Common Pain Disorders in Primary Care

Educational Objectives

The goal of this program is to improve the management of common pain disorders in the primary care setting. After hearing and assimilating this program, the clinician will be better able to:

1.   Use the American College of Physicians and American Pain Society clinical guidelines to distinguish among the 3 general etiologic categories of low back pain.

2.   Describe the comprehensive physical examination of the patient with back pain.

3.   Recognize psychosocial factors that affect prognosis in patients with back pain.

4.   Use clinical criteria for migraine and a detailed history to evaluate the patient presenting with headache..

5.   Identify signs and symptoms of underlying organic disease in patients presenting with headache.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning com­mittee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose. In her lecture, Dr. Nahas discusses the off-label or investigational use of a therapy, product, or device.

Acknowledgments

Dr. Battistone was recorded at Advances in Internal Medicine 2009, held February 1-6, 2009, in Park City, UT, and spon­sored by the University of Utah, School of Medicine. Dr. Nahas was recorded at 32nd Annual Eastern Shore Medical Sym­posium, held June 22-26, 2009, in Rehoboth Beach, DE, and sponsored by Jefferson Medical College and the University of Delaware, with promotional assistance provided by the Medical Society of Delaware. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Low Back Pain in Primary Care

Michael J. Battistone, MD, Associate Professor of Medicine, University of Utah Health Sciences Center, Salt Lake City

Associated factors: obesity, physical inactivity, aging; psychosocial factors  —  depression and stress; underrecog­nized but vital for prognosis; occupation-related activities  —lifting, bending, vibration (eg, long-haul truck drivers, military personnel)

Prevention: no evidence that regular exercise, fitness, educational programs, or back supports helpful in prevention

Evaluation: American College of Physicians and American Pain Society issued new clinical guidelines in 2007; urge use of patient history and physical examination to categorize back pain as associated with 1 of 3 etiologies, 1) non­specific (most common etiology; usually of mechanical origin), 2) associated with neurologic symptoms (radicular pathology or stenosis of spinal canal), and 3) systemic causes; psychosocial issues also important

Physical examination

Indicators of nerve root involvement: leg pain worse than back pain; positive straight-leg-raise test; unilateral neu­rologic symptoms in foot; weakness of ankle and great toe dorsiflexion; loss of ankle reflexes

Straight-leg-raise test: variability in literature on how to perform; patient lies supine; physician flexes hip with leg extended; Lasegue sign positive if flexion (usually at 30°) provokes leg pain; next, lower leg slightly, and have patient dorsiflex ankle; resulting pain positive Bragard sign; can also test hip flexion with knee flexed

Features suggestive of spinal stenosis: severe leg pain that limits distance patient able to walk; relief upon sitting or bending forward; patients may describe pain as burning (suggests vascular pain, thus term pseudoclaudication); patients may have both pseudoclaudication and claudication; wide-based gait with abnormal neurologic findings (positive Romberg test) and pain with lumbar extension; uncommon in patients <50 yr of age

Systemic causes: 1% to 2% of low back pain; compression fracture  —  advanced age with steroid therapy; trauma; cancer (nondermatologic)  —  unexplained weight loss; no relief with bed rest; increased age; symptoms >1 mo; spondyloarthropathies  —  eg, ankylosing spondylitis, reactive arthritis, psoriatic arthritis, inflammatory bowel-re­lated arthritis; morning stiffness; improvement with exercise; extra-articular symptoms; infection  —  recurrent or chronic urinary tract infections; history of intravenous drug use; fever

Psychosocial factors: patients with severe psychosocial and emotional problems, (eg, depression) more likely to de­velop back pain and have worse prognosis; study showed correlation between heavy workload, stress, and back pain; treatment of psychosocial factors more important than physical factors; patients who take ownership of their pain and actively participate in care have better outcomes

Radiographic evaluation: recent guidelines advise against routine imaging and other diagnostic tests in patients with nonspecific low back pain; reserve imaging for patients with severe or progressive neurologic deficits, or pa­tients with suspected serious underlying conditions (eg, radiculopathy, systemic illness); when pain persistent and signs of radiculopathy or spinal stenosis present, think beyond imaging (eg, in patients unwilling to undergo sur­gery, advise that MRI not recommended); no consensus on when to follow negative x-rays with more advanced tests, or when to proceed immediately with advanced tests (eg, MRI, computed tomography [CT]); study showed higher satisfaction reported among patients with low back pain when x-rays done, despite more severe pain and lower function scores; must balance costs and patient satisfaction

Classification by duration and goals: acute  —  <4 wk; most common type; intervention usually unnecessary; reas­sure patient that spontaneous recovery likely; subacute  —  4 to 12 wk; dynamic group; some patients improve, oth­ers slip into chronic group; consider whether intervention suitable; chronic  —  >12 wk; discuss management with patient; stress that patient must be leader in care; goals  —  control pain, maintain function, and manage psychosocial distress; recommendations  —  provide patients with prognostic information based on duration of symptoms and clinical presentation; advise patients to remain active; direct them to appropriate educational resources

Drug therapies

Acetaminophen: acute back pain  —  no difference seen between acetaminophen and no treatment; chronic back pain  —  acetaminophen slightly inferior to nonsteroid anti-inflammatory drugs (NSAIDs); insufficient data com­paring acetaminophen to other drugs

NSAIDs: acute back pain  —  nonselective NSAIDs (cyclooxygenase [COX]-1 and COX-2 inhibitors) superior to placebo for global improvement; chronic back pain  —NSAIDs better than placebo; ineffective in back pain with sciatica; no evidence one NSAID superior to another; patients frequently have clear preferences

Antidepressants: better than placebo for pain relief in chronic back pain; effectiveness not consistent across classes; tricyclic antidepressants (TCAs) slightly to moderately more effective than placebo; paroxetine and trazodone in­effective; insufficient evidence comparing TCAs to selective serotonin reuptake inhibitors

Benzodiazepines: acute back pain  —  studies showed high likelihood of failure to experience pain relief or global improvement with tetrazepam

Antiepileptic agents: back pain with radiculopathy  —minor improvements in pain scores; no clear changes in func­tional status

Skeletal muscle relaxants: acute back pain  —  moderately superior to placebo for pain relief; sciatica  —  no effec­tiveness observed

Tramadol: chronic back pain  —  moderately superior to placebo for pain relief; no trials comparing tramadol to ac­etaminophen, NSAIDs, or opioids

Systemic corticosteroids (oral, intravenous, and intramuscular): no systematic reviews; 4 trials showed no clinically significant benefit, compared with placebo

Opioids: review looked at prevalence of use and abuse, and effectiveness; prescribing rates varied widely (3%-66%); 4 trials showed pain similar with opioids and either active treatment or placebo; rate of substance abuse disorders varied from 5% to 24%; overall study quality weak

Nonpharmacologic therapies: acute back pain  —  of numerous modalities studied, only superficial heat demon­strated efficacy; chronic or subacute back pain  —  benefit seen with spinal manipulation, exercise therapy, psycho­logic therapy and interdisciplinary rehabilitation

Bed rest vs activity: activity distinguished from exercise; defined as activity of normal daily living; 1995 Helsinki study showed activity superior to either bed rest or back-mobilizing exercise; systematic reviews found more pain and impairment of function with bed rest than with activity

Injection therapy: subacute and chronic back pain  —Cochrane review unable to find evidence for or against injec­tion therapy, regardless of type or dosage; may be effective for subgroup of patients

A Practical Approach to Patients with Headache

Stephanie J. Nahas, MD, Assistant Professor of Neurology, Director of Headache Medicine Fellowship Train­ing Program, Jefferson Headache Center, Jefferson Medical School of Thomas Jefferson University, Philadel­phia, PA

Diagnosis 

History: detailed history usually provides enough information for diagnosis; physical examination normal in most cases; rule out alternative etiologies; address impact of headache on patient; look for red flags; classify headache; most headaches migraine; useful questions  —  when did worst headaches begin? frequency of headaches that if untreated impair ability to function? description and duration of pain; do other symptoms accompany headaches? what improves or worsens headaches? frequency and type of medication taken for headaches? others in family with similar headaches? does patient get other kinds of headaches? any recent change in headaches?

Clinical features: nature of pain (eg, dull, throbbing, shooting, burning); severity; duration; frequency; exacerbation with physical exertion; nausea; vomiting; sensitivity to light, sound, odors; neck pain and muscle tension; physi­cal changes (eg, tearing eyes, sweating)

Criteria for migraine: presence of 3 characteristics (nausea, disability, and light sensitivity) confirms migraine; if 2 of 3 positive, 93% chance headache migraine; if 3 of 3 positive, 98% chance headache migraine

Migraine without aura: duration 4 to 72 hr; frequency <15 days/mo; pain features (2 required)  —  unilateral loca­tion; pulsating quality; moderate to severe pain intensity; aggravation by or causing avoidance of routine physical activity; nonpain features (1 required)  —  nausea or vomiting; photophobia and phonophobia; must not be attrib­utable to another disorder

Migraine with aura: 30% to 35% of migraines; aura defined as transient, slowly emerging (then regressing) neuro­logic symptoms; usually precede headache by »1 hr; visual aura  —  most common; scintillating scotoma (dark spot with shimmering rim); fortification spectra (jagged lines); photopsia (colored splotches, flashes of light); sensory aura  —  tingling, numbness, paresthesias; spreads slowly, often beginning in hand or mouth; other auras  —  less common (eg, weakness, aphasia)

Migraine triggers: hormones (eg, menstrual migraine); sleep (too much or too little); stress; physical exertion; envi­ronment (eg, bright lights, allergens)

Past treatment: inquire about past use of acute medications (pain medications, NSAIDs, opioids, and migraine-spe­cific drugs) and preventive medications (antidepressants, anticonvulsants, antihypertensives, and supplements); reasons for discontinuation  —  ineffectiveness; side effects; inadequate length of trial; unsuitable medication; note  —  overuse of acute medication may impede efficacy of preventive medication

Comorbidities: depression; anxiety; epilepsy; fibromyalgia; hypertension; diabetes; vascular disease

Benign indicators: regular or near-regular perimenstrual timing; appearance after sustained exertion; relief with sleep; food, odor, or weather triggers

Signs and symptoms of organic disease: abnormal signs (fever, hypertension, or hypotension); altered cognition or consciousness; stiff neck (meningeal irritation); papilledema (increased intracranial pressure); unequal or poorly reactive pupils; visual field deficit; tender, poorly pulsatile cranial arteries (especially in patients aged >50 yr); fo­cal weakness or sensory loss; clumsiness or ataxia; red flag mnemonic (“SSNOOP”); systemic symptoms or sec­ondary risk factors; neurologic symptoms or abnormal signs; onset (sudden, abrupt, or split-second); older (new onset at age >50 yr;); previous headache history (first headache or change in headache)

Migraine treatments

Acute therapy: nonspecific medications  —  NSAIDs; combination analgesics; opioids; neuroleptics and antiemetics; corticosteroids (for refractory migraine); specific medications  —  ergotamine and dihydroergotamine; triptans; general principles  —  tailor treatment to patient and attack; treat early; nonpharmacologic treatment, when appro­priate (eg, rest, quiet, hot or cold compress, massage, meditative exercise); use acute medications in stratified manner (first-line, backup, and rescue); match intensity of treatment to intensity of attack; mild to moderate pain  —  usually responsive to nonspecific treatment; moderate to severe pain  —  migraine-specific treatments; can be mixed with nonspecific treatments; if unsuccessful, resort to neuroleptics, opioids, or short-course corticoste­roids; Food and Drug Administration (FDA)-approved acute treatments include aspirin, ibuprofen, ergots, trip­tans, combination acetaminophen, aspirin, and caffeine (eg, Excedrin Migraine)

Medication overuse: limit use of ergots, triptans, opioids or simple combination analgesics to £10 days/mo; butal­bital-containing analgesics £5 days/mo; other analgesics £15 days/mo; total exposure (all acute drugs combined) £15 days/mo; consequences of overuse  —  refractory daily headaches; tolerance to medications; drug toxicity

Preventive treatment: indications  —  migraine significantly interfering with patient’s daily routine, despite acute treatment; >1 attack per week; acute medications ineffective, contraindicated, or not tolerated; patient preference; presence of uncommon migraine symptoms, eg, hemiplegic migraine, basilar migraine, migraine with prolonged aura (>60 min; can lead to migrainous infarction); medications  —  anticonvulsants; antidepressants (most com­monly TCAs and serotonin-norepinephrine reuptake inhibitors); blood pressure medications (including angioten­sin system drugs); supplements (eg, riboflavin, coenzyme Q10), botulinum neurotoxin (for chronic migraine); drug choice depends on headache type, drug efficacy and adverse events, current drug regimen, patient prefer­ence, and comorbidities

Protocol: start with low dose and increase gradually; ensure adequate drug trial (2-3 mo); avoid drug overuse and interfering drugs; evaluate efficacy of therapy (speaker recommends patients use calendar to record headache fre­quency and treatment usage); periodically re-evaluate suitability of treatment; ascertain use of birth control

Chronic daily headaches (CDH): treatment often fails; patients frequently overusing medication and have comorbid psychologic disturbances; »4% of world population has CDH; previously referred to as mixed or combination headache; criteria  —  evolves from episodic to chronic pattern; frequency increases; intensity may weaken while migrainous features abate; daily or near-daily (³15 days/mo)pain; chronic tension-type headache  —  mild to moder­ate; ³15 days/mo for ³3 mo; not associated with nausea or vomiting; tension-like characteristics (dull, featureless); new daily persistent headache  —  begins abruptly and fails to remit; often associated with viral illness; frequently no identifiable trigger or cause; can be highly refractory to treatment; common in younger patients; features similar to chronic migraine; hemicrania continua  —  rare, indomethacin-responsive headache; continuous and unilateral, with migraine and autonomic features (eg, tearing, ptosis, mydriasis); typically moderate baseline pain with severe exacerbations

Suggested Reading

Bude DC et al: Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clin Proc 84:422, 2009; Cohen SP et al: Management of low back pain. BMJ 337:a2718, 2008; Filippi M et al: Headache and migraine. Neurol Sci 29:336, 2008; Lenaerts ME: Pharmacotherapy of tension-type headache (TTH). Expert Opin Pharmacother 10:1261, 2009; Martell BA et al: Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 146:116, 2007; Matchar DB et al: The headache management trial: a randomized study of coordinated care. Headache 48:1294, 2008; Ra­gab A et al: Management of back pain in patients with previous back surgery. Am J Med 121:272, 2008; Rapoport A: An­timigraine drugs: new frontiers. Neurol Sci 30:S39, 2009; Roelofs PD et al: Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine 33:1766, 2008; Scher AI et al: Risk factors for headache chronification. Headache 48:16, 2008; Staal JB et al: Injection therapy for subacute and chronic low back pain: an updated Cochrane re­view. Spine 34:49, 2009; Urquhart DM et al: Antidepressants for non-specific low back pain. Cochrane Database Syst Rev 23, 2008; van der Windt D et al: Psychosocial interventions for low back pain in primary care: lessons learned from recent trials. Spine 33:81, 2008.