Nociceptive Views December Edition 10

Introduction

Physiology of chronic pain (Part 2)

How does pain become chronic?

After an injury or surgery, it is expected that pain threshold is restored to pre-injury levels, however this is not always the case. Sometimes pain persists, and eventually acute pain progresses to chronic pain. Minimizing the transition of acute to chronic pain through improving acute pain management will lessen the burden on the health care system. Chronic pain arises from intense repetitive acute (nociceptive) pain via a process referred to as ‘pain chronification ’ (Basbaum et al., 2009; Gill, 2018). This process of chronification results in gradual changes in the anatomical and physiological architecture of the pain pathways that consequently leads to decreased pain threshold, heightened and exaggerated responses to noxious stimuli. 

Headache classification: The use in clinical practice

Headache is a very common and a significant problem worldwide. Lifelong prevalence of headache is 96% with a female predominance. The global active prevalence of tension type headache is approximately 40% and migraine 10%. Doctors evaluating patients with acute headache must determine whether the condition is benign or if it signals dangerous neurologic or systemic pathology. Because headache has varying presentations, aetiologies, triggers and methods of management it can pose diagnostic and therapeutic dilemmas. Most headache diagnoses are based entirely on the patient history. Physical examination only rarely contributes significantly to the diagnosis. It is therefore important to have a classification system to help in the evaluation and treatment of headaches.

New era in migraine treatment

Since the beginning of modern medicine, advances have come with ever-increasing speed in all fields. Technology has enabled progress beyond our wildest dreams, robotic surgery enables surgeons to perform highly complex surgery without cutting open the patient, paralysed patients can walk with electrical implants in the spinal cord and telehealth allows patients to consult a doctor who is thousands of kilometres away through their smartphones. I was anticipating that in the future my bustling waiting room would be a ghost town and all that will be left is a giant screen, it seems that this eventuality was thrust upon me prematurely as the Covid-19 pandemic spread to our shores. In spite of our seemingly infinite scientific knowledge, there are still so many unanswered questions about the brain. Migraine, despite being the third most debilitating condition in the under 50 age group and rated 6th most disabling condition by the World Health Organisation, is one such neurological disorder that has remained an enigma, until recently!

Needle in my head! Interventional procedure options for headache management

Headaches are difficult and complex to manage. Interventional procedures are not the first treatment option for this group of patients. I will never forget the time I came into my clinic and my registrar had a stethoscope to the patient’s head. I think she did this out of pure desperation, because to diagnose and treat a headache is difficult.

Physiotherapy options for the management of headaches 

Physiotherapy treatment is one of the most common non-pharmacological treatment approaches used for headaches which have a neuromusculoskeletal and neurophysiological component to the origin of the headache. Goodman et al (2017), refers to causal factors linking certain types of headaches to the dysfunction of the cervical spine, thoracic spine, or the temporomandibular joints; muscle tension, poor posture, and nerve impingement.1 It is important to determine, through patient self-report and practitioner history-taking, the type of headache presenting and the best mode of treatment for the patient.