National Institute of Neurological Disorders and Stroke
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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