Types of pain - Padda Institute Center for Interventional Pain Management

Diabetes and Neuropathy

Diabetic Peripheral Neuropathy (DPN) is the most common complication of diabetes, and often presents as a distal, symmetric, sensorimotor neuropathy. In the United States, 26.8 million people are affected by diabetes; by the year 2030, that number is predicted to increase to approximately 35.9 million people.

In the U.S. alone, the annual total direct medical and treatment costs of diabetes were an estimated $44 billion in 1997, representing 5.8 percent of total personal healthcare expenditures during that year. When it comes to diabetic peripheral neuropathy and its complications, management is resource intensive and long-term, accounting for a large proportion of this total expenditure. In 2001, the total annual cost of diabetic peripheral neuropathy and its complications in the U.S. was estimated to be between $4.6 and $13.7 billion. Up to 27 percent of the direct medical cost of diabetes may be attributed to diabetic peripheral neuropathy.

More than half of patients who have type 1 or 2 diabetes develop DPN. Diabetes is associated with both macrovascular and microvascular complications, in which the major microvascular complication is diabetic neuropathy (DN) with a prevalence of 50–60%. The neuropathy progresses with decreasing nerve functionality and nerve blood perfusion which may result in malnourished nerve and leads to permanent nerve damage. The clinical manifestations of diabetic neuropathy include numbness, burning and tingling sensation, and intractable pain.

 

Many patients with neuropathy simply don’t now they have it

You may have nerve damage well before you experience its symptoms. The first time you may notice diabetic nerve pain symptoms is when the nerve damage has already progressed. Neuropathy is known to develop well before the patient has any symptoms, and the literature states unequivocally that the sooner treatment can be initiated, the greater the chances of reversal of the symptoms. Microvascular circulatory deficiencies, caused by errors in glucose metabolism, for example, have direct effects on the circulation to the nerves, and there are direct effects on the nerves themselves. Pain signals, in turn, trigger secondary peripheral and central hyperalgesia which enhance the body’s response to the microvascular insult. On a local level, microinflammation and edema around the nerves also contribute to the neuropathy. While this nerve damage can cause pain, it can also result in a loss of feeling in the feet and hands. Numbness can cause cuts and foot ulcers to go unnoticed. These cuts can lead to an infection. In severe cases, an untreated infection can even result in amputation.

 

DPN affects the nerves in the hands and feet, causing numbness, tingling, and pain. Clinical symptoms associated with DPN involve poor gait and balance associated with large sensory fibers and abnormal cold and/or heat sensation associated with small sensory fibers. Chronic pain associated with diabetes is represented by hyperalgesia, allodynia, paresthesias, and spontaneous pain. Symptoms are described as tingling, “pins and needles,” burning, itching, and an abnormal sensation to pain and temperature. Over time, these symptoms may advance from the toes to the foot and up the leg, and these symptoms may occur in the fingers and hands.

Tingling and Numbness

Scientists aren’t sure exactly how diabetes damages nerves. Some theorize that the excess blood sugar affects the protective coating on nerves. Others believe decreased blood flow to the nerves can cause damage.

Either way, as the disease progresses, patients may feel a tingling or numbness in the fingers, toes, hands, and feet. Patients may also report a “pins and needles” feeling, or even a burning sensation.

 

Shooting Pain

A nerve that’s pinched or suffering from damage may send out signals that cause shooting pains. People also described this sensation as an electric shock, or a sharp, stabbing pain. The sensations usually come and go, but they may also remain more constant at times.

These types of pains are most common at night, and can disturb sleep. They may also be the result of damaged nerves that are sending out mistaken signals to the brain (misfiring).

 

Inability to Feel Hot and Cold

Our nerves help us to sense the world around us. They are how we notice when we’re feeling hot or cold. They also tell us when we’ve stubbed a toe or suffered a paper cut.

When nerves are severely damaged, they can actually die off. Suddenly, you may no longer be able to tell when you’ve stepped on a tack or suffered a blister. That means small injuries can go unnoticed and untreated. This can cause more problems down the road.

 

Foot Problems

Once a person loses function in some of the nerves in the feet, they may not notice a blister, infection, or wound until it becomes infected, swollen, and inflamed. Nerve damage can also lead to changes in the shape of the toes. This can require shoe-fitting adjustments. Doctors always recommend that people with diabetes check their feet and hands daily for injuries, especially those who’ve suffered nerve damage and lack feeling in the fingers or toes.

 

Difficulty Walking and Performing Other Daily Tasks

It’s because of our nerves we can button up a shirt, create a hairstyle for ourselves, or even open a doorknob. Nerve damage in the hands and feet can make these everyday tasks more difficult or even impossible. But there are tools available that can help. Specialized orthotic inserts, diabetic shoes, and gripping tools are just a few examples.

 

Autonomic Symptoms

Did you know that nerves control the digestive system? They are also involved in perspiration, sexual function, heart rate, urinary function, and more. If diabetes affects any of these nerves, patients may experience the following symptoms:

  • stomach upset (constipation, diarrhea, nausea, vomiting)
  • urinary problems (incontinence or urinary tract infections)
  • erectile dysfunction or vaginal dryness
  • inability to stay warm or cool
  • difficulty focusing your eyes
  • dry, cracked skin

 

Nerve Pain and Sleep

Some nerve pain is worse at night and as a result, the individual can have difficulty sleeping. This loss of sleep can cause additional problems so people with this type of nerve pain need to discuss the problem with their doctor to receive early treatment.

 

Coping with Nerve Damage

To avoid or limit any of these symptoms, concentrate on controlling your blood sugar levels. The more you can keep your levels in the normal range, the slower any nerve damage will progress. Exercise regularly, manage your weight, and take steps to reduce stress.

Talk to your doctor about lifestyle changes and tools that can help you cope once nerve damage has occurred. Medications and specific treatment methods are also available to help reduce symptoms. Your doctor is your partner in controlling nerve pain. By answering all questions asked (pain type, duration, and how it has changed your lifestyle), you help your doctor to determine the cause of the pain and how to treat it.

 

Treating diabetic nerve pain requires a specific treatment:

Diabetic nerve pain, or painful diabetic peripheral neuropathy, is a separate condition from diabetes that is caused by high blood sugar related to diabetes. This nerve damage may cause foot pain and hand pain. If you suffer from diabetic nerve pain, you can’t undo the damage that has already occurred but it’s very important that you don’t ignore your pain either. The pain, which may get worse over time, can be treated.

Control of your blood sugar

If you have diabetes, it is important to control your blood sugar. Your doctor has probably tested your A1C level before. This measures your average blood sugar level over the past 3 months. The American Diabetes Association recommends a goal of 7% or lower.

Do something about your diabetic nerve pain

Controlling your blood sugar can prevent further nerve damage. However, that won’t reverse the damage or relieve your diabetic nerve pain. And since nerve pain isn’t like other kinds of pain, you may need to receive a specific diabetic nerve pain treatment.

 

What treatment options are available for diabetic nerve pain?

The most common approach is oral medications that only mask the symptoms.

  • 50 percent of patients with diabetic peripheral neuropathy receive treatment with opioids
  • 40 percent take anti-inflammatory drugs
  • 20 percent use serotonin selective reuptake inhibitors (SSRI)
  • 11 percent take tricyclic inhibitors
  • 11 percent take anticonvulsants (Neurontin and Lyrica).

 

Although there is a range of pharmacological agents available for treating the pain associated with diabetic neuropathy, only duloxetine and pregabalin are approved by US Food and Drug Administration (US FDA) for the treatment of diabetic neuropathic pain. The “gold standard” in treating peripheral neuropathy, pregabalin (Lyrica, Pfizer), helps 39 percent of patients achieve a 50 percent reduction in their discomfort and pain, but causes at least 38 percent to have complications. These medications have drawbacks and major adverse effects.

 

Over-the-counter pain relief pills are not approved by the FDA to treat this specific pain. Diabetic nerve pain is a form of nerve pain, a unique type of pain that is different than other types of pain, like pain from a headache, muscle ache, arthritis or sprained ankle. Over-the-counter pain relief pills are not approved by the FDA for the treatment of diabetic nerve pain.

 

What is Combined Therapy?

Combined therapy incorporates two well established procedures that have been combined into a protocol that is showing great promise as an effective treatment solution for diabetic and idiopathic neuropathies. Combined therapy consists of two procedures, an ankle block performed with local anesthetic, and Electronic Signal Treatment (EST), as delivered by a unique sophisticated electroanesthetic wave generator.

 

Ankle Block

The ankle block targets five nerves responsible for sensory supply distal to the ankle. The nerves consist of four branches of the sciatic nerve (the superficial peroneal, the deep peroneal, the sural, and the posterior tibial nerve) and one cutaneous branch of the femoral nerve (the saphenous nerve). The sciatic nerve gives off two terminal branches, the common peroneal and the tibial nerve.

 

Electronic signal treatment

EST is an electrical signal wave treatment that regenerates nerves and increases blood flow by using electrical waves to simulate nerve function in the damaged areas. Electronic signal treatment utilizes computer-controlled, exogenously delivered specific parameter electronic cell signals using both varied amplitudes (AM) and frequencies (FM) of electronic signals. This

digitally produced electronic sinusoidal alternating current with associated harmonics produces scientifically documented and/or theoretical physiological effects when one applies them to the human body. The electronic signal treatment medical device uses sophisticated communications technology to produce and deliver higher frequency signal energy in a continually varying sequential and random pattern via specialty electrodes. This alternation of sequential and random electronic signal delivery eliminates neuron accommodation.

With the help of 0.25% Marcaine, which is a vasodilator (opens the blood vessels for a short time to increase blood flow) and a local anesthetic. The more blood flow that your nerves get while stimulated the faster your regeneration takes place.

 

Combined therapy is believed to:

  • Increases cellular growth
  • Increases Metabolic Activity
  • Reduces swelling around the nerve
  • Stimulates nerve function
  • Increases oxygen and blood directly to the nerve
  • Promotes wound healing
  • Anti-inflammatory action
  • Reduces scar tissue development

The patient has the ability to attain increased movement once again with an effective and favorable pain management treatment plan.

Serious treatment options for serious foot pain

Nearly 60% of patient’s with chronic forefoot pain presenting to a podiatry practice have surgical intervention, yet only 50-60% of them get relief of foot pain long-term and 20% get significantly worse, requiring multiple surgeries. Accurate diagnosis is critical to appropriate treatment, common areas where foot pain is misdiagnosed include:

 

  • Plantar plate disruption

The metatarsophalangeal joint plantar plates are major stabilizers and form part of the plantar capsule. The plantar plates provide strength and support during ambulation. Disruption can lead to toe deformities.  The normal plantar plate is a slightly hyper echoic broad-curved band, which protects the metatarsal head and inserts onto the proximal phalanx. Plantar plate tears typically appear as hypo echoic defects.  The torn plantar plate is often swollen and hyper vascular in the acute phase of degeneration.

 

  • Adventitial Bursitis

Adventitial bursitis is acquired bursitis in the metatarsal fat pad as a result of trauma. Sonographically these areas may either be ill-defined or focal collections. These are generally compressible and hypo echoic, although complex collections may appear heterogeneous.

 

  • Synovitis

Joint effusions are compressible anechoic collections best seen on the dorsal aspect of metatarsophalangeal joints. Synovial proliferation appears on ultrasound as a thickening of the synovial layer. Hyper vascularity and bone erosions may also be present.

 

  • Morton’s Neuroma/ intermetatarsal bursitis

A Morton’s neuroma is caused by mechanical damage to the interdigital nerve, resulting in perineural fibrosis. On ultrasound it commonly appears as an ovoid hypo echoic mass, although the shape and echogenicity may vary. Intermetatarsal bursitis appears as a hypo echoic or anechoic zone in a normally echogenic webspace, generally dorsal to the interdigital nerve, although sometimes enveloping it. This soft tissue collection may become complex and heterogeneous with time. Dynamic assessment of a webspace will show poor compressibility of a neuroma and high compressibility of a bursitis (note: complex bursa may mimic a neuroma).  Treatment options include ultrasound guided cortisone or alcohol injection.

 

Morton’s neuroma or more appropriately entrapment syndrome

Common causes of forefoot pain include joint inflammation (arthritis, capsulitis & synovitis), plantar plate tears, tendinosis (“tendinitis”), bursitis and Morton’s neuroma.

A Morton’s neuroma occurs when scar tissue builds upon a nerve in between the toes known as the interdigital nerve (nerve between the digits, or toes). In Morton’s entrapment, the common plantar digital nerve, also referred to as the intermetatarsal nerve, gets compressed from forefoot plantar pressure in the late midstance and propulsive phases of gait against the distal margin of the transverse intermetatarsal ligament This is most frequently seen in women and is and is attributed to high heeled shoes. The pain is often severe and has an electric shock character to it.  Common symptom descriptions include some or all of the following: “It feels like my sock is wadded up under my foot,” “cramping,” “numbness,” “burning,” “radiating sensations into the adjacent toes,” “the inability to walk barefoot on a hard floor,” and “tingling.”   Others describe a feeling like having a pebble in their shoe or walking on razor blades.  Symptoms include: pain on weight bearing, frequently after only a short time. The nature of the pain varies widely among individuals. Some people experience shooting pain affecting the contiguous halves of two toes. Burning, numbness, and paresthesia may also be experienced.  Usually, patients with Morton’s entrapment demonstrate pain with plantar palpation of the interspace between the metatarsal heads.

As a true nerve entrapment no different in pathology from carpal tunnel syndrome, Morton’s entrapment treatment should be oriented toward decompression. Indeed, the treatment success rate of peripheral nerve decompression in Morton’s entrapment is higher than with surgical resection, has a much lower complication rate, and precludes serious complications associated with nerve excision.

Diagnostic lidocaine blocks are extremely beneficial in assisting in making an accurate diagnosis and can help the practitioner decide on a course of treatment, specifically when two adjacent interspaces are symptomatic.  It has generally been recommended that prior to surgical treatment for Morton’s entrapment, all methods of “conservative” care should be exhausted, including corticosteroid injections, application of offloading pads, sclerosing injections with alcohol or phenol, or radiofrequency ablation.

RADIOFREQUENCY

Radiofrequency nerve treatment is a technique, which has been used for over 10 years for the treatment of longstanding pain. Using local anesthesia, an electrode is placed into the tissue at the painful site and an electric current is delivered, generating heat that destroys the sensory nerve fiber.

The RF Procedure

A medical provider experienced in interventional procedures performs Radiofrequency ablation. The patient is placed in an appropriate position for the procedure; a diathermy pad is placed on the thigh and the injection site cleansed. Pain relief is achieved by injecting a local anesthetic around the nerve that is responsible for the patient’s pain. Once the nerve and area is anaesthetized (numbed), a fine needle is positioned in proximity to the nerve, with the position of which confirmed by imaging guidance (ultrasound or fluoroscopy).

A thin probe is then passed through the needle, which is connected to a generator that results in radiofrequency energy passing through the probe, resulting in heating of the probe tip. The result of this heat is to destroy the targeted nerve and therefore disrupting the ability of the nerve to transmit pain signals. Finally, long-term local anesthetic and cortisone are injected around the treated nerve in order to minimize discomfort, which may arise following the treatment. Treatment via RFA takes approximately 30 minutes. Further time spent at the clinic for post-procedure recovery may be suggested, depending on the exact nature of a patient’s condition. Ultrasound-guided RFA has successfully alleviated patients’ symptoms of Morton’s neuroma/ entrapment in >85% of cases. Less than 10% of patients progress to surgical intervention, such as endoscopic plantar fasciotomy.

ENDOSCOPIC PLANTAR FASCIOTOMY

EPF is an outpatient procedure. It takes about an hour to perform, and is be done at a hospital or a same-day surgical facility. Using special instrumentation we release the inside band of the plantar fascia responsible for causing your pain. After the procedure, you’ll be taken to a recovery area. As your foot heals, new tissue fills in the gap where the fascia was cut. This lengthens the fascia and reduces strain during foot movement. For best results, see your doctor as directed during the next few weeks or months. Physical therapy or stretching exercises are often prescribed to improve recovery. Wearing shoes with good support is essential for your long-term recovery.

 

 

 

 

Migraine Headache: Our position on five medical treatment options that patients with migraines should avoid

Headache is among the principal reasons for physician visits and a common cause of emergency department visits. The costs of tests and treatments for headache are not insubstantial, and when unwarranted, they needlessly expose patients to potential harm. In a recent study of the treatments and procedures that contribute most to the $13 billion dollar annual cost of outpatient neurology visits, migraine alone was the diagnostic category with the second highest costs. For example, using data from the National Ambulatory Medical Care Survey, CT scans ordered at neurology visits (many of which were probably done to evaluate headache) resulted in costs of roughly $358 million dollars.

Five tests and procedures associated with low-value care in headache medicine according to the American Headache Society (AHS).  Listed are five things that “physicians and patients should question” in order to make “wise decisions about the most appropriate care based on the individual situation.”

 

[box] (1) avoiding neuroimaging studies with stable headaches that meet the criteria for migraine

(2) except for emergency situations, computed tomography should not be performed for headache when magnetic resonance imaging is available

(3) outside of a clinical trial, surgical deactivation of migraine trigger points is not recommended

(4) opioids or butalbital-containing mediations should not be prescribed as first-line treatment for recurrent headache disorders

(5) prolonged or frequent use of over-the-counter pain medication is not recommended for headache [/box]

(1) avoiding neuroimaging studies with stable headaches that meet the criteria for migraine

In clinical practice, it is common to encounter patients with headache who have undergone multiple imaging procedures. These often involve exposure to ionizing radiation. The reasons for these repeated and unnecessary scans are not well understood, but probably include physician fear of missing a dangerous cause of headache and a desire to allay patient anxiety over possible missed abnormalities, especially when treatment is unsuccessful. In some cases, duplicate scans may be ordered because the physician is unaware of previous testing. The risk of unneeded testing may be especially high in the emergency department, where physicians are unfamiliar with the patient and fear missing serious causes of headache.

In ordering diagnostic tests, though, the possible adverse effects of testing must be balanced against the likely benefits to the patient. In particular, the potential adverse health effects of radiation exposure should be taken into consideration when ordering diagnostic testing for headache. In many situations, it is very unlikely that a repeat imaging study of the head will identify any abnormality that will alter management. The radiation risks of CT scanning are not negligible. Younger people are at higher risk of radiation adverse effects than older people.

Numerous evidence-based guidelines agree that the risk of intracranial disease is not elevated in migraine. However, not all severe headaches are migraine. To avoid missing patients with more serious headaches, a migraine diagnosis should be made after a clinical history and an examination that documents the absence of any neurologic findings, such as papilledema.

The key element is a change in headache symptomology or a new diagnosis of severe headache.

(2) except for emergency situations, computed tomography should not be performed for headache when magnetic resonance imaging is available

When neuroimaging is needed for the evaluation of headache, good quality evidence supports the view that MRI is more sensitive than CT scanning to detect most serious underlying causes of headache. The exception is settings in which acute intracranial bleeding is suspected. A Canadian government health technology assessment group recently reviewed the evidence and cost-effectiveness of the use of CT and MRI scanning for the evaluation of patients with headache. The researchers found that when performed for the indication of headache, the diagnostic yield of CT scans was 2%, while that of MRI scans was 5%. Because MRI was better at detecting abnormalities, the cost per abnormal finding of CT scans was $2409 compared with $957 for MRI.

When neuroimaging for headache is indicated, MRI is preferred over CT, except in emergency settings when hemorrhage, acute stroke, or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions, and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure that may elevate the risk of later cancers, while there are no known biologic risks from MRI.

(3) outside of a clinical trial, surgical deactivation of migraine trigger points is not recommended

The idea of a surgical “solution” to migraine is inherently attractive to patients. Interest in surgical approaches to migraine has been motivated by serendipitous improvement in headaches noted in patients who have undergone various plastic surgery “forehead rejuvenation” procedures. These procedures are based on the premise that contraction of facial or other muscles impinges on peripheral branches of the trigeminal nerve.

The procedures involved are often referred to collectively as “migraine deactivation surgery,” although a variety of surgical sites and procedures are involved. These include resection of the corrugator supercilii muscle with the placement of fat grafts in the site, “temporal release” procedures involving dissection of the glabellar area, transection of the zygomatical temporal branch of the trigeminal nerve, and resection of the semispinalis capitus muscle with placement of fat grafts in the area with the aim of reducing pressure on the occipital nerve. Finally, some surgeons also perform nasal septoplasty or otherwise attempt to address possible intranasal trigger points.

The value of this form of “migraine surgery” is still a research question. Observational studies and a small controlled trial suggest possible benefit. However, large multicenter, randomized controlled trials with long-term follow-up are needed to provide accurate estimates of the effectiveness and harms of surgery. Long-term side effects are unknown but potentially a concern

(4) opioids or butalbital-containing mediations should not be prescribed as first-line treatment for recurrent headache disorders

Primary recurrent headache disorders (of which migraine, tension-type, and cluster headache are the most common) are conditions of long duration for which such treatment will be used repetitively over many years. Risks and harms that are unimportant in treating a single attack can become important when treatment is used for long periods of time. Once established, medication overuse can be difficult to treat and recidivism is common. Thus, treatments such as triptans or nonsteroidal anti-inflammatory drugs, which are not associated with dependence or sedation, are preferred first-line.  However, there are many clinical situations in which the use of opiates and butalbital is appropriate, including some situations where they are first-line treatments. These include patients for whom triptans or nonsteroidal anti-inflammatory drugs are contraindicated or ineffective.

These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should be monitored for the development of chronic headache.  This is not meant to imply that opioid or butalbital medications are always inappropriate treatments for recurrent headache treatments. Rather, it is meant to address the appropriate order in which medication classes should typically be used.

(5) prolonged or frequent use of over-the-counter pain medication is not recommended for headache

Over-the-counter (OTC) medications are appropriate treatment for occasional headaches if they work reliably without intolerable side effects. Frequent use (especially of caffeine-containing medications) can lead to an increase in headaches, resulting in “medication overuse headache” (MOH). To avoid this, OTC medication should be limited to no more than 2 days per week. In addition to MOH, prolonged overuse of acetaminophen can cause liver damage, while overuse of nonsteroidal anti-inflammatory drugs can lead to gastrointestinal bleeding.

 

 

Severe Head and Neck Pain

Caution:

If you’re having your worst migraine ever or symptoms that are unusual for you or frightening, see a doctor as soon as possible. You need to be sure this IS a Migraine and not something more serious such as a stroke. 

Caution:

Pregnant women should immediately alert their physician as many of the medications used to treat migraines can cause birth defects.

 

 

The goal of the Padda Institute Headache Section is to provide diagnosis and treatment that will help people who experience severe pain regain a better quality of life.  (The treatment needs of patients who have occasional mild headaches are significantly different from those patients whose attacks are frequent and completely disabling.)  If your quality of life is impacted from migraine, chronic head pain, or nerve pain in the face you need a plan of action from a team of highly experienced specialists. We provide a collaborative approach combined with the latest technology resulting in individualized care. Our goal is to provide effective, compassionate care to improve your quality of life.

Headaches are serious

Headache remains one of the most common health issues which challenge physicians and other health professionals, migraine is the 12th most disabling disorder in the United States..  The symptoms of head pain are a frequent cause of human suffering and disability.  According to a World Health Organization analysis, severe Migraine attacks are as disabling as quadriplegia (paralysis of both arms and legs).  Suicide attempts are three times more likely among people who have Migraine with aura than among people who do not have Migraine.  More than 1,400 American women with Migraine with aura die each year from cardiovascular diseases compared to women who do not have Migraine.

Migraines permanently affect your brain

Some 37 million Americans suffer from migraines, those incredibly painful and often debilitating headaches. While they’ve been known to knock a person out, migraines weren’t thought to permanently affect the brain – until now.  A study published in the journal Neurology suggests migraines permanently alter brain structure in multiple ways.  The risk of white matter brain lesions increased 68% for those suffering migraines with aura, compared to non-migraine sufferers. Those who suffered from migraines without aura saw that increased risk cut in half (34%), but they too could get lesions in the part of the brain that is comprised of nerve fibers.  Migraine affects about 10 to 15% of the general population and can cause a substantial personal, occupational and social burden.  According to the American Migraine Foundation, migraines cost the United States more than $20 billion a year in both direct medical expenses like doctor visits and medication and indirectly when employees miss work resulting in lost productivity.

For many patients with headache, an organized, multidisciplinary headache center environment is necessary to provide the entire spectrum of headache management.

 

  • Patients in whom comprehensive services are essential to address the multifunctional components of their headaches.
  • Patients who have not responded to medication and have a history of recurring acute care needs or progressive persistent headache.
  • Patients who have undergone multiple diagnosis and therapeutic interventions yet the diagnosis remains uncertain or questionable.
  • Patients who have had frequent emergency room visits, who have used hospital inpatient services excessively, and who have overused different oral analgesics, including opiates, or who have been treated repeatedly with intramuscular or intravenous medications.

 

 

The History of Headaches

The clinical entity of headache dates back to ancient times.  As early as the dawn of civilization, primitive headache remedies included procedures aimed at ridding the body of the “demons and evil spirits” that were believed to cause headaches.  As early as the Neolithic period dating back to 7000 BC, skulls have been found bearing man made holes (called trephination) presumably done for medical reasons which may have included the treatment of headache.  Skulls demonstrating trepanation have also been found in Peru dating back to the thirteenth century.  The writings of the early Greeks referred to headache as a serious medical condition.

Hippocrates (400 BC) may have been the first to describe the clinical symptoms of migraine.  In the historical Hippocratic books Hippocrates discussed what appears to have been the visual aura that can precede migraine.  The term “migraine’ itself is derived from the Greek word hemicrania. Throughout history, there have been famous individuals such as Plato, Thomas Willis, Erasmus Darwin (Charles Darwin’s grandfather), and others who have contributed to our understanding of headache. More recent scholars, such as Dr Harold Wolff, played an important role in our classification of different types of headache and their treatment. Following his classic 1948 publication of the first edition of Wolff’s Headache, it was Dr Wolff who introduced important scientific concepts which have served to modernize the study of headache.  Since that publication there has been an explosion in headache research which has resulted in our better understanding of this clinical condition.

There are now scientific mechanisms which more clearly define the pathophysiology of some headaches such as migraine.  This has also led to the development of new migraine specific medications, specialized pain management techniques, and ultimately more effective treatment opportunities.

Migraines have affected people for centuries and played an influential role throughout world history. Many famous and accomplished people have experienced severe headaches.  Julius Caesar, Napoleon, Ulysses S. Grant and Robert E. Lee; great painters Vincent Van Gogh, Georges Seurat and Claude Monet,; and famous authors Virginia Woolfe, Cervantes and Lewis Carroll all experienced migraines. Thomas Jefferson wrote the Declaration of Independence during an intense period of productivity after being bedridden for six weeks with a migraine.  The famous authors Virginia Woolf, Cervantes (best known for Don Quixote) and Lewis Carroll (Alice’ Adventures in Wonderland) had migraine. There is even evidence to suggest that at least some of Alice’s Adventures were based on Carroll’s personal migraine visual aura perceptions. As Cheshire Cat observed, “One pill makes you smaller; one pill makes you larger, the pills mother gives you do nothing at all”.  There has been literature which indicates that Thomas Jefferson’s headaches were so severe and debilitating that they often interfered with his ability to function.  As he wrote to Martha Jefferson in February 18, 1784, “Having to my habitual ill health….lately added an attack of my periodical headache; I am obliged to avoid reading, writing, and almost thinking”.  In March 1807, while still President, Jefferson wrote “…Indeed, I have but little moment in the morning in which I can either read, write, or think, being obliged to be shut up in a dark room from early in the forenoon till night, with a periodical headache”.

Headache sufferers constitute one of the largest groups of patients within a neurological practice.  More patients who visit doctors complain of headache than any other single ailment. Headache and migraine in particular, may be considered as a universal human condition which continues to be under diagnosed, misdiagnosed and/or mistreated.  Whereas in some individuals, headache may be an occasional episodic, sometimes nuisance, for others the symptoms of headache may be a manifestation of a disabling chronic disease.  In the latter group, headache disrupts daily routines and impairs quality of life.  The frequency, severity, and even life consequences of headache sufferers vary widely.  The causes of headache are different in different individuals.

 

Range of Disorders:

Each year, millions of Americans suffer from chronic headaches.  There are four main headache types: tension, cervicogenic, migraine and cluster.

  • Tension headaches are the most common and may be described as a mild to moderate constant band-like pain, tightness, or pressure around the forehead or back of the head and neck.

 

  • While cervicogenic headaches are slightly less common and are caused by any number of conditions in the neck, causing referred pain, most often the cervical facets or the cervical discs.  Some studies suggest that the trigeminal sympathetics and parasympathetics mediate pain from the region of the Occipital Nerve, such to the degree that the Occipital Nerve may be considered the “V4” of the trigeminal.  Cervicogenic pain can trigger Migraine headaches and Cluster headaches.

 

  • Migraine headaches are severe headaches that are described as a chronic, throbbing head pain that can cause significant pain for hours or even days.  Symptoms can be so severe that light or sound can cause exacerbation and most patients must find a dark quiet room to lie down.  The typical Aura of Migraines is only present in 25-30% of all cases.

Status Migrainosus: A rare, sustained and severe type of migraine headache, lasting more than 72 hours that is characterized by intense pain and nausea, often leading to hospitalization.

Chronic daily headaches occur frequently, usually more than 15 days per month. Chronic daily headaches are classified as either long duration (lasting more than four hours) and short duration (lasting less than four hours). The majority of people who experience chronic daily headaches have long-duration headaches.

Medication overuse headaches, sometimes called rebound headaches, occur when people who experience migraine or tension headaches take too much analgesic or anti-migraine medication. When the effect of one dose wears off, the next headache occurs and another round of medication is taken. A vicious cycle is created of ever-increasing headaches and more frequent medication use.  Taking Migraine abortive medications, pain relievers, or alternating them more than two or three days a week can cause medication overuse headache.

Menstrual migraine is a headache that occurs during the menstrual cycle. It can occur two days before and up to three days after the beginning of a woman’s period. Although the cause is not explicitly known, menstrual migraine may be triggered by changes in hormone levels. The most likely cause is the fall in estrogen levels that takes place just before the beginning of menses.  When women experience menopause naturally, 1/3 experience worse Migraines. When women experience menopause following a hysterectomy, 2/3 experience worse Migraines.

Studies have shown that 90% of what people think are sinus headaches are really Migraines. A sinus headache is very rare without an infection.

  • Cluster headaches, also known as suicide headaches, are excruciating unilateral headaches of extreme intensity. The duration of the common attack ranges from as short as 15 minutes to three hours or more. The onset of an attack is rapid, and most often without the preliminary signs that are characteristic of a migraine. They are marked by repeated, short-lasting attacks of excruciating, unilateral head pain of short duration.  A cluster headache may be accompanied by redness or tearing of the eye and nasal congestion or runny nose. Often mistaken for sinus or migraine headaches, cluster headaches are characterized by sharp, stabbing pain in or around the eye, temple, forehead or cheeks.
  • Atypical facial pain of all types including trigeminal neuralgia

To assure an accurate diagnosis, we collect an extensive medical history and conduct a comprehensive neurological exam. At times we request a specialized MRI of the brain and neck or blood tests that search for causes of headache including hormone levels, vitamin levels, or markers of an overactive immune system. After the evaluation, treatment options are discussed including medications, lifestyle modification, pain relieving procedures and alternative therapies.  Nearly 30% of patients with dental pain after dental procedures are actually a form of trigeminal neuralgia.

 

Outpatient Treatment

For many people, medication is required to control their headaches. Avoiding the triggers which initiate headache onset is the most important step. There are two categories of headache medication: abortive and prophylactic.

 

  • Trigger Management

Trigger management is key to preventing a migraine attack, migraines don’t just happen; they have triggers.  Trigger factors are those circumstances or influences that can cause a migraine. Trigger factors vary from person to person; if recognized and avoided, a person may prevent a migraine from developing.

Examples of triggers include changes in weather or air-pressure, bright sunlight or glare, fluorescent lights, chemical fumes, menstrual cycles, and certain foods and food products, such as processed meats, red wine, beer, dried fish, fermented cheeses, aspartame and MSG.

  • Preventive or Prophylactic Medication Therapy

Prophylactic drugs are taken daily to prevent headaches. They may be prescribed for people who experience frequent severe headaches, usually two or more per month. These drugs may be taken until a person’s headaches are under control. Generally, the lowest effective dose is used for the shortest period possible. Examples of prophylactic drugs are anti-depressants, beta blocker and calcium-channel blockers.

Many people who take preventive or prophylactic medications will also need to take attack-aborting medications to relieve pain and other symptoms.

  • Abortive Medication Therapy

Attack-aborting medications can relieve the severity and/or the duration of migraine headaches and their related symptoms. In general, most attack-aborting medication should be taken as early as possible in an attack.

Many people who experience migraines or other severe headaches can recognize their early symptoms, allowing them to intervene early with the attack-aborting medication. This may allow them to avoid a more severe, prolonged episode. Attack-aborting medications include cerebral vascoconstrictor abortive agents and non-vasoconstrictive abortive agents.

Specialized Treatment Options for Headache, Migraine and Facial Pain

Our team cares for many patients each year which empowers countless people to achieve substantial improvement. Some of our specialized treatments offered include peripheral nerve injections, which numb the nerves of the scalp to shut off chronic migraine. On average, the injections can give patients weeks to months of benefit. In rare cases, our team provides occipital nerve stimulation by a surgically implanted device that delivers an electric charge to nerves in the back of the scalp to treat migraine, cluster headache, and other types of facial pain that doesn’t respond well to other treatments. This is a treatment few other centers offer.

We also offer a number of alternative therapies with special focus on nutraceuticals – nutritional supplements – and vitamin therapies that have anti-pain or anti-migraine suppressing properties. Also available is pain psychology which uses relaxation strategies and biofeedback to reduce migraine. Our clinic embraces a specialized hormone therapy, called bioidentical hormone replacement therapy. This is where a patient’s hormonal status is monitored and individualized hormonal therapy is provided to normalize the body’s natural cycle and reduce migraine or head pain associated with hormonal dysfunction. We also offer acupuncture.

 

Advanced therapies

  • Spenopalatine Block

The Sphenopalatine Gangion Nerve Block (SPG Nerve Block) is both a  preventative and abortive technique, and may infact prevent trigger activation altogether.

The Sphenopalatine ganglion (SPG) nerve block and the Trigeminal Nerve Block is a fast, highly effective, non-invasive treatment option for migraines and headaches without the use of pills or injections. This treatment uses a unique transnasal catheter to eliminate the pain in a safe and painless way. Aside from migraine and headache, It has been providing successful relief to a variety of painful conditions including trigeminal neuralgia.

Technical:

The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel’s ganglion) is located in the pterygopalatine fossa, posterior to the middle nasal turbinate. It is covered by a 1- to 1.5-mm layer of connective tissue and mucous membrane. This 5-mm triangular structure sends major branches to the gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, and the superior cervical ganglion. The sphenopalatine ganglion can be blocked by topical application of local anesthetic or by injection.

  • Trigeminal Blockade

Trigeminal neuralgia is an extremely painful condition that affects the trigeminal nerve in the face, which is also called the fifth cranial nerve.  The Trigeminal Nerve is often called the Dentist’s Nerve because it goes to the teeth, jaw muscles, jaw joints (TMJ),and periodontal ligament. Trigeminal innervation of the sinuses, eustacian tubes, tensor of the ear drum (tensor tympani), soft palate, tongue and meninges of the brain explain why there are so many disorders associated with jaw function, TMJ and TMD. The trigeminal nerve plays a very important role in the face, being responsible for sensing touch, pressure, pain and temperature in the jaw, gums, forehead and around the sensitive eye area. Since it controls sensation in almost the entire face, pain in the trigeminal nerve can affect many different parts of the face.  Many people speculate that most atypical facial pain, most dental pain, most sinus induced headache, and most headache originating from the base of the skull results from trigeminal activation.

 

Complex Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RSD)

The hallmark of CRPS is pain and mobility problems out of proportion to those expected from the initial injury.

“Of all the chronic neuropathic pain syndromes, none has perplexed patient, clinician, and scientist more than the complex regional pain syndromes (CRPS), heretofore known as reflex sympathetic dystrophy (RSD) and causalgia.”

  • Galer BS CRPS In Loeser J (ed) Bonica’s Management of Pain 3rd Ed. Lippincott Williams & Wilkins 2001 p 388

 

 

Complex Regional Pain Syndrome is the new term for what we used to call RSD or causalgia. Symptoms can develop into CRPS from a major nerve injury (CRPS Type II) or from minimal or no trauma (CRPS Type I).

 

Healthy nerve structure

 

 

Variety of methods by which nerves can suffer partial damage leading to CRPS.

 

 

 

Complex Regional Pain Syndrome is the new term for what we used to call RSD or causalgia.  Symptoms can develop into CRPS from a major nerve injury (CRPS Type II) or from minimal or no trauma (CRPS Type I).

 

Stage 1

The first stage typically lasts about 3 months and starts with severe, burning localized pain, hyperesthesia, localized edema, stiffness and vasospasm (warm, red and dry at first, then changes to cyanotic, cold and sweaty).

 

Stage 2

The second stage (which lasts 3-6 months), pain becomes more severe and diffuse.  Edema spreads, hair becomes scant, and nails become brittle, cracked and grooved.  Osteoporosis appears and spreads while muscles waste.

 

Stage 3

The third stage Pain may spread to the entire limb in stage 3, with marked muscle atrophy, extreme joint weakness and limited mobility.  Bone deossification becomes diffuse.  Contractures are often seen, with near mummification of the extremities.

 

 

 

RSD involves both pain and skin changes.

 

 

Pain from CRPS:

The hallmark of CRPS is pain and mobility problems out of proportion to those expected from the initial injury. The first and primary complaint occurring in one or more extremities is described as severe, constant, burning and/or deep aching pain. All tactile stimulation of the skin (e.g. wearing clothing, a light breeze) may be perceived as painful (allodynia). Repetitive tactile stimulation (e.g. tapping on the skin) may cause increasing pain with each tap and when the repetitive stimulation stops, there may be a prolonged after-sensation of pain (hyperpathia). There may be diffuse tenderness or point-tender spots in the muscles of the affected region due to small muscle spasms called muscle trigger points (myofascial pain syndrome). There may be spontaneous sharp jabs of pain in the affected region that seem to come from nowhere (paroxysmal dysesthesias and lancinating pains).

 

Skin changes in CRPS:

The skin may appear shiny (dystrophy-atrophy), dry or scaly. Hair may initially grow coarse and then thin. Nails in the affected extremity may be more brittle, grow faster and then slower. Faster growing nails is almost proof that the patient has CRPS.

 

CRPS is associated with a variety of skin disorders including rashes, ulcers and pustules.  Although extremely rare, some patients have required amputation of an extremity due to life-threatening recurring infections of the skin. Abnormal sympathetic (vasomotor changes) activity may be associated with skin that is either warm or cold to touch. The patient may perceive sensations of warmth or coolness in the affected limb without even touching it (vasomotor changes). The skin may show increased sweating (sudomotor changes) or increased chilling of the skin with goose flesh (pilomotor changes). Changes in skin color can range from a white mottled appearance to a red or blue appearance. Changes in skin color (and pain) can be triggered by changes in the room temperature, especially cold environments. However, many of these changes occur without any apparent provocation.

 

Reflex sympathetic dystrophy (RSD) or Complex Regional Pain Syndrome (CRPS) is a malignant pain syndrome most often seen in the distal upper or lower extremities, but in variant forms also affects more proximal structures.  It is characterized by:

 

  • extremity pain, often severe (often seen in a stocking or glove pattern)
  • most commonly, involvement of the hand or foot, following injury to that structure or to a proximal limb structure;
  • allodynia (pain to non-painful touch) and hyperpathia;
  • peripheral thermal abnormalities;
  • other symptoms and signs of local autonomic nervous system dysfunction may be present, including locally increased or decreased sweating and edema;
  • local trophic changes;
  • progressive osteoporosis of the affected extremity
  • flexion contracture with significant atrophy

 

CRPS usually remains restricted to one limb, but it can spread to other body parts. Processes in the spinal cord as well as supraspinal changes are responsible for spontaneous spread in CRPS to other extremities.

 

Diagnosis:

Diagnosis is made largely on the basis of history and clinical examination.  A dynamic phase bone scan may help to document perfusion abnormality and is the most sensitive and specific study applicable in diagnosis.  Local sympathetic anesthetic block, performed for treatment, typically results in pain relief outlasting the transient anesthetic effect, which is supportive of the diagnosis.

Evaporative skin testing with loss of temperature discrimination and development of allodynia upon evaporation is a useful screening tool.

Electrodiagnostic testing to exclude nerve entrapment as well as Neurodiagnostic imaging may be necessary to exclude a neuraxial pathology, such as a bulging disc.

 

Patients with ischemic rest pain (pain from insufficient blood supply due to advanced CRPS):

  • Frequently are sleep deprived
  • Are limited in mobility and activities of daily living
  • Often will consent to amputation for pain relief
  • Often are unable to obtain adequate pain relief from narcotic medication
  • Rarely improve spontaneously, unless the blood perfusion to the affected area can be improved
  • Have a high incidence of major depression disorder and are high risk of suicide

 

Treatment options:

Early diagnosis in the first six months to maximal two years is the key to successful treatment. Surgical sympathectomy procedures (removal of a part of the chain of sympathetic ganglia on the side of the spine) have limited application for the treatment of RSD.

 

Management options include sympathetic blocks utilizing regional anesthetic techniques and radiofrequency thermoneurolysis or neuromodulation with spinal cord stimulation or peripheral nerve stimulation.  Radiofrequency neurolysis is an extension of a continuous regional sympathetic block or neurolytic block providing long-term relief with added safety.

Consideration of sympathetic blocks is to facilitate management of CRPS with analgesia commensurate with a program of functional restoration and sympatholysis to provide unequivocal evidence of sympathetically maintained pain. Once it is established that sympatholysis is effective in relieving not only the burning dysesthesia but also allodynia or hyperalgesia, it is important to repeat the procedure to determine whether an increasing duration of effect can be expected in any particular patient. If this is the case, these individual blocks may be all that are necessary to enable a patient to regain function. When sympatholysis completely relieves the symptoms and facilitates exercise therapy but is limited to its duration of effect, it is appropriate to consider a prolonged block using radiofrequency neurolysis.

Radiofrequency has been described for lesioning of the cervical sympathetic chain, thoracic sympathetic chain, and lumbar sympathetic chain, in cases of CRPS I and II, as well as for neuropathic pain.