Current pain and headache reports
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The purpose of this review is to provide an overview and update on the common causes of headache attributed to arterial hypertension with a focus on secondary headache disorders. We will also highlight uncommon and recent findings in this area of research. ⋯ There is some controversy in the relationship between chronic hypertension and headache, particularly migraine; recent research suggests that there may be a link, but it is likely complex and multifactorial. Many recent studies and case reports demonstrate that the pathophysiology underlying the onset of headache as it relates to abrupt rises in blood pressure seems to lie at the cellular level and mechanically becomes an issue with disruption of the blood-brain barrier. Although not a formally defined headache entity, carotid revascularization syndrome demonstrates this phenomenon and also has a recent set of proposed criteria that include headache and elevated blood pressure. This paper reviews the various etiologies of hypertensive headaches, mostly in regard to headache as a secondary symptom of elevated blood pressure. We will also discuss trends of hypertensive headache in pregnancy. Finally, we will touch on controversy that exists in relation to chronic hypertension and its causal relationship to headache as well as the relationship between hypertension and migraine.
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Enhanced recovery after surgery (ERAS) has become a widespread topic in perioperative medicine over the past 20 years. The goals of ERAS are to improve patient outcomes and perioperative experience, reduce length of hospital stay, minimize complications, and reduce cost. Interventions and factors before, during, and after surgery all potentially play a role with the cumulative effect being superior quality of patient care. ⋯ Preoperatively, patient and family education, optimization of nutritional status, and antibiotic prophylaxis all improve outcomes. Recovery is also expedited by the use of multimodal analgesia, regional anesthesia, and opioid reducing approaches. Intraoperatively, the anesthesiologist can have an impact by using less-invasive monitors appropriately to guide fluid and hemodynamic management as well as maintaining normothermia. Postoperatively, early enteral feeding, mobilization, and removal of invasive lines support patient recovery. Implementation of ERAS protocol in cardiac surgery faces challenges by some unique perioperative perspectives in cardiac surgery, such as systemic anticoagulation, use of cardiopulmonary bypass, significantly more hemodynamic variations, larger volume replacement, postoperative intubation and mechanical ventilation and associated sedation, and potentially significantly more co-existing morbidities than other surgical procedures. ERAS in cardiac surgery may benefit patients more related to its high risk and high cost nature. This manuscript specifically reviews the unique aspects of enhanced recovery in cardiac surgery.
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Curr Pain Headache Rep · Mar 2019
ReviewRegional Catheters for Outpatient Surgery-a Comprehensive Review.
This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques. ⋯ Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.
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Curr Pain Headache Rep · Mar 2019
ReviewCGRP Antagonists for the Treatment of Chronic Migraines: a Comprehensive Review.
The purpose of the following review is to summarize the most recent understanding of migraine pathophysiology, as well as of basic and clinical science pharmacologic literature regarding the development of calcitonin gene receptor peptide (CGRP) antagonists as a novel therapeutic modality for the treatment of migraine headaches. A review is provided of erenumab, the first of its class FDA approved CGRP antagonist. ⋯ Despite its high prevalence, the occurrence and treatment of migraine headaches is poorly understood. Erenumab and CGRP antagonists as a whole significantly reduce the average number of migraine days experienced in migraine sufferers. CGRP antagonists appear to significantly improve treatment outcomes in patients who suffer from episodic and chronic migraines. Erenumab is the first CGRP antagonist to be FDA approved for public use; however, further development of biologics in this class is underway.
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Curr Pain Headache Rep · Mar 2019
ReviewLow Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment.
Low back pain encompasses three distinct sources: axial lumbosacral, radicular, and referred pain. Annually, the prevalence of low back pain in the general US adult population is 10-30%, and the lifetime prevalence of US adults is as high as 65-80%. ⋯ Patient history, physical exam, and diagnostic testing are important components to accurate diagnosis and identification of patient pathophysiology. Etiologies of low back pain include myofascial pain, facet joint pain, sacroiliac joint pain, discogenic pain, spinal stenosis, and failed back surgery. In chronic back pain patients, a multidisciplinary, logical approach to treatment is most effective and can include multimodal medical, psychological, physical, and interventional approaches. Low back pain is a difficult condition to effectively treat and continues to affect millions of Americans every year. In the current investigation, we present a comprehensive review of low back pain and discuss associated pathophysiology, diagnosis, and treatment.