Pain Flashcards
What is hyperalgesia?
Increased pain from a stimulus that normally evokes pain
What is allodynia?
Pain due to stimulus that does not normally evoke pain
What is Parasthesia ?
Abnormal sensation which can be spontaneous or evoked
What is dysaesthesia?
An unpleasant abnormal sensation evoked or spontaneous
What is neuralgia?
Severe pain in the distribution of sensory nerves
Chronic pain?
Pain that persists beyond normal tissue healing for more than 3 months
It is real, subjective, influenced by past experiences
Neuropathic pain?
Pain that arises from a lesion of the somatosensory system
Patients with chronic pain disorder present with which features?
Somatization and catastrophizing
Somatization: physical symptoms as a manifestation of psychological stress)
Symptoms are medically unexplained
Catastrophizing: unbearable, horrible
What is Trigeminal neuralgia? And what is the pathology behind it?
Sudden, Unilateral, brief stabbing pains in the distribution of one or the V branches
Always involved peripheral trigeminal afferant neurone. Likely that patients have lesion pressing on where the nerve exists brain stem eg via superior cerebellar eatery which causes demyelination and hypermyelination
What are the causes of pain in the head and neck region?
oral facial (tmj, sinus, salivary glands) vacular neurological psychogenic
What is the incidence of TN? Who is more common amongst?
2-5/100 000
More common in females than males
What is the peak age of onset for people with TN? What is this pain quality like in TN?
50-60
Sharp agonising electric shock felt superficially in skin or buccal mucosa which can be triggered by light, mechanical touch at the trigger zone which usually lasts a few seconds but occasionally 1-2 mins
Pain may occur at intervals followed by an interval free period
What are the two broad categories for management of TN?
Medical and surgical
What medications are implicated in TN?
Carbamazepine 100mg Gabapentin Phenytoin Lamotrigene Valproate Topirimate
Which medication can be used as a diagnostic aid for TN?
Carbamezapine
When taking carbamezapjne for TN what investigations are needed?
Blood pressure
FBC
Liver function
Plasma levels
What are the side effects to carbamezapjne?
High blood pressure, Ataxia Drowsiness Leukopania Liver toxicity
How can you treat TN surgically ?
Local surgical treatment or central surgical treatment
Which local treatment methods for TN exist?
LA + bupivicane
LA + Glycerol block
Cryotherapy Peripheral neurectomy (alcohol phenol)
What are the disadvantages to local surgical treatment for TN?
Temporary sensory loss
How do you treat V neuralgia using central surgery?
Micro vascular decompression
Partial sensory rhizotomy
Radio frequency lesion or thermocoagulation
Retro gasserian glycerol injection
What is micro vascular decompression?
Separation sup cerebellar artery from Trigeminal nerve
No sensory loss
What is partial sensory rhizotomy?
Section sensory fibres off Trigeminal nerve
Leads to sensory loss
Radio frequency lesion or thermocoagulation involves what?
This is when the heat is applied to the sensory lesion behind ganglion
This leads to sensory loss, corneal anaesthesia and dysaesthesia
How do you perform a retro-gasserian glycerol block?
Glycerol is infected into the meckels cave
This doesn’t cause sensory loss and recurrs after 1 year
What is Glossopharyngeal neuralgia?
Sharp pain along distribution of CN9
Pain felt in the throat, Tonsillar fossa and adjacent fauces
What provokes the pain sensation felt in Glossopharyngeal neuralgia?
Can be spontaneous or evoked by mechanical stimulation of Tonsillar area eg coughing of swallowing
Where does the pain in Glossopharyngeal neuralgia radiate to?
External ear, angle of jaw and neck
How is the pain in Glossopharyngeal neuralgia relieved?
LA to trigger zone
What is the incidence of Glossopharyngeal neuralgia?
1/200 000
What is post herpetic neuralgia?
Chronic pain with skin changes in the distribution of a nerve following herpes zoster
What type of pain is characteristic of post her petic neuralgia?
Burning, dysaesthesia, Parasthesia, cutaneous pain
Usually moderate intensity but since content and intractable can be intolerable
Which nerve if usually involved in PHN?
Va
What mood disorder is associated with PHN?
Depression
T/F the area skin affected by herpes zoster shows no changes?
F
On occasion there may be cutaneous scarring and lack of pigmentation in that area
What is the prevention and treatment for PHN?
High dose Acyclovir during initial herpes zoster infection to prevent
Treatment Amitryptulin Pregabalin Topic LA Capsaicin patches
What are tension headaches?
Dull aching head pain usually symmetrical in nature
Nausea occasional vomiting
Exacerbations with pounding headaches, but less intense than migraine
Where do tension headaches usually arise?
Frontal/orbital occipital whole scalp
Diffuse and band like usually bilateral and sometimes more on one side
Who is more commonly affected by tension headaches? Males or females?
Females 4:1
What age do tension headaches begin
Usually before 30 as young as 8
What are the precipitates to tension headaches ?
Emotional stress
Depression anxiety
Exercise
Alcohol (sometimes can relive it)
How so you manage tension headaches?
Relaxation techniques
Analgesics
Anxiolytics although should be avoided since some patients becomes depressed and others become dependant
TCA: amitrtiptyline
what is atypical atypical facial pain?
chronic facila pain of unknown aetiology
what are the features of atypical facial pain? T/F midline is often crossed?
constant pain, dull, usually unilateral and maxilliary
poorly localised and doesnt have a single provoking factor
T midline often crossed
what mood disorders is atypical facial pain associated with?
anxiety and depression
What age group and sex does atypical facial pain usually affect?
Females>male
30 years +
what type of diagnosis is atypical facial pain?
a diagnosis of exclusion, no organic cause
how do you manage atypical facial pain?
Reassurance topical: difflam, lignocain, TCA: ami gapapentin psychoterapies
what syndrome presents with a severe throbbing pain in a tooth and GINGIVAE which may be mild or severe pain and may move from tooth to tooth?
atypical odontolgia
Other features include: maybe wide spread or well localised and frequently precipitated by dental procedure may last for few minutes to couple of hours
what other conditions is atypical odontalgia associated with?
TMJDS, oral dysaesthesia and pains of psychological origin and often excessive concern with OH
what is oral dysaesthesia?
unpleasnt abnormal sensation in the mouth
what is burning mouth syndrome?
burning pain in the tongue or other mucous membranes
which areas of the tongue are most commonly affected?
tip and lateral borders of the tongue (anterior hard palate and lips often involved and any mucosal areas ) bilateral
increases intensity mid morning and late afternoon
what is the demographics of BMS?
more common in females more than males and age of onset is 50
what are the symptoms are assocated with BMS?
dry mouth thirst denture intolerance metallic taste Burning increases with tension, fatigue, speaking and not food and decreases with sleeping
what investigstions are asscoiated with BMS? And how do you mange it?
bloods: anaemia, Haamatiniic def, diabetes and CT disease
candida: swab
Management: correct any underlying path Topical rinses: diff lam and Zn sulphate Vitamin B TCA Gabapatentin and pregabalin Psychotherapists
what are cluster headaches? What are the pain type?
Periodic migranous neuralgia
severe unilateral headache usually in ocular, frontal and temporal region
Constant stabbing burning or throbbing patient my pace floor and not usually able to lie down
what is the prevelance of cluster headaches?
7/10000 more common ni males age 20-40
what is the nature of attack for cluster headaches?
occur in bouts, lasting 4-12 weeks which last for 6-18 months
1-3 attacks lasting 2 hours each within 24 hours
Nocturnal attacks
which two things being unbearbale during cluster headache onset?
altitude and alcohol
what are the symptoms of cluster headache?
ANS symtpoms Ipsilateral miosis, ptosis, lacrimation photophobia irreugular heart rate in severe attacks Dysaesthesia when touching scalp in area of CNV1
how do you manage cluster headaches?
Ergot preparation
oxygen inhalation
intransal lignocaine
steroids, verapamil, lithium or pizotifen
Serotonin 1Dreceptors antagonist eg sumatriptan
what is the incidence of classic migraine?
females more than males
what are the stimulants for classic migraine?
Stress, mood changes, dietary (bananas, chocolate, cheese, citrus, fruits) OCP, flashing lights, atmospheric change
what are the features of classic migraines? And what is the frequency?
aura, 20-25 mins of sensory or motor disturbances usually visual changes
unilateral throbbing headache usually in front temporal region photophobia and phonophobia
nausea
Usually lasts for 4-72 hours if no medication used
Pulsating action increase with moderate physical activity or stooping
Frreuqncy: usually 1-4 during month reduced in pregnancy
What deficiency can carbamezapjne cause?
Folate
What are the side effects of using TCA?
Nausea
Analgesics
Sedation
Anticholinergic effect
What percentage of TN affects the different decisions?
Opthalmic: 3%
Max: 35%
Man: 30%
What percentage of TN is bilateral?
2%
What percentage affects CNV1 and CNV2?
10%
What percentage of TN affects CNV2 and CNV3?
20%
What is pain?
Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of damage
What are the pain pathways?
Anterolateral pathways ascending to cerebral cortex via thalamus
What are the 3 dimensions of pain?
Sensory physiological
Motivational affective
Cognitive evaluative
What are the neuralgias of the head an face?
- Primary trigeminal neuralgia (Tic Doulourex )
- post herpetic neuralgia
- Glossopharyngeal neuralgia
What are the Craniosacral pain of musculoskeletal origin?
Tension headache
TMJ
What are the lesions of the ear nose and oral cavity that cause pain?
Odontalgia : tooth pain not associated with lesions (atypical)
Glossodynia and sore mouth also known as BMS and oral dysaesthesia
What are the primary head ache syndromes, vascular disorders that cause chronic pain?
Classic migraine (migraine with aura)
Common migraine (migraine without aura)
Cluster headache
Temporal arteritis
What percentage of people have unilateral TN?
95%
T/F TN is strictly limited to CNV?
T
Which branch is Trigeminal is affected most commonly and which is affected least?
CNV2 then 3 then 1
Which side is pain more frequent?
Right
What is the diff dx for trigeminal neuralgia?
Secondary TN aneurysm / trauma
MS
What is TMJDS?
Aching pain in the mom and sometimes brief severe pain on chewing and associated with limited jaw movement and clicking and popping of jaw
What type of pain is seen in TMJDS?
Intermittent
Unilateral dull and aching
But can be constant
Maybe exacerbated by jaw movement, chewing hard food or yawning and worse on waking often.
What are the signs of TMJDS?
Restricted mandibular movement with or without deviation of the jaw to the affected side on opening
Tenderness to palpating of the MoM
Clicking or popping of the jaw on auscultation and palpatin
Changes in ability to occlude teeth fully
How can you manage TMJDS?
Occlusal splints Heat pack TMJ exercise and massage Medication eg NSAIDS, anxiolytics TCA Psychotherapy Surgical
What is the age of onset for classic migraine?
Childhood until about 35 usually starts Late puberty
What are the types of migraines?
Classic
Common
Complicated
How do you manage classic migraine?
NSAIDS paracetamol Anti emetic Ergot prep Prophylactic Bbblocker Serotin 1D receptor agonist
What is the incidence of temporal arteritis?
3-9/100,000
F more than M
Age of onset 50-60
What is temporal arteritis?
This is a vasculitis affecting the branches of the external carotid artery with resulting obliteration of the vessel lumen and ischsmis to suppled part
T/F temporal arteries is unilateral?
F can be uni or bilateral
What are the features of temporal arteritis pain?
Unilaterla or bilateral temporal headache which may be continuous with aching and throbbing
Systemic disturbances like malaise and low grade fever and wight loss
T/F Temporal arteritis is associated with poly myalgia rheumatica?
T
What is the complication with temporal arteritis and how does this happen?
Blindness due to involvemtn of the crntral retinal artery
What is the treatment for temporal arteries?
Titrre ESR with high dose steroids
What may happen to the tongue in temporal arteritis?
Ischamic necrosis and gangrene
What investigations would you do for temporal arteritis?
Biopsy: Giant cell arteritis
Bloods: raised ESR
How do you treat temporal arteritis?
Steroids and immunosuppressants eg azothiarpine
What are the names of the common medications used in pain?
Carbamezapine Oxycarbamezapine Gabapentine Pregabalin Lamotrigene Baclofen TCA SSRI
What is the usually dose for carbamazepine? And what are the side effects?
Initially 100-200mg od/bd
Max dose : 1.6g/24 hours
Nausea vomiting Headache Blood dyscrasia Hepatitis Hypertension Actute renal failure Stevens Johnson
What is the dose of oxycarbamzapine and what are the side effects?
300mg bd
Max dose is 46mg/kg/day
Same side effects as carbamezapine but better tolerated
What are the dose and side effects of gabapentine?
Day 1: 300mg
Day 2: 300mg bd
Day 3: 300mg tds
Max dose: 3.6g/24 hours
When does the pain sensation felt in BMS become worse?
Mid morning
Late afternoon
T/F. In cluster headaches, you can suffer from nocturnal attacks .
T
