Current pain and headache reports
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Curr Pain Headache Rep · Feb 2002
ReviewThe psychopharmacologic treatment of depression and anxiety in the context of chronic pain.
Chronic pain afflicts millions of people, commonly causing depression and anxiety. These conditions must be treated to achieve a good functional outcome from pain treatment. ⋯ Antidepressants with noradrenergic and serotinergic activity, and anticonvulsants, which may also stabilize mood, are effective in neuropathic pain. Other medications have limited but important pharmacotherapeutic roles.
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Curr Pain Headache Rep · Feb 2002
ReviewHow could the validity of the DSM-IV pain disorder be improved in reference to the concept that it is supposed to identify?
This article examines the dilemmas inherent in psychiatry's attempts to incorporate pain disorders into the standard psychiatric nomenclature. Each succeeding Diagnostic and Statistical Manual has broadened the concept of pain disorders, and, gradually, the diagnosis has become increasingly removed from the original idea of "psychogenic pain." The advantage of this broadening has been the increased use of the diagnosis in clinical settings. ⋯ After examining this problem, the article looks at some alternative models, and offers some generalizations regarding the dimensions of the pain experience. The article ends by tentatively offering some suggestions for future approaches to pain diagnoses in psychiatry.
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This last decade has seen remarkable progress made toward unraveling the mystery of primary headache disorders like migraine and cluster. The vascular theory has been superseded by recognition that neurovascular phenomena seem to be the permissive and triggering factors in migraine and cluster headache. ⋯ Prior to these imaging techniques it was impossible to study the primary headache disorders because these had no structural basis. There is now an increasing body of evidence that the brain is involved primarily in cluster and migraine and that vessel dilatation is an epiphenomenon.
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The design and execution of clinical trials poses special problems for cluster headache. Although there is less inter-individual and intra-individual variability of attacks than seen with migraine, the brevity of attacks, spontaneous remissions unrelated to treatment, and the relative rarity of cluster headaches challenge investigators. The International Headache Society has developed guidelines that represent a compromise between scientific rigor and practicality. Only injectable sumatriptan for acute attacks and verapamil for prophylaxis have demonstrated a robust therapeutic effect in controlled clinical trials.
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Cluster headache is the most painful of the primary headache disorders and elucidating pathophysiology and treatment for this disorder is crucial. There is justification for studying attacks untreated, and even for precipitating these attacks. Placebo-controlled studies should only be undertaken for regulatory purposes; otherwise, active control should be used.