In our next section, we will review other common pain syndromes that you'll probably see in your pain clinic. For the first pain syndrome that we will cover, it is a very common pain syndrome that people encounter throughout their lifetimes, multiple times, and that is the headache. As you probably know from medical school, there are multiple types of headaches, and we'll get into each of these a little bit more in detail in the following slides, but there's migraines, tension-type headache, trigeminal neuralgia, cervicogenic headache, sinus headache. Each of these have their own types of pain presentations, and let's get into it. Starting with a very common headache is the migraine. It is very common. Two-thirds of the patients that will get it will be women. The cost of this in productivity is greater than $20 billion per year in the United States alone. And one interesting part of this is now researchers are considering this to be a neuronal versus vascular in origin. When the neural system, the trigeminal vascular system, is activated, peptide neurotransmitters are released near blood vessels, leading to vasodilation with consequent extravasation of plasma. Leakage of the plasma proteins from the vessels stimulates the trigeminal nerve endings, which cause nociceptive orthodromic signals to the trigeminal ganglion, which in turn leads to the perception of pain. For migraines, the diagnosis is made by suggestive clinical history and normal neuro exams. Migraines can show as recurrent headaches lasting two to 72 hours of moderate to severe intensity, pulsating, aggravated by routine physical activity, and associated with nausea, emesis, photophobia, phonophobia, and or osmophobia. The migraine can be with or without aura. Auras are most frequent migraine aura consists of visual symptoms such as bright or dark spots, tunnel vision, or zigzag lines. Other common auras include numbness or paresthesia in one arm or on the side of the body. The aura is followed or sometimes accompanied by an intense crescendo headache pain, frequently unilateral or retro-ocular. It may be described as pounding, throbbing, pressure-like, exploding, stabbing, or vice-like. Migraine auras, particularly visual ones, occasionally occur independently of pain. These are called migraine equivalents. Typically, the headache phase lasts from 30 minutes to one day. Occasionally, the headache becomes intractable and lasts a week or longer. This is called status migraines. Treatment options for abortive treatments, there are triptans, and then for prophylactic treatments, we try beta blockers, VPA, or carbamazepine, and then there's also immature pilling or venlafaxine. And our next discussed type of headache is the tension-type headache. This is one of the most common types of headaches affecting over 70% of the population at one time or another. Almost all patients with other types of headaches will also have an interposed tension-type headache as well. We're not really sure what causes the tension-type headache. Pathophysiology, people have spoken about the muscle contraction theory, which relates to pain to prolonged contraction or spasms of cervical or pericranial muscles, but no objective data has been able to support that theory. To diagnose a tension-type headache, we hear patients describe it as more of a dull, less intense, or less localized than migraine. Pain can refer from the neck, but neuro exams are usually normal. They may have an associated disorder of the pericranial musculature, involving tenderness to palpation over those muscles, and also increased activity on electromyography. For treatment, some of the abortive medications can be over-the-counter analgesia with caffeine, such as aspirin, acetaminophen, ibuprofen with caffeine. Stronger headache medications may require addition of codeine or butalbitol. Some prophylactic medications for a tension-type headache can include antidepressants, such as imitriptyline or nortriptyline, and beta blockers. The next headache on our list is trigeminal neuralgia. This is the most recognized cause of severe morbidity, the most common form of facial neuropathic pain in the elderly population. For incidence, it is occurring in about 4 to 5 out of 100,000 people, with 15,000 new cases annually in the United States. Females for trigeminal neuralgia are one and a half times more likely to get it than males. Regarding the pathophysiology, there's neurovascular compression of the trigeminal root, most frequently by the superior cilibellar artery. For treatment, for non-interventional, we've tried carbamazepine or baclofen. And for interventional procedures, we can try decompressive intervention, ablative, or neuromodulatory. In regards to trying to diagnose trigeminal neuralgia, the patient will usually have symptoms in a unilateral fashion, describe them as brief electric shock-like pains that are abrupt in onset and termination, and are limited to distribution of a division of the trigeminal nerve. Pain can be evoked by stimulation. For diagnostic criteria, it has to be in one of the divisions of the trigeminal nerve, and have at least three of the four following characteristics. Recurring in paroxysmal attacks, lasting from a fraction of a second to two minutes, severe intensity, electric shock-like shooting, stabbing, or sharp in quality, precipitated by a noxious stimuli to the effective side of the face. Regarding the clinical presentation, usually starts in the B2 or B3, is unilateral, usually a refractory period. There'll be a normal neurological exam, and have mild autonomic symptoms, such as lacrimation or redness of the eye. The next type of headache discussed is the cervicogenic headache. This headache is provoked by neck movement or pressure over tender points in the neck with decreased range of motion of the cervical spine. The pain can be referred from cervical structures that are innervated by the upper three cervical spinal nerves. This will come from the enlato-occipital joint, medial and lateral enlato-axial joint, cervical 2-3 intervertebral disc, cervical 2-3 zygopophyseal joint, or facet joint, the upper posterior neck and perivertebral muscles, which include the trapezius and SCM, the spinal and posterior cranial fossa, dura mater, cervical spinal nerves and the roots, as well as the vertebral artery. To diagnose a cervicogenic headache, we ask the patient how they respond to when we block the nerve supply or an inter-articular injection of the symptomatic joint. On the graph on the right, you can see some types of algorithm for the diagnosis and management of a cervicogenic headache. First, you want to start with establishing if there's pain with the upper C-spine movements. You want to roll out and isolate the pain. You want to roll out myofascial pain, as well as roll out lower cervical facet pain. If it is in the upper C-spine area, you can go down the algorithm. On the left, you have the enlato-occipital joint pain. In the middle, you have the enlato-axial joint pain. And on the right, you have the third occipital headaches. For each of those, you can do a nerve block or an injection. And then if you finally need to, you can perform a joint injection or a radiofrequency ablation if needed. Some of the more interventional treatments for headaches can include injections and procedures like we previously spoke about. For cluster headaches, you can try glycerol injections, pulsed radiofrequency, or an injection of the trigeminal or sphenopalatine ganglion. There's also botulinum toxin injections, which are also available. They're now FDA-approved for chronic migraines. For this, we use in resistant or refractory or severe cases. It's also effective in chronic tension-type headache, or chronic daily headaches, or headaches with myofascial components. For the chronic migraine, we inject into the glabellar frontalis, temporalis, occipitalis regions, as well as the traps. Other therapies and modalities for headaches can include behavioral therapy, preventative therapy, and avoiding triggers or precipitants of that specific type of headache, naturopathy, acupuncture, and other complementary and alternative medicine therapies. The next painful condition that you will see in your pain management office commonly is fibromyalgia. It is a centralized pain disorder that is chronic and disabling. It used to be thought of as controversial, but the more time that goes on, there are more studies that come out that shows that it is a real disease. It's associated with changes to the central nervous system with higher levels of neurotransmitters that increase pain, such as glutamate, substance P, and there's lower levels of neurotransmitters that decrease pain, which is things like GABA. There's also an increase in endogenous opioid levels in the brain, which is a very common opioid levels in the central nervous system, which is the thought to explain the non-responsiveness to exogenous opioids. There's multiple associated problems and, therefore, varied treatment approaches to fibromyalgia. Some common features seen in fibromyalgia patients are widespread chronic pain in the muscles and soft tissues surrounding the joints, headaches, trouble thinking and morning stiffness, fatigue, sleep disturbances, anxiety, and depressed mood. They can also have paresthesias and vague, poorly defined symptoms. In regards to fibromyalgia patients, there's a 2% to 8% prevalence in the general population. 20% of rheumatic patients have fibromyalgia symptoms. It predominantly is affecting women with a 10 to 1 female to male ratio and is rarely seen in children. The average duration of symptoms before diagnosis is made is approximately five years. Patients with fibromyalgia do not always present the same. They can have a constellation of symptoms that differ from patient to patient. Some might have diffused or chronic musculoskeletal pains. They can have headaches from dental or oral maxillofacial symptoms, GI, mental, constitutional symptoms, cognitive symptoms, and neurological symptoms. Again, if patients with fibromyalgia are all presenting differently, the treatment for those patients will also be different. You can have non-pharmacological therapies such as education and expectation management. Exercise is very important for fibromyalgia patients. We can try cognitive behavioral therapy, improved sleep, reducing stress, and also the triatins unit. It's important for the patient to play an active role in treatment so that they know what they're trying to get out of it. Some of the best pharmacological therapies are chosen based on what is their predominant symptoms. Things that we have tried in the past include trisepal antidepressants, SNRIs and SSRIs, gabapentinoids and cannabinoids, NSAIDs, and we have tried opioids.

headaches

migraines

fibromyalgia

treatment options

non-pharmacological therapies