common conditions treated
HEADACHE
(modified with permission)
YOU ARE NOT ALONE....
In fact, more people complain about headaches than any other physical
problem. At least 90 percent of us have them. Almost everyone knows what
a headache is. Headache is a major public health problem. It is one of
the 10 most common presenting symptoms in general practice and is among
the prominent causes of sickness, absence from work, resulting in
millions of lost working days each year. In fact, 76 percent of women
and 57 percent of men have had a significant headache in the past month.
Unfortunately, despite the millions of headaches suffered, no other
ailment is more misunderstood or more under estimated. Most of us are
told that there is "nothing to find" and "nothing to fix".
IT IS NOT ALL IN YOUR HEAD!
Headache is like many illnesses that are identified initially due to
psychological causes such as epilepsy, schizophrenia, and Alzheimer
disease. Patients with frequent and disabling headaches not only suffer
from the illness but its complications from rejection and cynicism, from
family and physician, discrimination and repudiation by insurance
carriers and employers. Chronic headache is generally an inherited
disorder, which results from changes in brain physiology.
WHAT ARE THE TYPES OF HEADACHES?
The following are major categories and types of headaches seen in most
people:
1. MIGRAINE HEADACHES. Migraine is one of the most common
headache conditions known to mankind affecting 18 percent of total of
adult population. These headaches are called vascular headaches as they
are linked to changes in blood flow to the brain. There are two major
types of migraine headaches, migraine with aura or classic migraine and
migraine without or common migraine. Ten to 20 percent of people who
have migraine experience an aura. They see flashes of light, blind
spots, or zigzag lines before the headache starts. Other symptoms
include nausea, vomiting, tingling in the lips and face, and sensitivity
to light. A headache can last anywhere from a few hours to a full day or
more.
2. CLUSTER HEADACHE. Cluster headaches are more common in the
spring or fall in middle age men who smoke heavily. Cluster headache is
generally very severe. It develops behind or around one eye and rarely
moves from side to side. This type of headache appears quickly in about
five minutes and lasts between 45 minutes to an hour.
3. CERVICOGENIC HEADACHES. Cervicogenic headache gets its name
from its origin from the neck, which is very common. Now, it is well
known that there is a connection between the first three cervical nerve
roots and the fifth cranial nerve in the cervical cord. So, we
understand that muscle spasm or nerve root irritation in the neck can
cause the pain in and around the eyes and the face by means of this
fifth nerve, otherwise known as the trigeminal nerve. Sometimes, the
headache arising from the neck is also associated with neck, shoulder,
and arm pain. Dr. Ogoke has extensive experience in the management of
cervicogenic headaches and has published and spoken at seminars on this
topic. He also served as a resource to physicians in the region who
refer patients needing advanced care in this area. Atlanto-occipital and
atlantoaxial joint injections are a highly delicate but effective tool
like no other in the management of chronic headaches when such headaches
originate from these specific upper cervical facet joints. Frequently,
chronic headaches have been incorrectly diagnosed as migraine headaches,
only to resolve completely with appropriate evaluation, diagnosis, and
treatment. Atlanto-occipital and atlantoaxial joint injections have been
very helpful in this regard.
4. TENSION TYPE HEADACHE. This is the most common type. These
headaches occur when muscles in the head, neck, upper back, or face are
tense for a long period. A tension headache may be set up by physical,
mental, or emotional stress, also.
5. POST CONCUSSION SYNDROME. Post concussion syndrome is
frequently seen following a motor vehicle accident with whiplash
injuries, especially when the patient is rear-ended. Headaches are
frontal in location unless associated with cervicogenic headaches as
well, in which case it is occipitofrontal, associated with insomnia and
are constant, usually associated with dizziness and lightheadedness. In
severe cases, nausea or even vomiting may occur. Memory loss is rare
unless severe, but loss of concentration is not uncommon. Tinnitus
(ringing in the ears) and blurry vision are present in moderate to
severe cases. These headaches respond well to use the tricyclic
antidepressants like amitriptyline (Elavil) and respond poorly to the
use of most conventional headache or migraine medications.
6. MIXED HEADACHE SYNDROME. Headaches frequently are
multifactorial. For instance, following a motor vehicle accident, a
patient who usually suffers from migraine continue to have worsening
migraine headaches. In fact, a likely diagnosis and proper evaluation
may be a superimposed post concussion syndrome and cervicogenic origin
headache in addition to "baseline" migraine headaches. More medications
for migraine headaches will not provide as good a benefit as treating
specifically for post concussion syndrome and cervicogenic headaches.
7. DANGEROUS HEADACHES. Remember, most headaches are not signs of
serious illness. Immediate medical help is advisable if the following
happens with respect to headache:
- strike suddenly and cause severe pain
- are accompanied by vision changes, confusion, loss of
consciousness, numbness, or any similar changes
- wakes you up during the night
- becomes more frequent or severe
- follow a blow to the head
- occur with a fever or a stiff neck
- occur in young children or older adults
- repeatedly affect the same are such as an eye or ear
- are accompanied by convulsions
TREATMENT TECHNIQUES
The kind of treatment you receive will be largely depend on what has
been found out about you and your headache, but he most common element
to almost all individual treatment plans will be learning. You will
learn the following:
- how to recognize the early signs of headache and avoid the
occurrence
- how to avoid circumstances that trigger your headache or how to
react to the circumstances differently
- how to change habits that can increase muscle tension and produce
headaches
- how to actually reduce stress in your body by using biofeedback
techniques. It is extremely important to remember that headache
treatment is not passive. You should be willing to take an active role
in your treatment.
MEDICATIONS FOR TREATING HEADACHES
In general, with your cooperation and consent, we must decide to
approach your headache by the abortive, also known as the "symptomatic
method". Trying to stop a headache once it has already begun or by the
preventive method "trying to prevent the onset of the headache" by
treating you daily, similar to the principle concerning the use of birth
control pills. The preventive approach is most often used when the
headaches are frequent and occur with regularity.
CHRONIC DAILY HEADACHES
Chronic daily headache affects 10 million people in the United States.
It affects more women than men. A few headaches per week gradually
become daily, sometimes without stopping. The pain is mild to moderate,
usually on both sides of the head and described as pressing, squeezing,
and occasionally throbbing.
DRUG REBOUND HEADACHES
Drug rebound headaches are those headaches that are usually caused by
the frequent use of painkillers, prescription, and over-the-counter
medications. Although aspirin, Tylenol, and many prescription
painkillers (codeine, Demerol, barbiturates, ergot, and caffeine) are
helpful to the occasional headache sufferer, use of these drugs can also
make an existing headache worse.
WARNING HEADACHE
Rarely, some headaches, about 2 percent present as a warning sign of
disorders of the eyes, ears, teeth, jaw, sinuses, allergies, temporal
arteritis, brain tumor, or aneurysm.
TREATING HEADACHE WITHOUT DRUGS
Even though it is a common practice to give drugs for almost all types
of pain and drugs have represented the mainstay of traditional headache
treatment, it is important to try find safer and equally effective means
of relieving or preventing headaches without resorting to the use of
drugs. There are options available:
- PSYCHOTHERAPY: it means treating the mind, but in a broad
sense, psychotherapy can include any method of lessening tension,
anxiety, or depression.
- INJECTION THERAPY: Various types of injections and nerve
blocks have been used for management of headaches and have proven to
be successful. These include epidural steroid injections and various
types of nerve blocks including occipital nerve blocks and atlanto-occipital
and atlantoaxial joint injections. Facet joint injections are also
beneficial in some with the appropriate diagnosis.
- BIOFEEDBACK AND SELF-REGULATION: Biofeedback training is a
means of teaching you to develop conscious control over various
autonomic. The tightness of your neck muscles or even the temperature
of your fingers can be altered through control over your body.
- EXERCISE: Many of the patients who are joggers suggest that
a headache can be aborted by jogging. Some even suggest that they have
suffered far fewer headaches since taking up a regular exercise
program. A regular exercise such as jogging lasting for 15 or 20
minutes four times a week for patients who are physically fit may be
helpful to both mind and body.
LOW BACK PAIN
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Many people suffering with low back pain, which is persistent or
complicated, require advanced care. Low back pain is an extremely common
phenomenon involving almost 80 percent of the population at one time or
the other in their lifetime. Approximately 50 percent of people who have
experienced a first episode of back pain continue to experience
recurrent or persistent back pain. All back pain is not the same. For
some, it may be just a "sore back", for others, it may be a bothersome
or aching pain, and for some others it is severe and disabling and
compromises their lifestyle. Nerve blocks are a modality of therapeutic
intervention available for treatment of chronic low back pain similar to
surgery, drugs, manipulation, and behavioral therapy.
Since chronic low back pain has many individual causes, each patient
must be treated differently. This pain management center's unique
approach to managing your pain is based on medical and scientific
principles and treatment. Chronic low back pain is much too complex a
medical problem to respond with anything less than a comprehensive
evaluation and management.
Low back pain is not a diagnosis in and of itself, but is a description
of symptoms under which there are multiple diagnoses. In a vast majority
of cases, low back pain is contributed to by more than one diagnosis or
pain source, and careful evaluation and diagnostic steps are needed to
identify each contributor and treat accordingly. For instance, a patient
with lumbar disk protrusion may have an associated sacroiliitis and
facet joint mediated pain, each of which upon taking the appropriate
steps to establish the diagnosis may require a separate treatment
protocol to complete eliminate the pain. In general, we can tell where
your pain is coming from based on your physical examination, history,
x-ray, C.T. scan, an MRI evaluation, and nerve conduction studies in
only approximately 15 percent of cases. However, in most cases,
approximately 85 percent, physicians cannot find an appropriate cause of
the pain. Pain management physicians can identify an appropriate cause
of the pain without further steps being taken. In these cases,
diagnostic accuracy can be improved to approximately 85 percent with
diagnostic nerve blocks leaving another 15 percent who continue to
remain without a final diagnosis for their pain problems. It is
important to know that the average pain management physician receives
patients who have already tried to undergo treatment under the care of
other providers, including their primary care physicians and other
referral sources who have tried to treat the patient without success.
Hence, leaving the pain management physician with this subgroup of
patients who can benefit from our knowledge.
NECK PAIN
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The neck, or cervical spine area, is composed of vertebrae beginning at
the base of the skull and ending in the upper torso, just before the
ribs begin. The bony vertebrae and thick elastic ligaments protect the
spinal cord and the various nerves leading into the arms, head, and
torso. Because the neck has a large range of motion, it is less
protected than the lower areas of the spine and supports the weight of
head, it is vulnerable to injury and disorders. Neck pain may result
from a variety of injuries, abnormalities, and disorders. Listed below
in alphabetical order are many of the causes that have been associated
with neck pain.
CAUSES OF NECK PAIN:
· Bone spurs (osteophytes)
· Degenerative disk disease
· Disk herniation/disk bulge/pinched nerve
· Disk infection (discitis)
· Infection in the vertebral body (osteomyelitis)
· Osteoarthritis
· Pinched nerve
· Spondylolisthesis/mechanical instability
· Spondyloarthropathies, ankylosing spondylitis
· Spinal stenosis
· Whiplash
WHAT IS WHIPLASH?
Whiplash is an injury to the neck, which may occur following sudden,
violent, backward and forward hyperextension and hyperflexion of the
head. This type of injury commonly occurs in automobile accidents,
especially when the patient is rear-ended. Whiplash may damage
intervertebral joints, disks, ligaments, cervical muscles, and nerve
roots. Symptoms may include neck pain or stiffness, headaches,
dizziness, paresthesias (tingling or burning), and shoulder, arm, back,
face, and jaw pain. These symptoms may be manifest immediately after the
injury and may be delayed for several days or even weeks. In some cases,
the patient may experience somatic, cognitive, or psychological
condition such as memory loss, nervousness, irritability, sleep
disturbance, fatigue, concentration impairment, or depression.
HOW COMMON IS WHIPLASH?
Approximately 1,000 people a year are subject to whiplash injury in the
U.S. leading to chronic pain and disability in 25 percent while 40
percent will still have significant pain more than three years after the
accident. Because certain injuries acquired during aging may weaken the
vertebrae, middle-aged individuals are generally more vulnerable to
anatomical injury such as facet nerve root damage.
WHAT ARE THE TREATMENT OPTIONS?
Interventional techniques: Interventional techniques are usually
combined with oral medications in this facility to
achieve resolution of most neck pain problems. In some cases, injection
therapy may not be necessary. However, when offered, injection therapy
may include the following:
- Epidural blocks (interlaminar or transforaminal approach)
- Facet joint blocks
- Discography
Other modes of treatment include medial branch block, implantation of
morphine pumps, and spinal cord stimulator implantation.
REFLEX SYMPATHETIC
DYSTROPHY SYNDROME
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WHAT IS RSDS?
Reflex sympathetic dystrophy syndrome is a multi-symptom condition
usually affecting arms, legs, or both, but may affect any area of the
body. It is a disease that is poorly understood by patients, their
families, and healthcare professionals. In some, the disease is mild, in
some it is moderate, and in others it is a severe condition. It is a
disease involving the nerves, skin, muscles, blood vessels, and bone.
The only common factor in all patients is either pain or stiffness. Some
of the other names given to this condition are causalgia, Sudeck
atrophy, shoulder/hand syndrome, and sympathetic maintained pain
syndrome. More recently (1995) RSDS has been renamed CRPS (complex
regional pain syndrome).
WHAT DO WE KNOW ABOUT RSDS?
It was described during the Civil War. It is not a rare disorder and may
affect millions of people in this country. This syndrome may follow 5
percent of all injuries. The diagnosis often is not made early, and some
of the very mild cases may resolve without treatment and others may
progress through the stages and become chronic and often disabling.
A very few patients who are not treated early will experience spread of
the disease, and this may become a lifelong problem. Even with early
treatment, RSDS may become a chronic condition. It can start as young as
three years of age. This is not a psychological disease. Children may
develop psychological problems when physicians, parents, teachers, and
other children do not believe they are suffering.
WHAT CAUSES RSDS?
A number of mechanisms have been proposed to describe this condition.
There is a general consensus that a vicious cycle is initiated due to
injury to a nerve or nerve endings. Whatever the theory, it is the basic
belief that there is activity of sympathetic nervous system resulting in
various symptoms, which can be explained on a scientific basis. The
sympathetic nervous system controls blood flow along with other
functions. RSDS may start after fractures, dislocations, soft issue
injury, head injury, stroke, spinal cord injury, or brain tumor. Some
may experience rapid onset with marked deterioration and resistance to
treatment. Some may have slow onset over a period of weeks or months and
show impressive progress after therapy.
WHAT ARE THE SYMPTOMS OF RSDS?
The most common symptoms are:
· PAIN - This is the primary component, constant pain, which varies in
degree from moderate to severe and is burning in character.
· STIFFNESS - Loss of motion and loss of ability to use joints and
muscles with activity.
· MUSCLE CHANGES - swelling, spasms, atrophy
· SKIN CHANGES - dryness, changes in temperature (mostly cold),
intolerance to cold or warmth, bluish discoloration, changes in nail
beds, increased sweating.
· BONY CHANGES - softening of the bone
IS IT ALL IN MY HEAD?
RSDS is difficult for many physicians, patients, and public alike to
understand. It is not surprising that family and friends, employers, and
health insurance officials do not understand the pain and disability.
Because it can vary from day to day, and if you are having a good day
when seen by a doctor, he or she may find it difficult to understand the
severity of the problem. Patients who get RSDS are not any different
from the rest of the population psychologically. Once they get RSDS,
they are in constant pain, friends, family, and employers not believing
them, they may become depressed and suffer the psychological changes. As
with any group of individuals, there is a small percentage of RSDS
patients who get satisfaction from a chronic illness. The vast majority
of RSDS patients were active, productive individuals prior to the
disease and do not enjoy the pain, the loss of independence, the loss of
job, and the loss of income.
HOW DO YOU DIAGNOSE RSDS?
There is no single symptom, clinical science, or laboratory test that is
100 percent diagnostic of RSDS. Your physician will look for symptoms
like burning pain, color changes, temperature changes, edema, hair and
nail growth changes, among various other symptoms. To assist in the
diagnosis of reflex sympathetic dystrophy, various tests can be
performed. These include three-phase bone scanning, x-rays, phentolamine
test, and diagnostic sympathetic blocks.
THREE-PHASE BONE SCANNING - The three-phase bone scan has
been shown to be one of the best tests for the diagnosis of reflex
sympathetic dystrophy. However, this is positive in only 60 percent of
the cases with incidence of 10 percent false positives, in essence
leading to the appropriate diagnosis in only 50 percent of the cases.
PHENTOLAMINE TEST - In this test, under appropriate monitoring,
high doses of phentolamine are infused slowly.
SYMPATHETIC BLOCKS - Blocking the sympathetic nervous system by
injecting a numbing medication around the sympathetic ganglia has been
considered as the gold standard for diagnosis of RSDS. However,
recently it has been shown that the response to sympathetic block is
not 100 percent, even in classic cases.
Various other tests described in the diagnosis of reflex sympathetic
dystrophy have been shown to be unreliable or positive only in end
stages when the patient no longer responds to treatment.
HOW IS RSDS TREATED?
There are many forms of treatment for RSDS. Treatment may include
medication, injection therapy, psychological support,
etc. A coordinated approach with a multidisciplinary team of physicians
who understand the problem and attempt to address all pain patterns,
physical as well as psychological, will be most helpful. The benefit of
a multidisciplinary pain management center is that is offers the
necessary diagnostic treatment, alternatives, carried out by individuals
well trained in their implementation and complications.
SYMPATHETIC BLOCKS - Various means include paravertebral
sympathetic blocks, epidurals, and intravenous regional sympathetic
blocks (DIER blocks). With these techniques, pain relief will be
gradually lengthened and the problem resolved. These techniques are
effective in 50 to 90 percent of the time. The number of the blocks
needed and the degree of pain relief achieved with each injection are
unpredictable.
RADIOFREQUENCY SYMPATHETIC NEUROLYSIS - A small controlled,
localized burn is produced utilizing radiofrequency current similar to
a laser, which produces long-term relief in some patients.
PHYSICAL THERAPY - This is the second most important part of
the therapy in reflex sympathetic dystrophy. After the intense pain is
relieved with a sympathetic block, you are treated on a gentle, active
exercise program. It should be carried out by a physical therapist who
is familiar and well versed with this syndrome.
BIOFEEDBACK TRAINING - Biofeedback training and relaxation with
emotional support and other psychological strategies involving coping
skills are very helpful in managing reflex sympathetic dystrophy
OTHER TECHNIQUES
- Medications
- Transcutaneous electrical nerve stimulation (TENS)
- Acupuncture
- Chemical sympathectomy
- Implantation of spinal cord stimulator
- Morphine pump implantation, etc.
GOALS OF TREATMENT
The major goal of treatment of pain management is to put you back in
charge of your life. It is possible that you will always have to live
with a certain amount of pain, but you can learn to work and enjoy life
in spite of it.
SHINGLES AND POSTHERPETIC
NEURALGIA
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POSTHERPETIC NEURALGIA "PAIN AFTER SHINGLES"
Postherpetic neuralgia is a condition that produces, agonizing pain and
suffering for many patients following the viral infection, herpes
zoster, more commonly known as shingles. This painful condition
resulting from shingles will last several months to years. In addition
to the patient's suffering, the management and control of the pain and
anguish is one of the most difficult and persistent problems being
handled by the patient's physician.
SHINGLES
Shingles, herpes zoster, an acute viral infection affecting the skin and
nerves and is characterized by groups of small blisters appearing along
side a nerve segment. The lesions are most often seen on the back and
may be preceded by a dull ache or severe pain in the affected site.
Shingles is caused by the same viral infection as that of chicken pox.
It is more commonly seen in individuals with reduced defense mechanisms
to fight infection by a reactivation of the chicken pox virus, which was
inactive. It most commonly affects the chest wall and upper body (50
percent of cases), upper back and upper limbs (20 percent of cases),
lower back and lower limbs (15 percent of cases), and the eye (15
percent of cases).
HEALING PROCESS AND COMPLICATIONS
In most cases (85 percent), complete healing occurs in two to six weeks.
Overall, 20 percent of patients progress to a condition known as
postherpetic neuralgia (inflammation of nerves after shingles). In most
young patients, this may last for only a week or two after healing.
Other complications include generalized herpes zoster, wherein lesions
may spread all over the body, even to the head and neck. This is more
frequently seen in patients with Hodgkin's disease (a type of cancer)
and patients receiving medication that affects the immune system. It is
reported that as many as 70 percent patients over age 60 may develop
postherpetic neuralgia and continue to have varying degrees of pain for
months or even years after the skin lesions have healed.
CAUSES OF PAIN
This disease involves commonly nerve root ganglion (a collection of
nerve tissue), which may be replaced by scar tissue. This scar tissue
may be the cause of various problems, one being reducing the diameter of
blood vessels. There may be unequal damage of the large diameter nerve
fibers than small fibers, which changes the balance and allows the brain
to transmit pain impulses without obstruction. In general, older
patients have fewer large fibers and the capacity of regeneration of
these fibers is slow.
TREATMENT TECHNIQUES
There are basically two approaches to treatment used by physicians: one
approach tries to prevent shingles from developing into postherpetic
neuralgia and another treats the neuralgia after it starts. Some
physicians believe that shingles can cure itself and that we should
treat the patient only when it develops into postherpetic neuralgia.
However, treatment of postherpetic neuralgia is frustrating for both
patients as well as physicians, as there is no reliable treatment after
the painful condition starts. Hence, we agree with the physicians who
believe that treatment should be started in the early stages of the
disease to obtain the best result.
GOALS OF TREATMENT
The major of pain management is to put you back in charge of your life.
The overall relief from chronic pain depends on more than just treating
the damaged area of the body. It is possible that you will always have
to live with a certain amount of pain, but you can learn to work and
enjoy life in spite of it. Our aim is to make progress with small
victories, which add up and produce a big improvement in your life.
TREATMENT MODALITIES
We offer numerous approaches:
- Injection therapy
- Psychological counseling
- Prescription of alternative medications
INJECTION THERAPY
Injection therapy is done in various forms such as subcutaneous or
intracutaneous infiltration, trigger point injections (injections into
the area responsible for pain), nerve blocks (around the nerves
transmitting pain), sympathetic block (injections around sympathetic
ganglions), epidural blocks and epidural steroid injections (injections
into the space outside the membrane covering the spinal cord).
Injections are very successful in this condition if started in the early
stages. In a typical case of therapy, a series of injections are
required. Each injection provides relief that exceeds the duration of
action of local anesthetic, and additional blocks also provide relief
that exceeds relief by the previous block. Often a staircase phenomenon
is reached in which there is some degree of permanent relief with each
injection. Injections are repeated as pain starts returning, however,
with reducing frequency as time passes. Some patients require only one
or two injections while some may need several.
PAIN MEDICATIONS
- Antiviral agents
- Anti-inflammatory agents
- Antidepressant
- Lidocaine 5 percent gel patch (Lidoderm patch)
SUMMARY
In summary, there is a causation between the duration of the neuralgia
and the effectiveness of treatment. Prompt treatment in the first three
weeks shortens the progressive course of the disease and also decreases
its severity. There is also a correlation between the age of the patient
and response to therapy. The incidence of postherpetic neuralgia is
higher in older patients and their response to therapy is poor. Hence,
the best way to prevent neuralgia following shingles is diagnose and
treat the disease early in the acute stage.
WEB RESOURCES
www.nlm.nih.gov/medlineplus/shinglesherpeszoster.html
