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Chronic Pain: Hope Through Research

The Major Pains

September, 1997

  • Headache. Tension headache, involving continued contractions of head and neck muscles, is one of the most common forms of headache. The other common variety is the vascular headache involving changes in the pressure of blood vessels serving the head. Migraine headaches are of the vascular type, associated with throbbing pain on one side of the head. Genetic factors play a role in determining who will be a victim of migraine, but many other factors are important as well. A major difficulty in treating migraine headache is that changes occur throughout the course of the headache. Blood vessels may first constrict and then dilate. Changing levels of neurotransmitters have also been noted. While a number of drugs can relieve migraine pain, their usefulness often depends on when they are taken. Some are only effective if taken at the onset.
  • Drugs are also the most common treatment for tension headache, although attempts to use biofeedback to control muscle tension have had some success. Physical methods such as heat or cold applications often provide additional if only temporary relief.

  • Low back pain. The combination of aspirin, bed rest, and modest amounts of a muscle relaxant are usually prescribed for the first-time low back pain patient. At the initial examination, the physician will also note if the patient is overweight or works at an occupation such as truck-driving or a desk job that offers little opportunity for exercise. Some authorities believe that low back pain is particularly prevalent in Western society because of the combination of overweight, bad posture (made worse if there is added weight up front), and infrequent exercise. Not surprisingly, then, when the patient begins to feel better, the suggestion is made to take off pounds and take on physical exercise. In some cases, a full neurological examination may be necessary, including an x-ray of the spinal cord called a myelogram, to see if there may be a ruptured disc or other source of pressure on the cord or nerve roots.

    Sometimes x-rays will show a disc problem which can be helped by surgery. But neither the myelogram nor disc surgery is foolproof. Milder analgesics (aspirin or stronger nonnarcotic medications) and electrical stimulation -- using TENS or implanted brain electrodes -- can be very effective. What is not effective is long-term use of the muscle-relaxant tranquilizers. Many specialists are convinced that chronic use of these drugs is detrimental to the back patient, adding to depression and increasing pain. Massage or manipulative therapy are used by some clinicians but other than individual patient reports their usefulness is still undocumented.

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  • Cancer pain. The pain of cancer can result from the pressure of a growing tumor or the infiltration of tumor cells into other organs. Or the pain can come about as the result of radiation or chemotherapy. These treatments can cause fluid accumulation and swelling (edema), irritate or destroy healthy tissue causing pain and inflammation, and possibly sensitize nerve endings. Ideally, the treatment for cancer pain is to remove the cancerous tissue. When that is not possible, pain can be treated by any or all of the currently available therapies: electrical stimulation, psychological methods, surgery, and strong painkillers.
  • Arthritis pain. Arthritis is a general descriptive term meaning an affliction of the joints. The two most common forms are osteoarthritis that typically affects the fingers and may spread to important weight-bearing joints in the spine or hips, and rheumatoid arthritis, an inflammatory joint disease associated with swelling, congestion, and thickening of the soft tissue around joints. Recently, a distinguished panel of pain experts commenting on arthritis reported that "in all probability aspirin remains the most widely used ... and important drug ... although it may cause serious side effects." In the 1950's the steroid drugs were introduced and hailed as lifesavers -- important anti-inflammatory agents modeled after the body's own chemicals produced in the adrenal glands. But the long-term use of steroids has serious consequences, among them the lowering of resistance to infection, hemorrhaging, and facial puffiness -- producing the so-called "moonface."

    Besides aspirin, current treatments for arthritis include several nonsteroid anti-inflammatory drugs like indomethacin and ibuprofen. But these drugs, too, may have serious side effects. TENS and acupuncture have been tried with mixed results. In cases where tissue has been destroyed, surgery to replace a diseased joint with an artificial part has been very successful. The "total hip replacement" operation is an example.

    Arthritis is best treated early, say the experts. A modest program of drugs combined with exercise can do much to restore full function and forestall long-term degenerative changes. Exercise in warm water is especially good since the water is both relaxing and provides buoyancy that makes exercises easier to perform. Physical treatments with warm or cold compresses are helpful sources of temporary pain relief.

  • Neurogenic pain. The most difficult pains to treat are those that result from damage to the peripheral nerves or to the central nervous system itself. We have mentioned tic douloureux and shingles as examples of extraordinarily searing pain, along with several drugs that can help. In addition, tic sufferers can benefit from surgery to destroy the nerve cells that supply pain-sensation fibers to the face. "Thermocoagulation" -- which uses heat supplied by an electrical current to destroy nerve cells -- has the advantage that pain fibers are more sensitive to the treatment resulting in less destruction of other sensations (touch and temperature).

    Sometimes specialists treating tic find that certain blood vessels in the brain lie near the group of nerve cells supplying sensory fibers to the face, exerting pressure that causes pain. The surgical insertion of a small sponge between the blood vessels and the nerve cells can relieve the pressure and eliminate pain.

    Among other notoriously painful neurogenic disorders is pain from an amputated or paralyzed limb -- so called "phantom" pain -- that affects up to 10 percent of amputees and paraplegia patients. Various combinations of antidepressants and weak narcotics like Darvon® are sometimes effective. Surgery, too, is occasionally successful. Many experts now think that the electrical stimulating techniques hold the greatest promise for relieving these pains.

  • Psychogenic pain. Some cases of pain are not due to past disease or injury, nor is there any detectable sign of damage inside or outside the nervous system. Such pain may benefit from any of the psychological pain therapies listed earlier. It is also possible that some new methods used to diagnose pain may be useful. One method gaining in popularity is thermography, which measures the temperature of surface tissue as a reflection of blood flow. A color-coded "thermogram" of a person with a headache or other painful condition often shows an altered blood supply to the painful area, appearing as a darker or lighter shade than the surrounding areas or the corresponding part on the other side of the body. Thus an abnormal thermogram in a patient who complains of pain in the absence of any other evidence may provide a valuable clue that can lead to a diagnosis and treatment.

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This article was provided by U.S. National Institutes of Health. Visit NIH's website to find out more about their activities, publications and services.
 

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