Articles: neuralgia.
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The objective of this study was to assist clinicians in the diagnosis of the occipital neuralgia syndrome by describing its clinical characteristics. Bibliographies and clinical descriptions of occipital neuralgia syndrome were identified through a review of literature published between 1966 and 1993. A prospective case series was performed by the authors in a university emergency department during a 1-year period. ⋯ Occipital neuralgia is a benign extracranial cause of headache, and it may be confused with other more serious headache syndromes. Recognition depends on an understanding of the symptoms along with a careful history and physical examination. Local anesthetic injections produce significant relief of the headaches and can aid in the diagnosis of the syndrome.
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The objective of this study was to review the effectiveness and safety of antidepressants in neuropathic pain. In a systematic review of randomised controlled trials, the main outcomes were global judgements, pain relief or fall in pain intensity which approximated to more than 50% pain relief, and information about minor and major adverse effects. Dichotomous data for effectiveness and adverse effects were analysed using odds ratio and number needed-to-treat (NNT) methods. ⋯ Compared with placebo, of 100 patients with neuropathic pain who are given antidepressants, 30 will obtain more than 50% pain relief, 30 will have minor adverse reactions and four will have to stop treatment because of major adverse effects. With very similar results for anticonvulsants it is still unclear which drug class should be first choice. Treatment would be improved if we could harness the dramatic improvement seen on placebo in some of the trials.
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Herpes zoster occurs rarely in immunocompetent children and infrequently in immunocompetent young adults. However, its incidence increases with age, particularly after age 50. Reactivation of varicella-zoster virus (VZV) is characterized by a rash and is generally accompanied by considerable pain, dysesthesias, and skin hypersensitivity. ⋯ More than 50% of zoster patients over 60 years old will develop PHN, which may persist for months and even years. Thus, established PHN is difficult to manage, often causing serious morbidity, depression, and high costs in terms of consumption of healthcare resources. Currently, early antiviral treatment with famciclovir has shown promise of reducing the duration of PHN.
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A variety of mechanisms may generate pain resulting from injury to the peripheral nervous system. None of these mechanisms is disease-specific, and several different pain mechanisms may be simultaneously present in any one patient, independent of diagnosis. Diagnosis of neuropathic pain is often easily made from information gathered on neurologic examination and from patient history. ⋯ An adequate trial for each agent tried is key to pharmacologic treatment of neuropathic pain. Tricyclic antidepressants are first-line agents, although other drugs, including anticonvulsants, local anesthetic antiarrhythmics, clonidine, opioids, and certain topical agents, also offer pain relief in some patient populations. The novel antidepressants venlafaxine and nefazodone are potentially useful new drugs that are better tolerated than tricyclic antidepressants.
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Postherpetic neuralgia, when defined as neuropathic pain persisting 1 month or longer after herpes zoster infection, affects about 10% of all patients who have contracted the disease. The incidence of postherpetic neuralgia increases with age; at age 60, about 50% of herpes zoster patients will suffer significant pain, and this proportion grows with subsequent decades. If therapy is carefully chosen and monitored, it is possible to give satisfactory relief, taking pain from severe to mild, to between 60 and 70% of patients. This article will review current treatment and focus on antidepressant drugs, treatments that are contentious and of current interest such as topical agents, and the use of opioids for this type of chronic neuropathic pain.