Current pain and headache reports
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Curr Pain Headache Rep · Feb 2003
Review Comparative StudyAntidepressants for chronic neuropathic pain.
Tricyclic antidepressants have been used to manage pain for several decades, and are superior treatments for some patients suffering from neuropathic pain. Unfortunately, older antidepressants have dose-limiting side effects that can lead to drug intolerance. The most common are anticholinergic side effects, although some patients experience sexual dysfunction. ⋯ Taking an overdose of tricyclic antidepressants can be lethal in overdose. Several weeks of therapy may be required before antinociception occurs, but tricyclic antidepressants in optimal doses appear to be the most effective treatment for neuropathic pain; this is supported by systematic reviews comparing them with other agents. Newer medications such as atypical antidepressants and anticonvulsants may be overtaking older antidepressants, but they should not be overlooked as important options for the management of pain.
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Antidepressants, particularly tricyclic antidepressants, have been a mainstay in the prophylactic therapy of migraine. The tricyclic antidepressants amitriptyline, nortriptyline, and doxepin have been the major agents for prophylactic treatment of migraine. ⋯ The high-affinity selective serotonin reuptake inhibitors and other newer antidepressants have been disappointing and much less effective in the treatment of migraine. In patients who are depressed with severe migraine, a tricyclic antidepressant may treat both conditions; however, the addition of a newer atypical antidepressant may be needed.
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A greater understanding of the mechanisms that produce chronic pain states has led to a search for novel agents with the potential to produce analgesia by directly modulating specific processes involved in the transduction, transmission, modulation, perception, and encoding of pain. It is hoped that compounds directed at these specific targets will produce better analgesics with an improved side-effect profile. ⋯ In addition, these compounds have demonstrated the ability to prevent the development of tolerance to opioid analgesic therapy. This has led to investigations of therapies that combine an opioid agonist with an N-methyl-D-aspartate receptor antagonist.
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Chronic low back pain is one of the most common ailments in modern medicine, with as many as 79% of patients with acute pain continuing to suffer with chronic or recurrent low back pain 1 year after its onset. Lumbar epidural fibrosis and post-lumbar laminectomy syndrome are increasingly recognized as being responsible for persistent low back pain. ⋯ Epidural adhesiolysis with myeloscopy is an interventional technique based on the premise that the three-dimensional visualization of the contents of the epidural space provides the physician with the ability to directly visualize the structures, perform appropriate adhesiolysis, and administer drugs specifically to the target. This review describes pathophysiologic aspects, purposes and goals, rationale and indications, complications, and effectiveness of epidural lysis of adhesions with myeloscopy.
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Curr Pain Headache Rep · Dec 2002
ReviewCognitive-behavioral issues in the treatment and management of chronic daily headache.
Chronic daily headache is a heterogeneous group of daily or near-daily headaches that afflicts close to 5% of the general population and accounts for close to 35% to 40% of patients at headache centers. First-line drug or cognitive-behavioral therapies administered alone have minimal impact on reducing the frequency or severity of headaches. ⋯ Cognitive-behavioral therapies focus on preventing mild pain from becoming disabling pain, improving headache-related disability, affective distress, and quality of life, and reducing overreliance on medication. For cognitive-behavioral therapies to be effective, it is important to address complicating factors, including medication overuse, psychiatric comorbidity, stress and poor coping, and sleep disturbance.