Current pain and headache reports
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Curr Pain Headache Rep · Feb 2009
ReviewChronic migraine: current pathophysiologic concepts as targets for treatment.
Chronic daily headache (CDH) affects approximately 4% of the population and exerts a significant degree of disability on its sufferers. Chronic migraine (CM) is a subset of CDH that represents migraine without aura occurring on 15 or more days per month for at least 3 months. Although numerous risk factors are associated with the development of CM, the pathophysiology governing its genesis is largely unknown. The role of neurotransmitters, such as glutamate, as well as disruptions of antinociceptive systems and structures, are implicated in CM and are supported by the fact that treatments targeting these abnormalities are effective.
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The chronicity of pain is the feature of pain that is least understood and most directly linked with our inability to effectively manage pain. Acute pain is relatively responsive to our current pharmacologic and interventional armamentarium. However, as pain persists, our ability to treat effectively diminishes and the patient's frustration and resource utilization increases. This article explores our current understanding of the factors linked to pain duration and the transition from acute to chronic pain in both human and animal models, and across a spectrum of human chronic pain conditions.
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At least half of women migraineurs experience menstrual migraine (MM), suggesting a hormonal explanation for the incidence of these headaches. Basic science efforts suggest a relationship between estrogen and the neurotransmitters and neuronal structures critical in the pathophysiology of migraine. ⋯ Triptans have been shown to be effective as both an abortive and short-term preventive treatment, and estradiol has been shown to be an effective short-term preventive treatment. Ergotamines, combinations of drugs such as sumatriptan-naproxen sodium, and rizatriptan with dexamethasone show promise in the treatment of MM.
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Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are two noninvasive brain stimulation techniques that can modulate activity in specific regions of the cortex. At this point, their use in brain stimulation is primarily investigational; however, there is clear evidence that these tools can reduce pain and modify neurophysiologic correlates of the pain experience. ⋯ Furthermore, TMS and tDCS can be applied with other techniques, such as event-related potentials and pharmacologic manipulation, to illuminate the underlying physiologic mechanisms of normal and pathological pain. This review presents a description and overview of the uses of two major brain stimulation techniques and a listing of useful references for further study.
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Curr Pain Headache Rep · Feb 2009
Comment Review Comparative StudyEpidural steroid injections are useful for the treatment of low back pain and radicular symptoms: con.
Lumbar epidural steroid injections are commonly performed in the United States for treating radicular low back pain. However, the best available data suggest that the benefit afforded by these injections is quite limited; in fact, new data suggest that in geographic areas where many such injections are performed, more and not fewer spine surgeries are actually completed annually. We suggest that further high-quality studies are required and their results respected through their implementation in daily practice to better ensure that only appropriate patients are advised to undergo this procedure.