comparing traditional low-frequency tonic waveforms to modern high frequency and burst stimulation for the treatment of patients with chronic intractable low back pain and/or leg pain. ⋯ Several recent studies have demonstrated the benefit of novel SCS therapies over traditional low-frequency SCS for the treatment of patients with chronic low back and/or leg pain. SENZA-RTC showed that paresthesia-free high-frequency SCS was superior to low-frequency stimulation for treatment of chronic low back pain with leg pain. The SUNBURST crossover trial recently found that high-frequency burst stimulation was preferred over low-frequency tonic SCS with patients citing better pain relief and a preference for paresthesia-free SCS. The new ongoing EVOLVE workflow retrospective multicenter study uses technology that can deliver both low-dose and high-dose SCS. Further, the wavewriter technology addresses patient variability with its ability to layer sub-perception waveforms and paresthesia inducing low-frequency stimulation tailored to patient needs via an interactive feedback feature. Neuromodulation for the treatment of chronic pain is rapidly evolving with technology at its forefront. Modern SCS systems use novel waveforms, frequencies, and stimulation modes to deliver paresthesia-free pain relief to patients suffering from chronic low back pain and/or leg pain with better results than traditional tonic low-frequency SCS. As the field advances, new studies are needed comparing new waveform and delivery systems to optimize patient selection and treatment response.
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Curr Pain Headache Rep · Mar 2019
ReviewLow Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment.
Low back pain encompasses three distinct sources: axial lumbosacral, radicular, and referred pain. Annually, the prevalence of low back pain in the general US adult population is 10-30%, and the lifetime prevalence of US adults is as high as 65-80%. ⋯ Patient history, physical exam, and diagnostic testing are important components to accurate diagnosis and identification of patient pathophysiology. Etiologies of low back pain include myofascial pain, facet joint pain, sacroiliac joint pain, discogenic pain, spinal stenosis, and failed back surgery. In chronic back pain patients, a multidisciplinary, logical approach to treatment is most effective and can include multimodal medical, psychological, physical, and interventional approaches. Low back pain is a difficult condition to effectively treat and continues to affect millions of Americans every year. In the current investigation, we present a comprehensive review of low back pain and discuss associated pathophysiology, diagnosis, and treatment.