Current pain and headache reports
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Curr Pain Headache Rep · Jul 2019
ReviewLinking Traumatic Brain Injury, Sleep Disruption and Post-Traumatic Headache: a Potential Role for Glymphatic Pathway Dysfunction.
Traumatic brain injury (TBI) is a major public health concern in the USA and worldwide. Sleep disruption and headaches are two of the most common problems reported by patients after TBI. In this manuscript, we review the current knowledge regarding the relation between post-traumatic sleep disruption and headaches. We also describe the role of the glymphatic system as a potential link between TBI, sleep, and headaches. ⋯ Recent studies show a reciprocal relation between post-traumatic sleep disruption and headaches: patients with sleep disruption after TBI report more headaches, and post-traumatic headaches are a risk factor for developing disrupted sleep. Despite this clinical association, the exact mechanisms linking post-traumatic sleep disruption and headaches are not well understood. The glymphatic pathway, a newly described brain-wide network of perivascular spaces that supports the clearance of interstitial solutes and wastes from the brain, is active primarily during sleep, and becomes dysfunctional after TBI. We propose a model where changes in glymphatic function caused by TBI and post-traumatic sleep disruption may impair the clearance of neuropeptides involved in the pathogenesis of post-traumatic headaches, such as CGRP. The relation between TBI, post-traumatic sleep disruption, and post-traumatic headaches, although well documented in the literature, remains poorly understood. Dysfunction of the glymphatic system caused by TBI offers a novel and exiting explanation to this clinically observed phenomenon. The proposed model, although theoretical, could provide important mechanistic insights to the TBI-sleep-headache association.
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Curr Pain Headache Rep · Jul 2019
ReviewTreatment Strategies and Effective Management of Phantom Limb-Associated Pain.
Phantom sensations are incompletely understood phenomena which take place following an amputation or deafferentation of a limb. They can present as kinetic, kinesthetic, or exteroceptive perceptions. It is estimated that phantom limb pain (PLP) affects anywhere from 40 to 80% of amputees. ⋯ Psychiatric illnesses such as depression, anxiety, and mood disorders have higher prevalence in amputees than in the general population. Pharmacologic treatment has been used as first-line therapy for amputees suffering from PLP with agents including gabapentinoids, amitriptyline, and other tricyclic anti-depressants, opioids, and local anesthetics. Non-invasive treatment modalities exist for PLP including sensory motor training, mirror visual therapy, and non-invasive neuromodulation. Non-invasive neuromodulation includes interventions like transcutaneous electrical nerve stimulation (TENS) and transcranial magnetic stimulation. While many promising therapies for PLP exist, more clinical trials are required to determine the efficacy and protocols needed for maximum benefit in patients suffering from PLP.
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Curr Pain Headache Rep · Jul 2019
ReviewChronic Headache: a Review of Interventional Treatment Strategies in Headache Management.
To provide an overview of current interventional pain management techniques for primary headaches with a focus on peripheral nerve stimulation and nerve blocks. ⋯ Despite a plethora of treatment modalities, some forms of headaches remain intractable to conservative therapies. Interventional pain modalities have found a niche in treating headaches. Individuals resistant to common regimens, intolerant to pharmaceutical agents, or those with co-morbid factors that cause interactions with their therapies are some instances where interventions could be considered in the therapeutic algorithm. In this review, we will discuss these techniques including peripheral nerve stimulation, third occipital nerve block (TON), lesser occipital nerve block (LON), greater occipital nerve block (GON), sphenopalatine block (SPG), radiofrequency ablation (RFA), and cervical epidural steroid injections (CESI). Physicians have used several interventional techniques to treat primary headaches. While many can be treated pharmacologically, those who continue to suffer from refractory or severe headaches may see tremendous benefit from a range of more invasive treatments which focus on directly inhibiting the painful nerves. While there is a plethora of evidence suggesting these methods are effective and possibly durable interventions, there is still a need for large, prospective, randomized trials to clearly demonstrate their efficacy.
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Curr Pain Headache Rep · Jul 2019
ReviewStem Cell Therapies for Treatment of Discogenic Low Back Pain: a Comprehensive Review.
Discogenic low back pain (DLBP) stems from pathology in one or more intervertebral discs identified as the root cause of the pain. It is the most common type of chronic low back pain (LBP), representing 26-42% of attributable cases. ⋯ The clinical presentation of DLBP includes increased pain when sitting, coughing, or sneezing, and experiencing relief when standing or ambulating. Dermatomal radiation of pain to the lower extremity and neurological symptoms including numbness, motor weakness, and urinary or fecal incontinence are signs of advanced disease with disc prolapse, nerve root compression, or spinal stenosis. Degenerative disc disease is caused by both a decrease in disc nutrient supply causing decreased oxygen, lowered pH, and lessened ability of the intervertebral disc (IVD) to respond to increased load or injury; moreover, changes in the extracellular matrix composition cause weakening of the tissue and skewing the extracellular matrix's (ECM) harmonious balance between catabolic and anabolic factors for cell turnover in favor of catabolism. Thus, the degeneration of the disc causes a shift from type II to type I collagen expression by NP cells and a decrease in aggrecan synthesis leads to dehydrated matrix cells ultimately with loss of swelling pressure needed for mechanical support. Cell-based therapies such as autologous nucleus pulposus cell re-implantation have in animal models and human trials shown improvements in LBP score, retention of hydration in IVD, and increased disc height. Percutaneously delivered multipotent mesenchymal stem cell (MSC) therapy has been proposed as a potential means to uniquely ameliorate discogenic LBP holistically through three mechanisms: mitigation of primary nociceptive disc pain, slow or reversal of the catabolic metabolism, and restoration of disc tissue. Embryonic stem cells (ESCs) can differentiate into cells of all three germ layers in vitro, but their use is hindered related to ethical concerns, potential for immune rejection after transplantation, disease, and teratoma formation. Another similar approach to treating back pain is transplantation of the nucleus pulposus, which, like stem cell therapy, seeks to address the underlying cause of intervertebral disc degeneration by aiming to reverse the destructive inflammatory process and regenerate the proteoglycans and collagen found in healthy disc tissue. Preliminary animal models and clinical studies have shown mesenchymal stem cell implantation as a potential therapy for IVD regeneration and ECM restoration via a shift towards favorable anabolic balance and reduction of pain.
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Curr Pain Headache Rep · Jul 2019
Review Case ReportsPresentation and Management of Headache in Pituitary Apoplexy.
Pituitary apoplexy (PA) occurs in the setting of an infarction and/or hemorrhage of a pre-existing adenoma. The most common presenting symptom is a severe, sudden onset headache. However, the characteristics of headache in the setting of PA are varied and can sometimes mimic primary headache disorders. The purpose of this article is to review the various presentations of headache in PA. We also outline treatment options for persistent headaches following PA. ⋯ A recent retrospective review of patients undergoing transsphenoidal resection of sellar lesions, including PA, found that gross total resection and short duration of preoperative headache were predictors of improvement in headaches postoperatively. This strengthens the importance of timely recognition of PA as potential etiology of headache. The most common presentation of PA is thunderclap headache; however, several other primary HA disorders have been described including status migraine, SUNCT, and paroxysmal hemicrania.