Posts Tagged "chronic pain"

Last updated on July 13th, 2021 at 06:49 am

STOP LETTING YOUR CHRONIC MIGRAINE AND CHRONIC PAIN DEFINE YOU AND YOUR BRAIN PLASTICITY.

@Neuralgroover

Background

I see the worst of the worst headache, migraine, chronic migraine, facial pain, fibromyalgia, and chronic pain from many states and countries. I see patients who have been debilitated by pain, patients whose pain has destroyed their family, marriage, work life, social life, and the ability to function normally. They are void of hope and have lost all self-esteem and confidence, replaced by depression and seclusion. They hide in the shadows of life. They come into the office with dark sunglasses, hoods up, appear detached, soft-spoken with little to say, and have fully committed themselves to the mindset that they will never get better. And they won’t because they don’t allow their brain to develop the plasticity to escape out of that mindset and behavior. We’ll talk about this concept and brain plasticity more later. I have seen patients who slide into this mindset commit suicide because they see no way out. These patients are rampant and come from all walks of life; professionals such as attorneys to blue collar workers to the jobless. It is an equal opportunity nightmare of chronic pain syndromes. These patients evolve from a once normal life and function to one of minimal to no ability to function normally in life, career, or relationships. I have seen plenty of people pull out of this described rut of a chronic pain lifestyle. It’s possible, but it takes work. Most importantly, it takes the step of convincing yourself that it is possible and will be done, and then readjusting your behaviors, mindset, and thought process accordingly. Give yourself no other option than improvement and realize that there is always hope for improvement. The placebo response in clinical trials involving pain patients (and similar in other subgroups) averages around 30%! That means on average, 30% of pain patients will develop significant improvement despite taking a placebo (fake) treatment. This happens because they convince themselves that they are using the new treatment, and thus they convince their mind that they are improving, and they do! Your mind is the most powerful weapon in your battle against your chronic pain, so learn to use it to your advantage.

Let me be clear that chronic pain is real, it is valid, it can be debilitating, it shouldn’t be ignored or overlooked, it can validly negatively impact all aspects of life which can be out of the control of the patient. I profoundly empathize with these patients. However, there is a lot that is in control of the patient which they often do not realize, and that is my purpose for this blog article. Specifically, they do not realize that they are creating a self-fulfilling prophecy of never improving in pain or function, directly related to their behavior and mindset. No, this discussion doesn’t apply to everyone and all cases, but I would say it does apply to the majority of patients.

 

Many of these patients create websites, blogs, and social media accounts dedicated and centered around their chronic pain experiences. Their chronic pain becomes their persona, and who they are. It redefines them. This can certainly be helpful to others to learn about similar pain experiences and to feel that they are not alone, and I think it is fantastic that other patients can have these outlets and sources to share their experiences. However, it can also become a dominating way of life which dissolves away any thought, hope or attempt at improving their pain and overall function. These patients get to a point where living any other way besides centered around their chronic pain would seem abnormal to them. They focus their life, their daily activities, their restrictions, their abilities, and their relationships around their chronic pain. It defines them and dictates their life. They are chained and restrained from this focus. This behavior begins to feed into itself and they continue down a path where there becomes no chance at improvement because they don’t allow their mindset or focus to see that as a valid option, and thus do not initiate behavioral changes to try to influence positive changes.

 

This phenomenon is also reflected in patients who have chronic daily headache, chronic pain, chronic neck pain and whiplash syndrome related to a motor vehicle accident, work related injury, or some other event where they were injured. If there is litigation (lawsuit) involved, it is well known as a clinical predictor that they will rarely improve, because of potential secondary gain (financial, disability, etc.) from their pain, which their subconscious maintains focus on. There have been studies supporting this correlation as well. This phenomenon is not seen in other countries which are not as litigious and ready to sue over anything. We used to have a large unique chronic pain rehabilitation program which was very effective and helpful to many patients. A large focus of this program was on behavioral changes to influence improvements in overall pain and functional abilities. However, patients were excluded from entry if they were involved in any ongoing lawsuit related to their pain, because these patients invariably never got better until the lawsuit was settled and done, and it would be much more beneficial and cost effective to them after legal issues were resolved. We would then admit them following the conclusion of their legal battles if they continued to have chronic pain issues. I have seen many patients reverse their course from that dark reclusive patient scenario described above with the right mindset and approach.

 

How does pain behavior influence brain plasticity and your chances of improvement?

Anatomically and physiologically, this reclusive and socially isolated behavior and mindset of telling yourself that it is impossible for pain to improve or that one cannot function and live a normal life with chronic pain becomes a self-fulfilling prophecy. DON’T LET THAT HAPPEN!! This is solidly based in scientific and biological evidence. Behavior influences cellular, molecular, and physiological changes in the body and brain. Studies have shown that behavior (such as pain limiting behavior, social avoidance, etc.) causes structural and circuitry changes in the brain, which can be lifelong. Social behavior can also cause changes in the brain, although this can be more reversible. These structural changes in the brain and the circuitry of the brain, influenced by behavioral changes (behavioral neuroscience) and mindset, are called brain plasticity. Essentially, plasticity refers to the nervous system’s ability to constantly modify its organization, structure, function, and circuitry connections in response to experiences, behavior, and an endless list of other influencing factors such as pain, stress, diet, emotion, medications, and many other things. Brain circuits related to chronic pain overlap with circuits involving anxiety, depression and some mood disorders. Mood disorders such as depression can affect the plasticity of chronic pain, and likewise chronic pain can influence plasticity of depression and other mood disorder circuitry.

Treatment and conclusions of chronic pain

Treatment is difficult, requires patience, and involves treatment trial and errors (if one treatment doesn’t work, another is tried). The single most important treatment involves you, your behavior in how you respond to your pain, your mindset, and attitude which all in turn influence your brain plasticity positively, and chances of improvement. Do not let your pain define who you are and what you are able to do. Expectations are important in that you should realize that (typically) there is no quick fix or “cure” (but if you stumble across one, which can happen, great!). Learning to live, deal, and function with the chronic pain is vital. If you realize this and make it a primary goal, it can in turn lead to improvements over time by modulating your brain plasticity and electrical circuitry. Most preventive treatments can take 2-3 months to see effects, and there is no way to expedite that. Hang in there and be patient.

 

Chronic migraine, fibromyalgia, and some other chronic pain syndromes often cluster together. The way to look at these types of chronic pain syndromes is that the neurological system is “hyperactive”, “overactive” or “hypersensitive”. So, the goal is to try to “turn down the volume” of this “hypersensitive” neurological system with medications or other types of treatments.  Never conclude that there is no possibility of improving. Remain active physically, socially, emotionally, and maintain active relationships. Treating depression or mood disorders is very important, and a good psychiatrist can make a big difference with this. Chronic migraine and chronic daily headache should have appropriate treatments which may include preventive treatments, CGRP mAb once monthly treatments, supplements and natural therapies, neuromodulation devices, eliminating rebound (medication overuse headache), and using appropriate abortive (as needed) therapy such as triptans, gepants and ditans. Most importantly, remain hopeful. There is always hope and there are constantly new types of treatments becoming available. You can do this!!!

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

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Last updated on April 30th, 2021 at 11:29 pm

CHIARI MALFORMATION HEADACHE, AND WHY YOU MAY STILL HAVE A DAILY HEADACHE FOLLOWING CHIARI DECOMPRESSION SURGERY.

@Neuralgroover

 

 

Chiari malformation is a common anatomical variation, specifically type I which this blog summarizes. It is most often a benign and asymptomatic finding found incidentally during routine imaging of the brain when an MRI or CT is done for other reasons, especially headache. The difficulty is often trying to associate the likelihood of a patient’s symptoms with the Chiari malformation vs. other headache disorder such as migraine, chronic migraine, and occipital neuralgia which can all have overlapping characteristics. Internet searching will give you a very long list of reported symptoms caused by Chiari malformation, many of which are inaccurate. Chiari malformation that is truly related to a patient’s symptoms typically include a “pegged” appearance of the cerebellar tonsils (back and bottom part of the cerebellum) which are pointed rather than rounded, suggesting compression at the cervicomedullary junction (area where the brainstem and upper cervical spinal cord merge between the bottom of the skull and upper cervical spine). The illustration above highlights this appearance compared to a normal brain. When this appearance is present, the patient often does have symptoms that correlate to the Chiari. Unfortunately, most of the time the Chiari malformation is not as extensive, making it more difficult to determine if some of the patient’s symptoms are correlated or not. A contrast brain MRI which includes a cine flow (cine-phase contrast) study can be helpful in determining the extent of compression and subsequent blockage of normal cerebrospinal fluid (CSF) flow throughout the craniocervical junction. A cervical MRI without contrast is also recommended to rule out a cervical syrinx (enlarged area in the center of the spinal cord), which can sometimes be associated with Chiari. If a cervical syrinx is found, an MRI of the remaining thoracic and lumbar spine should also be performed.

 

In general, Chiari malformation cerebellar tonsillar herniation is considered to be within normal anatomical variation in the following:
-First decade (0-10 years): 6mm or less
-Second and third decades (10-30 years): 5mm or less
-Fourth-eighth decades (30 to 80 years): 4mm or less
-Ninth decade (greater than 80 years): 3mm or less

 

Some mild or borderline Chiari malformations can be associated with extensive symptoms, while other times an extensive Chiari malformation is found, but the patient lacks any Chiari symptoms. So, a detailed history of symptoms including headache and associated features is crucial in determining whether a Chiari malformation is clinically relevant or not. This is more useful than basing treatment decisions purely on the extent of tonsillar herniation in Chiari. History is also important in excluding other disorders which can cause a reversible “pseudo-Chiari”, caused by a different disorder such as intracranial hypotension CSF leak, or low-pressure headache) or idiopathic intracranial hypertension (IIH) (previously known as pseudotumor cerebri).

 

According to the International Classification of Headache Disorders 3rd Edition (ICHD3), Chiari headache caused by Chiari type I malformation is usually occipital or suboccipital, of short duration (less than 5 minutes) and provoked by cough or other Valsalva-like maneuvers (straining in the abdominal region such as when having a bowel movement). It remits after the successful treatment of the Chiari malformation. Here are the ICHD3 diagnostic criteria and a Chiari malformation symptoms checklist:

 

Diagnostic criteria require Chiari malformation to have at least two of the following:

1. Either or both of the following:
a) Headache has developed in temporal relation to the Chiari or led to its discovery
b) Headache has resolved within 3 months after successful treatment of the Chiari

 

2. Headache has one or more of the following three characteristics:
a) Precipitated by cough or other Valsalva-like maneuver
b) Occipital or suboccipital location
c) Lasting less than 5 minutes

 

3. Headache is associated with other symptoms and/or clinical signs of brainstem, cerebellar, lower cranial nerve and/or cervical spinal cord dysfunction. (These may include symptoms such as hoarseness, slurred speech, swallowing or choking difficulty, unsteadiness, dizziness, vertigo, tongue weakness, trigeminal or glossopharyngeal neuralgia, tinnitus, absent gag reflex, facial numbness, autonomic symptoms (syncope, slow heart rate (bradycardia), drop attacks), loss of pain and temperature sensation of the upper torso and arms (from syrinx), loss of muscle strength in the hands and arms (from syrinx).

According to ICHD3 criteria, diagnosis of Chiari malformation by MRI requires a 5-mm caudal descent of the cerebellar tonsils or 3-mm caudal descent of the cerebellar tonsils plus crowding of the subarachnoid space at the craniocervical junction as evidenced by compression of the CSF spaces posterior and lateral to the cerebellum, or reduced height of the supraocciput, or increased slope of the tentorium, or kinking of the medulla oblongata.

 

Unfortunately, we see many patients who have had Chiari decompression, but they continue to have chronic daily headache which often resembles their pre-surgery headaches. When you delve deeper into their pre-existing headaches, many times they describe headaches which had/have migrainous features (throbbing, pounding, pulsating pain quality with nausea (+/- vomiting) and/or photophobia and phonophobia (sensitivity to bright light and loud sound with bad headache flares)). These pre-surgical headaches often fit criteria for chronic migraine, many times of which were likely sustained as chronic daily headache and chronic migraine due to medication overuse headache (rebound). So, if any of the history is suggestive of a migrainous component, this should empirically treated for first to ensure they won’t get a cranial surgery/decompression simply for chronic migraine! With that said, if it is an obvious prominent Chiari with clear Chiari headache type symptoms, this can certainly expedite the treatment plan.

 

Most of the time, the chronic daily headaches that patients continue to have after decompression surgery are associated with some variable degree of these migrainous characteristics. They typically resemble a chronic migraine pattern, and many times treating the headaches as chronic migraine rather than being distracted and treating only as ongoing Chiari headache can provide significant improvement. If the Chiari has been decompressed, then it is certainly no longer a “Chiari headache” at that point, and treatment and diagnoses should be reconsidered. However, as mentioned above, even more important is screening for these migrainous features prior to surgery, and if present, treatments targeting migraine and chronic migraine should always be exhausted first because pure Chiari headache is not going to cause migrainous features of throbbing, pounding, pulsating headache with nausea (+/- vomiting) and/or photophobia and phonophobia. Pure Chiari headache just doesn’t cause those symptoms. Those symptoms are migraine. It is common that patients can have both Chiari and migraine. The key is differentiating which is which and eliminating the migrainous component to get more clarity of how much of the symptoms are truly Chiari related, if any.

 

In addition to a chronic migraine appearing headache, patients who have had Chiari decompression frequently have associated occipital neuralgia in the back of the head and a component of chronic post-craniotomy headache. This is related to scarring of the tissues in the back of the head and base of the skull where the occipital nerves travel. This scarring can pull, twist, and tangle up the occipital nerves over time which causes persistent occipital pain in the back of the head. Post-craniotomy headache is technically similar to chronic post-traumatic headache since decompression surgery is, well, certainly a form of trauma to the head. Chronic post-traumatic headache itself commonly has a chronic migraine clinical appearance (with or without pre-existing migraine history), and treating as such can often be very beneficial. For example, we often seen concussion patients that develop chronic daily headache and chronic migraine which is “turned on” by the injury or head trauma.

 

Successful treatment with significant improvement of chronic daily headache with chronic migraine characteristics following Chiari decompression surgery is often a difficult task requiring patience and a good headache specialist. Daily medications used in migraine prevention should be considered, particularly ones that are good for not only migraine, but also occipital neuralgia and musculoskeletal pain such as anticonvulsants (topiramate, gabapentin, etc.), TCAs (amitriptyline, nortriptyline), or SNRIs (duloxetine, venlafaxine ER). Neck physical therapy can often be very helpful at stretching out the suboccipital tissues and lessening tension on the occipital nerves. If there are any migraine or chronic migraine features, then more aggressive migraine preventives such as Botox (OnabotulinumtoxinA) injections or the CGRP monoclonal antibodies should also be considered. As of 2010, Botox is still the only truly FDA approved treatment for “chronic migraine”, although all of the other treatments are still used for it as well. It should be done according to the “PREEMPT protocol”. I prefer to do additional dosing over the occipital nerves and often add numbing medicine such as bupivicaine which can provide additional temporary relief as the Botox starts to kick in over the next couple weeks. If there is an ongoing chronic daily headache driver from rebound headache (medication overuse headache), it is also crucial to eliminate this factor. Improvement will not happen while this is an ongoing factor (especially if there is a chronic migraine component). If there are migrainous features to headache exacerbations, then using more migraine specific abortive (as-needed) meds such as triptans, gepants (such as Nurtec or Ubrelvy) or ditans (Reyvow) should also be considered. Notably, the gepants do not cause medication overuse headache (rebound headache).

 

IF YOU HAVE HEADACHE, MIGRAINE, OR FACIAL PAIN AND ARE LOOKING FOR ANSWERS ON ANYTHING RELATED TO IT, A HEADACHE SPECIALIST IS HERE TO HELP, FOR FREE!

FIRST, LET’S DECIDE WHERE TO START:

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR THE LATEST INFORMATION, HOT TOPICS, AND TREATMENT TIPS, VISIT OUR FREE BLOG OF HOT TOPICS AND HEADACHE TIPS HERE. THIS IS WHERE I WRITE AND CONDENSE A BROAD VARIETY OF COMMON AND COMPLEX  MIGRAINE AND HEADACHE RELATED TOPICS INTO THE IMPORTANT FACTS AND HIGHLIGHTS YOU NEED TO KNOW, ALONG WITH PROVIDING FIRST HAND CLINICAL EXPERIENCE FROM THE PERSPECTIVE OF A HEADACHE SPECIALIST.

 

IF YOU DON’T HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR POSSIBLE TYPES OF HEADACHES OR FACIAL PAINS BASED ON YOUR SYMPTOMS, USE THE FREE HEADACHE AND FACIAL PAIN SYMPTOM CHECKER TOOL DEVELOPED BY A HEADACHE SPECIALIST NEUROLOGIST HERE!

 

IF YOU HAVE AN EXISTING HEADACHE, MIGRAINE, OR FACIAL PAIN DIAGNOSIS AND ARE LOOKING FOR FURTHER EDUCATION AND SELF-RESEARCH ON YOUR DIAGNOSIS, VISIT OUR FREE EDUCATION CENTER HERE.

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