Current pain and headache reports
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Curr Pain Headache Rep · Jul 2021
ReviewKetamine in the Past, Present, and Future: Mechanisms, Metabolites, and Toxicity.
While ketamine's analgesia has mostly been attributed to antagonism of N-methyl-D-aspartate receptors, evidence suggests multiple other pathways are involved in its antidepressant and possibly analgesic activity. These mechanisms and ketamine's role in the nociplastic pain paradigm are discussed. Animal studies demonstrating ketamine's neurotoxicity have unclear human translatability and findings from key rodent and human studies are presented. ⋯ Ketamine's metabolites, and (2R,6R)-hydroxynorketamine in particular, may play a greater role in its clinical activity than previously believed. The activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and the mammalian target of rapamycin by ketamine are mechanisms that are still being elucidated. Ketamine might work best in nociplastic pain, which involves altered pain processing. While much is known about ketamine, new studies will continue to define its role in clinical medicine. Evidence supporting ketamine's neurotoxicity in humans is lacking and should not impede future ketamine clinical trials.
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Chronic pain is highly prevalent in patients with rheumatoid arthritis (RA) and can cause various physical and psychological impairments. Unfortunately, the appropriate diagnosis of chronic pain syndromes in this population can be challenging because pain may be primary to RA-specific inflammation and/or secondary to other conditions, typically osteoarthritis (OA) and fibromyalgia (FM). This disparity further poses a clinical challenge, given that chronic pain can often be discordant or undetected with standard RA-specific surveillance strategies, including serological markers and imaging studies. In this review, we provide a robust exploration of chronic pain in the RA population with emphasis on epidemiology, mechanisms, and management strategies. ⋯ Chronic pain associated with RA typically occurs in patients with anxiety, female sex, and elevated inflammatory status. Up to 50% of these patients are thought to have chronic pain despite appropriate inflammatory suppression, typically due to peripheral and central sensitization as well as secondary OA and FM. In addition to the standard-of-care management for OA and FM, patients with RA and chronic pain benefit from behavioral and psychological treatment options. Moreover, early and multimodal therapies, including non-pharmacological, pharmacological, interventional, and surgical strategies, exist, albeit with varying efficacy, to help suppress inflammation, provide necessary analgesia, and optimize functional outcomes. Overall, chronic pain in RA is a difficult entity for both patients and providers. Early diagnosis, improved understanding of its mechanisms, and initiation of early, targeted approaches to pain control may help to improve outcomes in this population.
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We define dehydration and its relationship to pain physiology including both primary and secondary headache disorders. ⋯ Intravenous fluids administered for acute migraine attacks in an emergency department setting have not been shown to improve pain outcomes. However, increased intravascular volume before diagnostic lumbar puncture may reduce the frequency of post-lumbar puncture headache from iatrogenic spinal fluid leak. Maintenance of euhydration can help treat orthostatic and "coat-hanger" headache due to autonomic disorders. Similarly, prevention of fluid losses can mitigate secondary headaches provoked by dehydration such as cerebral venous thrombosis or pituitary apoplexy. Dehydration alone may cause headache, but oftentimes exacerbates underlying medical conditions such as primary headache disorders or other conditions dependent on fluid balance.
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Curr Pain Headache Rep · Jul 2021
ReviewHIV Neuropathy-a Review of Mechanisms, Diagnosis, and Treatment of Pain.
This article is a systematic review of data from 2018 to 2020 regarding information from publications on epidemiologic, diagnostic, and therapeutic advancements in human immunodeficiency virus-associated peripheral neuropathy. ⋯ The epidemiology/pathology of HIV neuropathy is discussed. Diagnostics includes skin wrinkling-eutectic mixture of local anesthetic test and neurologic examinations. Therapeutic interventions include pharmacologic and nonpharmacologic management as well as self-management strategies. Peripheral neuropathy continues to affect the lives of persons living with HIV. First-line treatment with pregabalin or gabapentin for HIV neuropathic pain has limited data on adequate response. Exercise and self-management strategies may provide benefit in pain reduction. Continuing research on risk factors and biomarkers for HIV-related peripheral neuropathy will be critical for future diagnostic and therapeutic agents.
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Curr Pain Headache Rep · Jun 2021
Review Case ReportsThe Diagnosis and Management of Posttraumatic Headache with Associated Painful Cranial Neuralgias: a Review and Case Series.
Cranial neuralgias are common in the setting of posttraumatic headache. They may exacerbate underlying primary headache disorders and therefore may be overlooked in clinical practice. Frequently, cranial neuralgias generate neuropathic symptoms such as lancinating pain and sensory dysesthesias. Cranial neuralgias are identified based on a clinical history of focal neuropathic pain and physical exam findings including tenderness with palpation and percussion, at times eliciting radiating pain or paresthesias in the corresponding sensory nerve distribution. ⋯ Two patients presented with headaches that met criteria for posttraumatic headache, but their history and physical examination suggested the presence of a focal painful cranial neuralgia. One patient was diagnosed with auriculotemporal neuralgia, which was exquisitely responsive to an auriculotemporal nerve block. The second patient was diagnosed with supratrochlear neuralgia, which was effectively treated with a supratrochlear nerve block. In both cases, adequate treatment of the painful cranial neuralgia resulted in significant improvement of the baseline PTH. Painful cranial neuralgias frequently occur within the clinical spectrum of posttraumatic headache, but are often undiagnosed. Treatment options for painful cranial neuralgias are often different than those traditionally employed for posttraumatic headache without cranial neuralgias, which can include peripheral nerve blockade, neuropathic medications, and in refractory cases, peripheral nerve decompression surgery.