The Clinical journal of pain
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Review Case Reports
Pharmacologic management of bone pain in the cancer patient.
Cancer patients may experience acute or chronic pain caused by tumor infiltration of pain-sensitive structures or related to surgery, radiation, and chemotherapy. Acute bone pain, with or without associated neurologic deficits resulting from tumor metastasis to bone and contiguous neural structures (e.g., large peripheral nerve trunks or the spinal cord), is a common cause of intractable pain in cancer patients. ⋯ Less commonly, invasive therapies, such as resection of vertebral body tumor with spinal reconstruction or pituitary ablation and intraventricular opioid administration (for diffuse bone pain), are offered. In this article I discuss current approaches to the management of pain in cancer patients, emphasizing current hypotheses on the pathogenesis of bone pain and the rationale for its pharmacologic treatment.
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Headache is the most common complaint encountered in clinical practice. Approximately 45 million people in the United States experience chronic headaches. The management of migraine headache involves both pharmacologic and nondrug therapy. ⋯ Prophylactic therapy is focused on reducing the frequency and severity of the attacks. beta-Adrenergic blocking agents, such as propranolol, remain the primary agents for many migraine patients, although other drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), including ketoprofen, or calcium-channel blocking agents, such as verapamil, may be beneficial for many patients. For cluster headache and its variants, methysergide and corticosteroids are usually the drugs of choice. Patients with chronic cluster headache may achieve good results from long-term treatment with other therapies, including lithium carbonate, verapamil, and ketoprofen.
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Muscle contraction headache is the most common headache afflicting mankind. Acute muscle contraction headache usually presents no problem in treatment and is a self-limited condition. Chronic muscle contraction headache presents a very difficult treatment problem. ⋯ The pathophysiology of muscle contraction headache is unknown. There is much controversy as to whether muscle contraction is the primary cause of this condition or whether muscle contraction is merely another component of this syndrome. The extensive research now going on in the field of chronic pain should help clarify the issue.
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The recent development of new drug therapies for headache disorders has allowed for the tailoring of treatment to specific patient needs. This paper reviews the pharmacologic management of patients with both headache and concomitant medical illness. The discussion specifically includes the treatment of hypertension, coronary artery disease, mitral valve prolapse, asthma, peptic ulcer disease, obesity, and chronic Epstein-Barr virus infection, occurring concomitantly in patients with headache. Medications that can exacerbate either the headache or concurrent medical condition are noted, and alternative therapies are advised.