Current Pain and Headache Reports最新文献

Purpose of review: Intervention trials for cervicogenic headache (CGH) often yield equivocal results with marked treatment effect heterogeneity, possibly reflecting variations in underlying pain mechanisms throughout the CGH population. Pain phenotyping or classifying patients into subgroups based on their predominant pain mechanism may facilitate more precise CGH treatment. This review aims to explore the role of pain phenotyping in CGH management.

Recent findings: Clinical evidence suggests two predominant pain mechanisms in the CGH population: nociceptive and nociplastic. Arguably, treatments for nociceptive pain should address the source of peripheral nociception, and treatments for nociplastic pain should address factors contributing to maladaptive central pain modulation. Due to centrally mediated analgesic effects, muscle relaxants are strongly recommended for managing both nociceptive and nociplastic CGH pain. Antidepressant medications may be most relevant for nociplastic CGH pain. Cervical spinal mobilization and manipulation interventions are strongly recommended for both nociceptive and nociplastic CGH pain. Nociplastic CGH pain may benefit from educational interventions regarding lifestyle factors such as physical activity, diet and weight management, sleep hygiene, and stress reduction. The anesthetic blockade, glucocorticoid injection, and radiofrequency denervation are strongly recommended for nociceptive CGH pain. Patients with persistent nociplastic CGH pain may benefit from neuromodulation interventions. Pain phenotyping may facilitate more precise clinical management of patients with CGH. This review provides evidence-informed recommendations for CGH pain phenotyping, including specific subgroups, clinical criteria, and stratified treatment approaches. Further prospective investigation is needed to determine the effects of pain phenotyping on clinical outcomes in patients with CGH.

Purpose of review: The purpose of this review is to provide an update on the efficacy and safety of capsaicin in the treatment of neuropathic pain.

Recent findings: Capsaicin can provide prolonged relief from pain in various neuropathies. One proposed mechanism is the ability to cause degeneration of hypersensitized nerve tissue and incite regeneration of healthy nerve fibers. Capsaicin provides more significant relief than placebo and is non-inferior to pregabalin in the treatment of peripheral neuropathy. It is emerging as an alternative but effective and well-tolerated treatment for neuropathy due to diverse pathologic conditions. Capsaicin, a natural agonist at the TRPV1 receptor, has been studied for its therapeutic role in neuropathic pain. Capsaicin is an effective treatment with significant reduction in both diabetic and non-diabetic neuropathic pain. Due to its topical application, it is associated with fewer systemic adverse events and therefore, an attractive option in the treatment of peripheral neuropathy.

Background: Robot-assisted prostatectomy (RAP) can cause significant post-operative pain. Opioids are commonly used for relief, but they pose risks such as side effects and potential dependence. To reduce opioid usage, regional anesthesia approaches, especially various nerve block techniques, have been developed. However, evidence comparing the effectiveness of these different nerve blocks remains limited.

Methods: A systematic review was conducted to evaluate the effectiveness of different nerve block techniques on post-operative pain control after RAP. Databases were searched for randomized controlled trials (RCTs) that compared nerve blocks with either standard care or other regional anesthesia techniques. The primary outcomes assessed were pain scores, opioid consumption, recovery metrics, and treatment-related adverse effects.

Results: Eight studies comprising 696 participants were included. Intrathecal morphine consistently demonstrated the most significant reduction in post-operative pain and opioid use, though with increased incidence of pruritus and other side effects. Erector spinae plane blocks (ESPB) and rectus sheath blocks (RSB) were also effective, offering a favorable balance of analgesia and safety. Quadratus lumborum blocks (QLB) and pudendal nerve blocks (PNB) were found to effectively reduce pain, opioid usage, and side effects when they were used in a multimodal analgesic protocol. Alternatively, transversus abdominis plane blocks (TAPB) and caudal blocks were found to have mixed or no opioid-sparing effects. Because of methodological heterogeneity between studies, direct comparisons between blocks were limited.

Conclusion: Regional anesthesia techniques improve post-operative pain control and reduce opioid use after RAP. Given the lack of definitive superiority among techniques, analgesia should be individualized and incorporated into multimodal, opioid-sparing protocols. More large-scale, head-to-head trials are needed to guide optimal nerve block selection.

Purpose of review: This report aims to synthesize the literature at the intersection of pediatric chronic pain and gender diversity, highlighting recent conceptual and empirical developments.

Review of findings: Recent theoretical frameworks expand upon the biopsychosocial model by integrating minority stress, ecological-systems, and intersectional perspectives to better understand the chronic pain experiences of transgender and gender-diverse (TGD) youth. While TGD youth experience disproportionate pain-related risks, influenced by intersecting identity-based stressors, structural inequities, and systemic barriers to affirming care, this group remains underrepresented in pain research and intervention development. To promote equitable care, pain researchers and clinicians must adopt inclusive assessment tools, enhance provider education, implement strengths-based interventions, and advocate for policies that reduce disparities and affirm the identities of TGD youth with pain. Promoting gender-affirming, trauma-informed, and intersectional approaches may offer a clear path toward more inclusive and equitable pediatric pain management.

Purpose of review: This review provides evidence for the mechanism of action (MOA) of Remote Electrical Neuromodulation (REN), a non-pharmacological therapeutic technology for treating migraine and other symptoms manifested by certain idiopathic pain diseases. It discusses the main physiological and anatomical aspects associated with conditioned pain modulation (CPM), and how REN is applied for the treatment of migraine pain and other symptoms.

Recent findings: The REN wearable device (Nerivio^®) is FDA cleared for acute and preventive treatment of migraine in patients aged 8 years and above, and CE marked in patients aged 12 and above. In brief, the REN MOA is formulated on the observed concept that one of the descending pain inhibition mechanisms in the brain, known as CPM, is deficient among people diagnosed with certain idiopathic pain disorders, such as migraine. Hence, these people are more vulnerable to otherwise innocent external stimuli, which are misinterpreted in the brain as painful and can thus trigger a migraine attack, often presenting with increased pain sensitivity (hyperalgesia) and headache. Research has revealed that descending inhibitory mechanisms can be externally activated under certain conditions. REN operates through applying electrical stimulation with parameters designed to activate A-delta and C nociceptive nerve fibers in the skin to optimize this response, thereby enhancing CPM and increasing pain inhibition by releasing norepinephrine and serotonin. Based on current evidence, the review presents medical practitioners and researchers with a detailed explanation of the REN MOA in treating and preventing migraine, and potentially other idiopathic pain disorders.

Purpose of review: Cluster headache (CH) is a debilitating type of headache disorder, relatively rare and can be presented with atypical patterns. Aura is well determined in migraine patients, and recently it has been accepted to appear with other primary headache disorders, or even occurring in isolation. Hemiplegic Cluster Headache (HCH) is a rare variant of CH, defined and reported in patients presenting typical symptoms of CH along with reversible hemiparesis or hemiplegia, like reported in Migraine with Unilateral Motor Symptoms (MUMS).

Recent findings: We identified eight published HCH cases with convergent clinical features and treatment responses based on the possible shared pathophysiology in HCH and hemiplegic migraine. We proposed diagnostic criteria in this review, based on literature findings. HCH is rare but may be undiagnosed, aura features with concurrent motor unilateral weakness can be present due to associated comorbidity, motor aura, or in a secondary case. The proposed diagnostic criteria are useful for better recognizing the condition and afford improvement on treatment and future investigations.

Purpose of review: A transverse abdominal plane (TAP) block is a type of peripheral nerve block where local anesthetic agents are injected into the nerve fibers of the anterior abdominal wall to provide pain relief during gastric surgery. An appendectomy is one of the most common surgical procedures performed in the US, indicated for the treatment of acute appendicitis, and involves the surgical removal of the appendix.

Recent findings: The TAP block is one of many pain management options available to patient care teams during laparoscopic appendectomy procedures, so its efficacy must be weighed against alternative pain management options. While there is strong evidence that the TAP block is either equivalent to or superior to, alternative methods of pain management for the broad discussion of abdominal surgeries, we could not identify a clear answer on whether the TAP block is the most efficacious option for the specific purpose of laparoscopic appendectomy post-operative pain management. The decision to use the TAP block will be influenced by specific patient circumstances and the individual clinical expertise of the patient provider.

Purpose of review: Postoperative pain is a prevalent clinical challenge that often leads to high opioid consumption, delayed hospital discharge, and associated side effects. Inadequate pain control can delay recovery and contribute to the risk of chronic postsurgical pain and opioid dependence. Magnesium, an essential cation with diverse physiological roles, has gained attention as a non-opioid adjunct for perioperative analgesia related to multimodal mechanisms of action and a favorable profile.

Recent findings: Pharmacologically, magnesium acts as an N-methyl-D-aspartate (NMDA) receptor antagonist and calcium channel blocker in the central nervous system, dampening excitatory neurotransmission and reducing central sensitization to pain. It also exhibits anti-inflammatory and anti-nociceptive effects and is inexpensive and easy to administer intravenously. These properties make magnesium a cost-effective and simple addition to multimodal pain management protocols. When used as a preoperative or intraoperative adjunct, magnesium has demonstrated reduced postoperative pain intensity and decreased opioid requirements across various surgical populations. Trials and meta-analyses report that patients receiving perioperative magnesium experience lower pain scores and need fewer opioids in the first 24-48 hours after surgery, translating into an opioid-sparing effect and potentially less opioid-related nausea and sedation. Importantly, magnesium has a favorable safety profile at recommended doses and generally is well-tolerated with minimal side effects apart from infrequent hypotension or mild sedation. No significant respiratory depression occurs in patients with normal renal function. The present investigation highlights magnesium-mediated analgesic mechanisms, summarizes clinical evidence for efficacy as a preoperative pain adjunct, and describes implications for improving postoperative pain outcomes and reducing opioid reliance in perioperative care.

Purpose of review: Lumbar transforaminal epidural steroid injections (TFESIs) are a widely used interventional procedure for managing lumbosacral radicular pain and other spinal conditions. TFESIs help reduce inflammation and enhance function by delivering corticosteroids into the nerve root and epidural space. The transforaminal approach is commonly utilized for its precise targeting, offering both diagnostic and therapeutic benefits. Furthermore, this technique can be performed in patients with a history of laminectomy or contraindications to performing an interlaminar approach at the targeted levels. This study reviews current practice patterns, technical preferences, and procedural experiences of interventional pain physicians performing lumbar TFESIs.

Recent findings: A survey was distributed to interventional pain physicians via email, web links, and social media platforms. Respondents included academic physicians in ACGME-accredited fellowship programs, as well as hospital-based and private practice physicians. The survey contained questions focusing on fluoroscopic views used for TFESIs, frequency of one-level versus two-level injections, and the occurrence of paresthesias during lumbar TFESIs. Data were collected anonymously, and descriptive statistics were used to analyze responses. A total of 87 respondents completed the survey. For fluoroscopic guidance, 60.9% (53/87) preferred using a combination of AP, oblique, and lateral views. Regarding injection levels, 63.2% (55/87) reported sometimes performing two-level injections, while 27.6% (24/87) always performed two levels, and 9.2% (8/87) exclusively performed one-level injections. The frequency of paresthesia during TFESIs varied, with 73.6% (64/87) reporting paresthesia occurring sometimes, 18.4% (16/87) reporting it most of the time, and 6.9% (6/87) stating it never occurred. This study highlights diverse practice patterns among interventional pain physicians performing lumbar TFESIs. Most physicians prefer multi-view fluoroscopic guidance and adapt the number of injection levels based on clinical need. Paresthesia during TFESIs is commonly reported but varies in frequency. These findings provide preliminary insights into procedural techniques and decision-making in lumbar TFESIs, offering a foundation for future research to refine best practices and improve patient outcomes.