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Category: Pain Relief-Muscle Relaxers

MIGRAINE CLINICS

The realization that migraine is a disorder causing a vast amount of unnecessary suffering has led to an increased interest in the subject. Specialist centers have been set up with the support of the Migraine Trust for treatment and research of acute migraine attacks in London (the two clinics serving this purpose are the Princess Margaret Clinic and the Charring Cross Hospital Migraine Clinic). In addition to offering treatment of the acute attack, these and other clinics provide consultation facilities for general practitioner referrals, so that all sorts of treatment methods are tried and many trials undertaken.
Perhaps the most important function of the migraine clinic is to deal with and study the acute attack which, surprisingly, is rarely seen by most hospital doctors. In the clinic, tests can be performed on those with an acute attack which, it is hoped, when pieced together will give a better idea of what happens during the acute attack. This insight should help in the development of more appropriate treatment.
These studies are also important in the assessment of treatment. For instance, the recognition that tablets taken during an attack do not always help led to the measurement of levels in the blood of aspirin taken during an attack; these were shown to be lower than when taken at any other time. It was this finding that confirmed the slowness of emptying of the stomach and the consequent recommendation to use Maxolon to stimulate the gut and aid absorption, so making the levels of ingested drugs higher.
The advantage of grouping patients with the same disorder together is that it allows the clinic staff to concentrate on specialized areas and makes research easier. The facility for treatment of acute attacks helps not only patients but research workers. However, in countries where patients visit a specialist, a neurologist, directly rather than being referred on from their general practitioner, there is not such a demand for such clinics. This means that research workers do not have the opportunity of studying patients during an acute attack.
A town (or catchment area of population) has to be of a particular size in order for such facilities to be viable, e.g. about a quarter of a million people is probably the smallest size for this purpose. Alternatively, there needs to be a large concentration of commuter workers in the area (as there is in the City of London where the Princess Margaret Clinic is situated).
In the United States there are several organizations operating such clinics which, although privately run, are fully used.

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HEADACHES THAT ARE NOT MIGRAINE: TEMPORAL ARTERITIS, BRAIN TUMOUR AND BENIGN HEADACHES

Temporal arteritis
This produces a very severe headache, usually in older people over the age of 55 years. The arteries in the temples can be seen to be more thickened and tortuous and they are particularly tender. The sufferer is generally unwell and may have had pains all over the body (polymyalgia rheumatica) for weeks with loss of appetite and loss of weight. The diagnosis is easily made by doing a simple blood test with confirmation by examining a small piece of the temporal artery under the microscope (and finding ‘giant-cells’) – Early diagnosis is important in this condition because a major complication is blindness. The headache disappears completely following treatment with steroids.

Brain tumour
Of all the causes of headache, this is the one that most patients and doctors fear most. In fact, it occurs only in a very small minority of headache sufferers and can often be recognized by the characteristics of the headache.
The history is usually of short duration e.g. less than three months, but of increasing severity. The headache is made worse by coughing, sneezing, and bending down (but this can also occur in benign headaches). The headache may wake the patient from sleep and tends to be worse in the morning. There is often associated morning nausea or vomiting.
Other ominous symptoms include drowsiness, yawning, or hiccup. If there are neurological signs present, then further investigation is mandatory.

Benign headaches
These occur frequently and have no serious significance. Two types of these have recently been described by Dr. John Pearce: The ‘exploding head’ occurs in middle aged or elderly people, most often women. It always occurs at night when the sufferer is woken up with a painful sensation as if a forceful explosion has taken place in the head. Although the sensation soon goes, it leaves the person with a sense of fear, sweating, and rapid pulse rate. The ‘needle-in-the-eye’ syndrome is more common and feels like a sharp jab with a needle in the corner of the eye. It lasts only a matter of seconds and can recur several times a day.

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NERVOUS SYSTEM PAIN

Among the most severe of all chronic pain syndromes is trigeminal neuralgia or tic douloureux. This condition, known in some alarmist literature as ‘suicide pain’, is an affliction of a sensory nerve in the face.

Even a puff of wind, or a slight brushing touch, can set off a bout of severe pain. The pain is classically described as being fleeting in nature, occurring like lightning strikes — each one being as agonising as the others.

Although its cause is as yet unknown, it has been treated in the past by neurosurgical procedures which include lifting the nerve off from the artery thought to be causing compression on the nerve.

More damaging procedures such as alcohol injections of the nerve and a collection of nerve cells which control it, have been used, sometimes effectively, but sometimes leaving one side of the face totally numb.

Treatments Medications include the anti-epileptic drugs Tegretol and Dilantin. More recently, another anti-epilepsy medication, Ri-votril, has been successfully used in pain clinics in Australia and throughout the world.

Antidepressant drugs such as Prothiaden, Anafranil and Tolvon have also been used to modify the pain experience and to control the understandable depression that is caused by this most devastating of pain problems.

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CULTURAL ASPECTS OF PAIN: LOOK BEFORE YOU LEAP

Surgeons also sometimes play a game which is seemingly interminable: ‘If in doubt, cut it out’. Alternatively: ‘A chance to cut is a chance to cure’.But, there are also many surgeons who agree with those medical schools that teach that surgery is an admission of defeat and should only be seen as a last resort.

Before submitting to the knife, you should be certain the doctor has satisfactorily answered the following questions:

1. Why is the operation necessary?

2. What are the risks of complications, including death?

3. What are the risks without surgery? Are there alternative methods of treatment?

4. What are the chances that the surgery will achieve its aim? Surgery can never be undone. While a surgeon may cite a 75 per cent success rate, the other 25 per cent of failures sometimes develop long-standing problems that did not exist before!

The following poem is taken from The Pain Game by Dr C. Norman Shealy: There was a crooked man Who walked a crooked style He saw an orthopaedist Who sinisterly smiled. Ahah! I have the answer, Your problem is quite clear I diagnose a bulging disc We’ll remove it, have no fear. The surgery was ended The doctor got his fee And now the disc that was removed Is causing pain around the knee. So that crooked man who still had Pain and strife

Became another victim of a well-intended knife.

Information important for understanding

Closely allied with the ‘It’s all in your head!’ game is the implication, sometimes spoken quite frankly: ‘You’re too stupid to understand!’ Trading on this basis, doctors can excuse many of their own failures. They will fail to explain to a patient the risks of surgery or any other treatment, or the alternatives available.

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PHYSICAL EXAMINATION

Physical examination, and further questioning, usually leads to the impression that the complaint of pain is excessive compared with the physical findings and that emotional factors have significantly contributed to the pain — the presence of which medical treatment cannot offer a reasonable expectation of cure.

Common denominators are often lack of relief from medication and often depression, addiction and decreased ability to function normally as a result of over-medication. Frequently, there is also disability beyond that justified by the physical findings and the contribution of psychological and social factors for the reinforcement and perpetuation of pain behaviour is overlooked.

People often tend to over-value their pain. That is, the pain plays a central part in how they relate to themselves or others. In such cases, the pain controls the person rather than the reverse! Manipulation of others happens more often than most doctors would like to admit. Histories reveal that the patient has often succeeded in manoeuvring physicians into attempting ill-advised medical treatments or surgical procedures.

All this can be very tricky for the physician trying to make a diagnosis and decide the correct treatment. Often the presence of medical illness unrelated to pain is overlooked because of the patient’s restricted focus on the pain complaint. Most patients convey a sense of urgency, complain of distress and disability, and expect that the illness will be named and a definitive treatment started. Little pain management can be achieved until both patient and physician exchange the patient’s expectations, or desires for pain relief, for that of a mutual goal of rehabilitation.

After all, effective pain management involves an unwritten contract between patient and therapist.

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THE ESSENTIAL BACKGROUND — THE HISTORY OF PAIN

.fain exists in all age groups and is common to almost all humanity — affecting the psyche or mind as well as the soma or body.

It cuts across the boundaries of culture, heritage, socio-econom-ics and language. Pain has always been attended by controversy as it is symptomatic of many diseases and its problems involve many disciplines in medicine and philosophy. Its presence or absence has formed the basis for some philosophic systems, and has been the inspiration for much of the world’s literature.

Many penal codes are based on the notion of inflicting pain, both mental and physical on the transgressor. Even the word ‘pain’ has similar roots to the Greek word for penalty.

Pain is no ordinary sensory experience. It has several attributes which differentiate it from the sensations of touch, smell, taste, etc.

One is the emotional aspect of real or threatened pain; another is the subjective experience of pain, which makes it a unique experience different for each individual.

Pain is not always experienced as noxious, and in some aberrant behaviours it is sought for pleasure and recreation. Pain is a perceptual behaviourial state of the whole animal.

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CAUSES OF HEADACHES: FOOD

Food can cause headaches in a number of ways. Food sensitivities are however a very complex topic and I will only summarise the role of food and additives here, in order to set them in the wider context of chemical sensitivities.

Like any other chemical substance, food can cause problems in two ways. Firstly, there is a pharmacological reaction – where a substance in the food has a direct effect on the body’s cells. A pharmacological reaction like this is always dose dependent – the more you take in, the bigger the reaction (at least, up to a point). The other way foods can cause trouble is when the body has become allergic to a specific foodstuff; when the food is eaten, the body recognises it as a potential ‘foreign’ agent, and mobilises the immune system to try to deal with it. Allergic reactions like this tend to be much more like an on-off switch – they trigger off a maximal reaction at very low doses.

As an example of the two ways in which foods can react, tyramine is a constituent of chocolate and cheese, and in certain people can cause migraines via the direct pharmacological route. Reducing the level of tyramine in your diet will reduce the migraines. On the other hand, some people are allergic to various foodstuffs; they may also get migraines, but the migraines are triggered in a different fashion and usually require much smaller doses to start them off. Many different types of foods can cause migraine like this and the tendency to react to a particular food depends if you’ve been sensitised (become allergic) to this food. In turn, this relates more to the individual’s exposure to that food in the past, rather than to any specific chemical constituents of the food itself.

Food additives can cause problems in exactly the same way as foods.

Some foods and additives are much more potent than others in causing headaches. There is even the ‘Chinese restaurant syndrome’ – pressure in the face, pain in the chest and a burning sensation in the head and chest. This seems to be related to eating certain types of Chinese food, Wonton soup, in particular, especially when taken on an empty stomach. Only a certain group of people seem to be sensitive in this way; the offending agent is thought to be monosodium glutamate, which is often used in Chinese cooking. However, it may not be monosodium glutamate on its own that causes the problem; there may well be an interaction with other constituents of Chinese food.

Another food additive which can cause problems is sodium nitrite, which is used in cured meat products such as Frankfurter sausages, and luncheon meats. In some people, sodium nitrite can produce a similar headache, together with flushing and redness of the face.

The pattern of meals can also affect headaches. Some patients with migraine find that low levels of sugar in the blood can trigger off an attack, and so going without a meal may be hazardous. Note, however, that a migraine caused by the absence of food can also be caused by a food allergy; there is a distant relationship between food addiction and food allergy, and patients who are allergic often get withdrawal symptoms when they initially omit a food to which they are allergic from their diet. Therefore, a migraineur who develops an attack every time he misses breakfast may be triggering the attack by low levels of sugar in the blood, but it might just be that he’s allergic to milk (or tea, or coffee, or marmalade, or pork or eggs) and is having withdrawal migraines as a result of not eating any for some time.

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HEADACHES IN WOMEN

Some types of headaches occur only in women. These are headache: caused by the contraceptive pill; from toxaemia in pregnancy; and related to the menstrual

cycle.

A number of types of headache occur more frequently in women than in men -sub-arachnoid haemorrhage and migraine, for example. Other types attack men more often than women – such as cluster headache. And, of course, there are a large number of types of headaches which affect both sexes equally.

The female reproductive system is controlled by many different hormones. Each month during the fertile part of a woman’s life, they cause a single egg to complete its development in one of the ovaries, and to be released into the Fallopian tubes which eventually lead to the womb. Two of the main female hormones, oestrogen and progesterone, are made in the ovary. Oestrogen is created by cells which surround the developing egg, while progesterone is released from the region formerly inhabited by the egg, after it has been released.

The whole cycle is under the control of hormones produced by the pituitary gland. One of its hormones, follicle-stimulating hormone (FSH), causes the egg and its surrounding cells to begin maturation. The female hormones are low in childhood, rising as puberty commences, and then (unless interrupted by pregnancy) continue to vary in a monthly cycle until the menopause. The time of the menopause is determined by the number of eggs left in the ovary ready to develop; when these run out, the ovary is unable to produce oestrogen and progesterone as it previously did, and the levels of these hormones begin to fall.

However, from time to time, hormone imbalances can occur. These can cause a variety of diseases, including abnormal monthly bleeds, pre-menstrual syndrome (PMS) and menopausal problems. Pre-menstrual syndrome and menopausal problems both include a wide variety of symptoms, including headaches.

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WORK-RELATED HEADACHES’ CAUSES: THE ‘SICK BUILDING’ SYNDROME

Reaction to synthetic fabrics and petro-chemical fumes lighting flicker, allergy to fungi, and sensitivity to positive ions in the air can Individually produce headaches in susceptible people, but more commonly one, two or more of them act together. A recently labelled condition is the ‘sick building syndrome’, in which people in a particular office find that just attending work makes them ill, with headaches, a feeling of malaise, sniffles, and maybe even a slight temperature.

Sick building syndrome has a very loose definition, but quite a number of problems are relevant: poor ergonomic design of the computers and office furniture; fungal spores in the air-conditioning system; windows that won’t open so there are lots of positive ions inside; offices lit exclusively by fluorescent lighting; newly painted walls and new carpets that are giving off chemical vapours; and duplicators and photostat machines that exude chemical solvents. And, of course, it’s made worse if some of the employees smoke.

The cure for ‘sick building syndrome’ is to remove as many of the unwanted sources of stimuli as possible – cleaning up the air humidifying system using antifungal agents; fitting non-flicker fluorescent lights; and making sure that windows can open to let fresh air in from the outside, both to provide more negative ions, and also to blow away petro-chemical fumes, fungal spores and tobacco smoke.

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MISCELLANEOUS CAUSES OF HEADACHES: EXERTION HEADACHE

Exertion headache is a throbbing pain which can be brought on by exercise – such as running, swimming, sexual intercourse or sometimes even by sneezing and coughing. It particularly effects men over the age of forty. The headache is usually throbbing, extends over the whole of the skull, and lasts for a few hours. It is often associated with nausea – and sometimes even vomiting – and the need to avoid bright lights (photophobia), which are painful.

Exertion headaches may actually be a rare form of migraine. Very rarely they can be associated with tumours or abnormal blood vessel formations inside the brain, and because of this it is wise for a full set of investigations to be carried out.

Treatment of exertion headaches can be surprisingly simple. For some reason indomethacin, one of the non-steroidal anti-inflammatory drugs (NSAIDs) seems to be very effective in removing the pain; aspirin can also be used. Beta-blockers, such as propranolol, may also help. In those cases caused by blood vessel abnormalities or tumours, surgery may be necessary.

Complementary treatment

Lavender oil, applied neat to the nostrils can have a powerful effect on exertion headaches, or try a tiny valerian tablet.

Exertion headache shares a lot of similarities with migraine and may be a rare form of it; it is also identical to true coital headache.

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