Search for tag: "chronic pain"

Interviewer: Severe, sudden, and sometimes debilitating face pain is a symptom of a disease called trigeminal neuralgia and some people suffer with the condition and don't even realize that's what they have. Or maybe it was misdiagnosed as something else so they can't get treatment.

Dr. Shervin Rahimpour is a neurosurgeon who specializes in the surgical treatment of trigeminal neuralgia, and he's going to help us understand how to come to that diagnosis. So first of all, you tell me it's a poorly diagnosed disease. What exactly do you mean by that?

Dr. Rahimpour: Often this pain is distributed around the cheek and jaw area. And so it's natural for patients to think that this is likely a result of their dental health. And so they often seek treatment through a dentist, usually, you know, undergo a tooth extraction or something like that, and that pain persists. So that's often why this is poorly diagnosed is because it overlaps with other common issues like having tooth pain.

Interviewer: Yeah. And I think a lot of us think well, the pain is here, this must be the source of the pain. It's in my mouth or my cheek, it must be the source. But that's not the case with this disease. Where does the pain originate from?

Dr. Rahimpour: The trigeminal nerve, which is one of the 12 cranial nerves that we have, supplies, amongst other things, the sensation that we feel over our face. So there are two nerves, one for each side. Each nerve supplies the sensation to that half of the face. And the nerve has three divisions associated with it. There's one that kind of overlays the forehead and around the eye. The other division is around the cheek area, and then a third division encompasses the jaw. And so most commonly, the pain is likely to affect those bottom two divisions, which is around the cheek and the jaw area, and that's where this overlap comes with potentially pain coming from your teeth.

Interviewer: And somebody goes to the dentist, they have an extraction done and that doesn't solve anything. Do they try to get a diagnosis beyond that, or do most people just give up or do you know?

Dr. Rahimpour: Yeah, I should add that sometimes it can be your teeth. So it is worth having that evaluation done by your dentist. But eventually, this pain syndrome is referred either to a pain specialist or even a neurologist. Those are the folks that typically end up diagnosing this as trigeminal neuralgia-type pain.

Interviewer: Explain some of the common symptoms that people might experience.

Dr. Rahimpour: Yeah, absolutely. So again, this pain used to be . . . this disease used to be known as suicide disease because it was such a horrible pain for patients to experience. And it's often a severe electric type jolt or stabbing pain involving one or more of the divisions of the trigeminal nerve of the face. It's often set off by very relatively innocuous stimuli. What I mean by that is anything as simple as just a gust of wind, or talking or brushing your teeth, or having water hit your face when you're taking a shower. These are kind of the very, very basic and innocuous things that can trigger that type of pain.

Interviewer: And what's going on with the nerves that is causing this pain?

Dr. Rahimpour: The vast majority of cases are thought to be caused by a vessel sitting on the nerve root as it enters into the brainstem. And so what this vessel causes is damage over a period of time that ends up injuring the insulation around the nerve known as myelin. And then this can result in sort of aberrant firing of the nerve.

Interviewer: So it's rubbing against there, damaging the insulation every time your heart beats.

Dr. Rahimpour: That's exactly right.

Interviewer: It's damaging the . . . Okay.

Dr. Rahimpour: So the thought is that if we can remove or transpose this vessel from the nerve root . . .

Interviewer: Yeah, get it away from there.

Dr. Rahimpour: Get it away from there, that could potentially allow the nerve to heal and prevent some of this aberrant firing.

Interviewer: And if a patient has this type of pain, they would go to their primary care physician first likely. What would that workup look like?

Dr. Rahimpour: Typically, the patient has these classic types of symptoms or the stabbing electric type pains of the facial region, again, involving either one or more divisions of the trigeminal nerve. And we often ask patients, you know, "How is this pain brought about?" If it's something, again, wind, chewing, talking, anything like that, that's pretty consistent with trigeminal neuralgia. The pain also again persists to seconds to potentially minutes, and so that's another signature or hallmark of the disease. And we often look for patients that, you know, typically we find that this disease occurs more often in the older population. So the incidence kind of climbs as age goes up. But this can also be a result of some other secondary processes. Certainly, it can range anything from facial trauma and include other secondary causes like multiple sclerosis.

Interviewer: At what point should a person consider consulting with a physician who specializes in trigeminal neuralgia?

Dr. Rahimpour: I think early on it's best to have the medical therapy be optimized. So a lot of the medications we use for this type of pain are actually anticonvulsants used in epilepsy. The reason why is because, similar to epilepsy, the nerve can act on its own and fire. And so the idea is can we stabilize this nerve so that it prevents it from firing, the same way that we try for epilepsy. Those types of medications are started, they're increased to a therapeutic level and then the patient is evaluated to see if this treats their pain. Again, the vast majority of patients respond to these medications, something upwards of 90%, but half of those patients end up having unwanted drug side effects. And then, of course, there's a 10% that did not respond to the medication at all.

Interviewer: Yeah. And this medication, is it kind of a dialing-in process, you've kind of got to figure out the sweet spot for everybody?

Dr. Rahimpour: Yeah, I would say that most anticonvulsants are started at a low dose and gradually titrated up.

Interviewer: And for the individual that is not responding to medication, or the side effects are just so terrible that it's really impacting the quality of life, and that's where the microvascular decompression procedure comes in. That's what you're doing there.

Dr. Rahimpour: That's exactly right. So for patients that aren't responding to the medication, if they've had an MRI scan that shows that potentially there might be a vessel there pushing on the nerve, that's where microvascular decompression can play a role.

Interviewer: What about for patients where they have the condition, and it's not pressing against that nerve? That's possible, right?

Dr. Rahimpour: Patients where we don't necessarily see a blood vessel pushing on the nerve, or they might not necessarily be a good operative candidate, we can offer other minimally invasive approaches. Those approaches include percutaneous rhizotomies. The premise there is that we with a needle go to the base of this nerve, known as the trigeminal ganglion, and we try to damage that nerve to sort of disrupt the pain signal. The other option is using radiation in the same way that folks use it for tumors to try to focus the radiation and try to damage the nerve again, to stop this pain signaling.

Interviewer: Are these other last two procedures, are they an alternative to somebody getting a microvascular decompression?

Dr. Rahimpour: They are alternatives, but I should add that they're not as efficacious. So when we do find patients are good candidates for microvascular decompression, we try to advocate for that as it gives us the best chance for pain freedom.

Interviewer: After somebody has the microvascular decompression, what is the success rate that that actually takes care of the pain?

Dr. Rahimpour: We expect that patients often have immediate pain relief after surgery, especially if we do find a blood vessel that's compressing the nerve. Historically, 70% to 80% of patients are still pain-free at five years.

Interviewer: And the other 20%?

Dr. Rahimpour: Pain can reoccur. And if that's the case, we can always revisit other possible interventions, including some of the percutaneous and radiosurgery techniques that I mentioned.

Interviewer: For the patients who get the microvascular decompression, what's the satisfaction rate among those patients? I hear this could be life-changing for some people.

Dr. Rahimpour: Absolutely. So again, this is a very debilitating disease. I mean, you can imagine if it's affecting the way you eat, and the way you conduct yourself throughout your day-to-day in anticipation of a sudden pain strike, being pain-free means everything. And so when patients are pain-free again, where we expect that to be the case in the vast, vast majority of times after microvascular decompression, this is absolutely life-changing.

Dr. Miller: You've tried physical therapy for back pain, and you're not ready for surgery. What other options are there? We're going to talk about that next on Scope Radio.

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Dr. Miller: I'm here today with Dr. Richard Kendall. He's a professor of rehabilitative medicine, and he's also the Chair of the Department of Physical and Rehabilitative Medicine. Rich, tell us a little bit about what patients can do prior to surgery. I've heard about injections into the back for those patients who have sort of ongoing low back pain or pain in other parts of their back, but there are now injections that can be tried that might relieve their pain.

Dr. Kendall: So that's true. For people who have not done well with physical therapy program or medications like anti-inflammatories or Tylenol or even opiate medications, epidural injections are a tool for us to use to decrease pain. That's just what they are, they can decrease pain, they don't heal or cure a tissue, but getting rid or decreasing the pain is one option hopefully to let somebody go on, and further function before surgery.

Dr. Miller: So what exactly is an epidural injection? Where does that go on the back?

Dr. Kendall: The epidural space is the space around your spinal cord, and it's in the middle of the safe protection of the bones of the spine. It's a nice protected space that's filled with fat that we can put in some steroids and some Novocain in that can really help reduce inflammation as well as reduce pain.

Dr. Miller: Is this a difficult procedure or what does a patient expect when they come in to have this done?

Dr. Kendall: Honestly most of our patients expect the worst, but when we come in, we finish the procedure, and they say, "Wow, that's it? Are you kidding me? That's easier than the dentist." So . . .

Dr. Miller: That's pretty easy. If it's easier than the dentist, that's pretty easy.

Dr. Kendall: The thought of somebody poking a needle in your back is somewhat anxiety provoking but we do them with a lot of Lidocaine, and numbing under X-Ray guidance so most people really experience very little symptoms.

Dr. Miller: What are you injecting into that space that actually reduces the pain?

Dr. Kendall: We put in two medicines. One is corticosteroid or cortisone, and that gets rid of the inflammation. It'll sit in the fat cells for about two weeks around your spine and get rid of inflammation. The second is just a Novocain or a Lidocaine which is an anesthetic, and it'll numb those nerves and areas for several hours.

Dr. Miller: That lets you know that you're probably making a difference. I mean if the Novocain is working in the area where the back pain is emanating from, you'll know you're at the right place I guess, right?

Dr. Kendall: Yes, many people will be pain free when they leave. Some people that's only for four, five hours. However the Lidocaine does sometimes essentially stung the nerve if you will, and people's pain does disappear for much longer afterwards depending on the diagnosis.

Dr. Miller: How effective is this in reducing pain? Is it 80% effective, 50%, 30%? What's the story on that for patients that might be considering an epidural injection?

Dr. Kendall: Well in certain conditions, it can be very effective with disc herniations and people with radiculopathy or pain down the leg from that disc herniation. If you take all patients who could be surgical candidates and you do the injection, 60% of them choose not to have surgery because their pain improves significantly with the injection, and they choose to just not have the surgery because they're doing better.

Dr. Miller: So a great option to may be postpone or prevent surgery.

Dr. Kendall: So a great option for more than half the people . . .

Dr. Miller: That's great.

Dr. Kendall: . . . to really decrease pain, get them on, and avoid a surgery that lays you up for a few weeks or more.

Dr. Miller: Now can you have repeated injections if necessary or is there a limit on the number of injections one can have?

Dr. Kendall: There's not an actual limit, however we usually say three or so a year would be the most we would consider. Some people, it does take one or two injections to really get rid of that leg pain that they have and avoid the surgery. However if we do two injections and your pain comes back within a week, then actually surgery is probably a much better choice.

Dr. Miller: So you do these under imaging, and that helps direct the shot into the area that needs to be infused I guess.

Dr. Kendall: We do these all under X-Ray guidance, so we know exactly where we're going, we know exactly where the needle tip is. We inject a little bit of contrast die to make sure we're not in a nerve or a blood vessel. So overall these are very, very safe injections.

Dr. Miller: Now how would a patient find a physician that would be qualified to do these kinds of treatments? I don't think they necessarily need to go to a surgeon per se, do they?

Dr. Kendall: No, in fact most surgeons don't do these epidural injections. Most are non-operative either anesthesiology or physical medicine rehabilitation physicians. Most people who are pain board certified have done significant amounts of injections, and finding a physician who specializes in back pain and pain will certainly have enough training to do these.

Dr. Miller: Now last question is, if the injection is effective, how long could someone expect to have the effect last?

Dr. Kendall: Most of the time, I tell people until they do something that irritates their back again, it's really not easy for us to say a time frame. It's mostly until you bend funny again or slip or shovel too much snow or do something again that may irritate that disc again.

Dr. Miller: I'm assuming you'd also have them follow up with exercise therapy and physical therapy as another modality to continue to strengthen the back and prevent further injury.

Dr. Kendall: Yes, we always have our patients continues with their exercise program throughout this even before and afterwards just because that's going to decrease the likelihood of you flaring it up again.

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Interviewer: Chronic migraines are a mysterious and debilitating illness that affects an estimated 36 million people in the United States. That's a large number of patients who have a chronic illness for which there is no known treatment or cure.
Dr. K.C. Brennan is an assistant professor of neurology at the University of Utah School of Medicine. He's an expert in treating and researching migraines and he's here today to talk to us about migraines. Dr. Brennan, welcome.

Dr. K.C. Brennan: Thank you for having me.

Interviewer: Would you just quickly explain what a migraine is.

Dr. K.C. Brennan: Imagine a pounding headache, throbbing pain, then imagine that normal light hurts your eyes, sound hurts your ears, normal smells and tastes make you feel nauseous, you're completely incapacitated, that's what a migraine is.

Interviewer: What are the common migraine treatments right now and how well do they work?

Dr. K.C. Brennan: The best medications we have are called the triptan drugs, Imitrex, Maxalt, those are the names of these drugs and you see them advertised. There's been no single medication developed to prevent migraine.

Interviewer: How much do we know about these migraines right now, in terms of what causes them?

Dr. K.C. Brennan: We know that migraine is a pain disorder; it's a disorder where your pain system is activated when it shouldn't be activated. But we also know that migraine is an excitable disorder of the brain, it's the brain firing when it shouldn't be firing.
Migraine is also a disorder of plasticity, plasticity is the ability of the brain to change itself and it's what the brain does when it learns. When you see a chronic migraine patient you realize that their brain has learned to produce pain when it's not supposed to. I think that's a very important way of framing the question of migraine.

Interviewer: At the moment though we really don't know why the brain is doing this.

Dr. K.C. Brennan: We know that your genetics contribute a lot, there is your environment, you know, light and sound can trigger migraines, they sort of set the process off. Stress is a huge trigger of migraines, and release from stress, so not just a kid going into exams but that kid after they're done with exams suddenly stress releases and that's when they get their migraines.
Hormones are a very big part of it so two-thirds of people with migraine are women, only one-third are men, why is that? Well we think it's because of female sex hormones. So there's a lot of factors that can trigger or modulate, they can turn the volume knob up or down or start things off. We do not know the ultimate cause and that's probably because there are many ultimate causes.

Interviewer: Do migraines tend to run in families?

Dr. K.C. Brennan: They do tend to run in families.

Interviewer: What's the current state of research in migraines? How much are we learning and what are the big questions that people are looking at?

Dr. K.C. Brennan: I think there's been a real infusion of strength into the migraine field from two fronts, one is that we're now doing imaging in humans with migraine, so we're able to actually look at the brains of people with migraine. The other area where we've really had an infusion of strength is we're looking at migraine as a pain disorder, how pain works in the brain in general and then what makes migraine unique.

Interviewer: Can you just give us a little bit more in depth detail about what you've discovered and what you're hoping eventually to accomplish.

Dr. K.C. Brennan: What we've done recently is try and look at what this event, cortical spreading depression, which is the event that underlies the aura, what it does to the brain that might contribute to the migraine attack because the aura is something painless.

Interviewer: Yeah, and to be clear, when you talk about a spreading depression, the cortical spreading depression, define that if you would, that's a massive firing of?

Dr. K.C. Brennan: Right, it's got an unfortunate name, spreading depression is a massive wave of activity, it's like a tidal wave in the brain and it spreads out and it doesn't respect boundaries in the brain, it just moves out like a ripple in a pond.

Interviewer: And this itself, the aura itself is not, is it the migraine or is it what pre-stages the migraine?

Dr. K.C. Brennan: It's considered part of a migraine attack for people who have migraine with aura. Now there are people who have migraine without aura and there's fertile debate in our field about whether these are different kinds of migraine or whether they're all the same thing.

Interviewer: Where do you see research going and how much more do you think we will know about migraines 10 years from now?

Dr. K.C. Brennan: I'm optimistic we're going to know a huge amount more and I'm optimistic for a number of reasons. We've got tools to study migraine, in the lab and in the clinic that are just wondrous.

Interviewer: Is there some evolutionary reason that this volume knob might have been turned up?

Dr. K.C. Brennan: One line of thought goes, what goes on in migraine is essentially the sickness response. A person with migraine is very much like a person with a bad flu. When you have a bad flu or when you have meningitis or something like that, you know, all the senses hurt. And this is known as the sickness response that there's an inflammatory everything hurts reaction that goes on that incentivizes the person to get somewhere where they can get better, go to a dark room, lie down, heal up.
It seems like that sickness response gets switched on, that sickness volume knob gets turned up in migraine for reasons that don't make sense. The circuitry that creates migraine exists for a reason but it gets overused in migraine and then it entrains itself it becomes this daily miserable thing.

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