Treatment of Pain in Neurologic Disease
A working understanding of pain and its treatment is important in the management of many patients with neurologic disease. Consider the following points:
Pain is a subjective symptom. There are no physical findings that quantify or exclude the presence of pain. Assume that the patient has pain, and then approach management.
An adequate pain assessment includes documentation of pain location, intensity, quality, onset, duration, variation, what makes it worse, what makes it better, effects of pain on function and lifestyle, and the development of a pain plan.
It is important to consider disease factors that may cause pain, and evaluate the patient appropriately for pain-causing disorders that can be corrected (e.g., tumor causing pain, compressive nerve root lesion).
Pain can be quantified by the patient. Numerous studies have shown that a visual analog scale, in which the patient bisects a line that goes from “no pain” to “maximal pain,” is the best method of quantifying pain. It is simple and provides the physician with a “semi-objective” measure of whether pain is improving or worsening.
Patients with chronic pain often develop depression, and are misunderstood by physicians, or shunned as “difficult” patients. In addition, there may be workers’ compensation or litigation issues that complicate the doctor-patient relationship. The physician may develop “compassion fatigue” when dealing with a chronically disabled patient in pain. Chronic pain is often best managed in a center with comprehensive services.
TREATMENT OF PAIN
It is best to use a “stepped” approach in pain management.
Begin with simple analgesics such as acetaminophen, aspirin, and nonsteroidal medications.
Addition of a tricyclic antidepressant may be useful in chronic pain, neuropathic pain, and headache, and in depressed patients with pain. Gradual titration of the medication dose usually works best. Amitriptyline, imipramine, and nortriptyline are commonly used, and have been shown to have efficacy in neuropathic pain. Selective serotonin reuptake inhibitors are less effective in pain management. Venlafaxine and nefazodone are antidepressants with potential efficacy in pain management.
Antiepileptic medication also may be used in chronic pain management, particularly when pain is neuropathic. Phenytoin, carbamazepine, valproic acid, and gabapentin each can be of benefit. Gabapentin is particularly useful in trigeminal neuralgia, and in painful peripheral neuropathy. Gabapentin has minimal interaction with other medications. Pre-gabalin is FDA approved for painful diabetic neuropathy and has also been used for other neuropathic pain syndromes. Both gabapentin and pre-gabalin are renally excreted and dose adjustments need to be made for renal dysfunction. Other newer antiepileptic medications such as lamotrigine, topiramate, and levetiracetam also are used for this indication.Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
