Chapter 1

Beginning to Take Control of Your Pain

You may still have doubts about whether you can ever enjoy life again while you are in chronic pain, or whether life will ever be worth living with chronic pain.  Nevertheless, let’s at least explore how living a life of quality with chronic pain is possible.  THe keys are to take responsibility for your pain ( not in the sense of accepting blame for it yourself or assigning blame to others,, but in the sense of accepting ” ownership” of it); to determine exactly what your problems are as a result of the pain; and to reassess your goals in the light of this information.  This chapter gives you your first set of tools for begininng to take control of your pain: diary keeping and goal setting.  TO start with, however, let’s look at the first of the three keys: accepting ownership of your pain.

Accepting Ownership of Yours Pain

As you define it at this moment, your problem is that you are in pain and the pain won’t go away.  This is an important first step, before you can do anything about your pain, you need to acknowledge that it exists.  However, you may also feel inclined at this point to blame others for your pain.  You may feel that your doctors have failed you by not finding and curing the source of the pain, or at least for not making you feel better.  You may believe that your loved ones are not doing anything to help you, or are showing a lack of understanding or empathy about your problem.  You may even feel that society is to blame for causing the situation that put you in pain in the first pace, or for not making it easier for you to seek help.    The fact that you may be sad, angry, or anxious about the disruption of your whole life as a result of the pain experience is both understandable and normal.  Under these circumstances, it may be very tempting to feel that others are to blame for the pain and ought to be responsible for taking it away.  Indeed, may people in pain put their whole lives on hold waiting for others– their physicians, their families, or society– to do just this.   The difficulty with this, however, is that wanting to give away both the pain and the responsibility for it will only prolong and contribute to your feelings of powerlessness.  if you pain is not going away any time soon– and this is the very nature of chronic pain– then taking upon yourself the responsibility for living with it may begin to return control of your life to you.  If you can adopt an attitude of “ownership” of the pain problem, you have the potential for gaining the upper hand over it.   Although you may need assistance from your health care provider, your family and society in untangling yourself from your pain web, gathering the threads together and reweaving them into a safety net for yourself are ultimately your tasks and yours alone.        What you now may be thinking is something like this: ” Oh, great.  So I’m responsible for my pain, huh? I’m to blame? That’s what everybody’s been saying– or at least hinting–all along.  I feel bad and guilty enough as it is.” That is not what is meant here at all.  As you probably already know, self-blame and guilt can be paralyzing emotions.  They can make you feel that since you are such a bad and worthless person, there is no point in doing anything at all.  Accepting ownership of your pain, on the other hand, means acknowledging that you are a worthwhile prson, that there  is  a point in doing something, and that you  do have choices.  It is very different from blaming yourself.     Chronic pain is complex, with numerous origins and treatments, and is grossly misunderstood.  This will provide you with the information you need to mvoe forward. Even though your life will be different from the way it was before you developed pain, you can change some aspects of the pain, and can learn to accept or work with other aspects so that they cause you less distress.  Your task will be difficult– but not impossible.

Determining Exactly What Your Problems Are

  ORDER AND SIMPLIFICATION ARE THE FIRST STEPS TOWARD MASTERY OF A SUBJECT– THE ACTUAL ENEMY IS UNKNOWN. — Thomas Mann, THe Magic Mountain ( 1924)

The Importance of Tracking Your Pain Levels

 One important way to gain control over your pain is to record it so that you can see how certain factors– for instance, activities, the weather, tension, and sleeplessness– increase or decrease your pain levels.  This should be done three times a day, at regular times that are convenient for you.  For example, you might record your pain level when you awaken, after lunch, and then again at bedtime.   Such consistency is important, because if you record your pain only when you are aware of it, you won’t neccessarily feel it all the time when your pain is altered.  Recording the pain at regular intervals will allow you to detect over time whether there are any patterns to your pain experience.  These patterns should permit you to determine the exact nature of your problems more easily.    Many people are resistant to the idea of recording their pain, and you may be one of them.  Not only are you in pain to begin with, but it’s an additional hassle to have to record all this stuff– and three times a day! ” Why do i have to do this? It’s not fair!” you may say.  Perhaps the following story may help.

  Paula was very angry at the thought of recording her pain levels. Her back hurt and she already knew she was in pain.  Why did she have to write it down three times a day?  She didn’t have time for such a ridiculous activity.  At first, Paula was so misterable that recording the pain just made her realize how bad she felt.  Gradually, she realized how much she had denied the pain in her back and how it prevented her from doing anything productive or pleasurable.  Not only had she had to give up working outside of the home; she barely kept up with the household chores.  Her house certainly wasn’t as clean as it used to be.  Even worse, she was irritable toward her husband and yelled at her children. She rearely saw her friends, and really didn’t care any more about going out.  Somehow this just wasn’t the way Paula wanted to live.    Paula also began to see how she pushed herself throughout the day and then collapsed at night.  Her back was stiff when she awoke, and the pain gradually increased during the day.  What was causing it?  Was she not pacing herself? Was she stressed by her routine? Slowly, the answers because clear.  Over time, Paula saw that recording her painhelped her learn more about the relationship her pain had with what she did and how she did it.  She was able to incorporate the skills she learned in the pain management program into her daily routine,and was eventually able to bring the pain much more under her control.

If you don’t think that recording your pain will be a chore, that’s great.  If you do, consider this: You have done your best in your current situation, and it still has not been effective in controlling your pain.  Recording your pain levels can help you determine where you might be stuck and point you in the right direction.  You can’t count on remembering exactly what your pain feels like under all conditions over a long period of time.  So give the recording method a shot–it just might work for you. Remember:  what you know, you can master. 

 Keeping a pain diary

An effective way of recording your pain is to use the pain diary worksheet that is provided at the end of this book. There is a sample of a completed pain diary form, along with a blank pain diary form that can be copied.

Instructions

On the pain diary, it is important that you differentiate between ” Pain sensation” and ” Pain distress” as follows.  ” Pain sensation” refers to the phyiscal component of your pain– for example: th e achiness, stabbing,burning, tightness, and other physical sensations you may feel.  ” Pain distress” refers to your perception of pain and is a measure of the emotional suffering you experience– for example, the frusturation, anxiety, anger, or sadness you may feel. 

Note the word “feel” can be used to describe both physical/body sensations and emotional/mind reactions.  This can give rise to confusion when you try to describe the pain experience to yourself and to the outside world.  I began asking patients to make the sensation-distress distinction years ago when i noticed that at the last session of the pain group they were talking about how great they felt, and yet their pain recordings were only decreased a little from the beginning of the program.  I was puzzles by this, so i asked them to explain it.  They responded without hesitation: ” we still have the pain [ the physical sensation], but we feel so much better about it [ the distress]. We aren’t so helpless. We know what to do about our pain, and we feel in control again.”     Much can be done about your level of distress. You can begin by getting in touch with how you experience your pain, both physically and emotionally.  You may find that either the physical or the emotional feelings predominate, it will take some time for you to make the distinction.  Some of the exercises in the next few chapters will help you to seperate these feelings. 

1. Record your  pain level on the pain diary form three times a day at regular intervals, as described above– for example, morning, noon, and bedtime.
2. On the diary sheet there is a space to describe the situation for each pain  sensation/distress rating. For example. were you watching TV, eating lunch, sitting at a computer, fixing dinner? Note what activity you were engaged in at the time.
3. Rate your pain sensation and distress by using numbers from one to 10. As follows:

0 = No pain/ distress

1-9 = Range in degree of sensation/distress

10 = Worst pain/ terribly distressed

It may take several weeks to establish what the numbers mean to you.  This is quite normal. Pain is a personal experience, and you will only be rating your own experience.  ( If you have particular or continuing difficulty, however, see the ” Rating Your Pain” exercise under the ” Listening to Your Body” in Chapter 4)

OBJECTIVE

To train patients participating in The Pain Center treatment program self-regulation skills to reduce physical tension and positively modify their pain/stress experience, and influence their expressio of well behaviors.

PROCEDURE

Patients are initially evaluated for potential use of thermal ( i.e. peripheral skin temperature) electromyographic ( i.e. EMG muscle tension), or both biofeedback modalities.

Based on the initial evaluation, appropriateness for biofeedback treatment is evaluated and individuals who may benefit from biofeedback are identified. These patients participate in individual treatment sessions, usually four sessions per week, for the three week program. Treatment sessions are designed individually for each patient and may employ the full range of available relaxation and stress management techniques. Notes for each session are recorded on the ” Biofeedback Session” form.

EVALUATION

At the beginning and conclusion of each treatment session, patients discuss their subjective experiences plus rate their pain and stress. The biofeedback technician and supervising health psychologist use these aforementioned measures, along with physiological measures of change to evaluate the patient’s therapeutic progress and modify the treatment regiment as needed.

**( See seperate entry entitled Biofeedback Session for a look at the Biofeedback Session form)**

Pt Name: ____________________

Initl EMG:___________________ Initl Temp: __________

Final EMG: _________________ Final Temp: _______

___________________________________________

(delta) Change ______________& (Delta) _____________

Subjective ( Stress Index):

Comments: ______________________________

________________________________________

________________________________________

OBJECTIVES

1. At a post-discharge group session ( 4 weeks post discharge), patients continue to apply pain management skills in a variety of life situations.

2. Patients assist each other in applying pain management skills through support and problem solving.

3. Patients are supported/reinforced by peers and staff for continued use of pain management skills.

4. The topic areas covered by each group session will generally include pain management skills as identified below under ” concepts,” selection of the specific areas from this list will depend on that group’s needs, as identified by both the Health Psychologist and group members.

5. Over the course of the group sessions, all topic areas will be covered.

CONCEPTS
1. Review of pain management/self regulation skills, including problem solving, communication/social skills, relaxation, cognitive restructuring and attention-diversion techniques.

2. Application of these skills on an as needed basis to situations elicited from group members.

3. Use of others in group is useful for support and problem-solving.

4. Major emphasis is on the integration of pain management skills ( e.g. Assertive communication is essential to pacing, etc)

IMPLEMENTATION

1. Patients demonstrate their understanding of and ability to use pain management skills in specific situations which occur in their activities of daily living.

2. Patients actively participate in all group discussions and complete all homework assignments.

HANDOUTS

1. Depending on the needs of the specific group, handouts may include various self-report inventories covering topics of assertion, stress management, cognitive styles, and problem solving techniques.  Handouts may also be more informational, as supplements to information given to patients in the 20 day pain management program.

 An overview of the four types of chronic pain headaches: chronic migraine, chronic tension-type hheadache, new daily persistent hheadache, and hemicrania continua.

 Chronic daily headache (CDH) is a disorder that is distressing for patients and frustrating for clinicians. The reasons why some patients may be predisposed to having chronic daily headache are not entirely clear. We now know of certain predicting factors that may indicate the likelihood of chronicity for migraine patients. Although the etiology is still not clear, current theories suggest that trigeminal pathway and brain-stem are highly involved in initiating and maintaining chronicity of headaches. Several studies, using newer imaging technology, already show some interesting and promising results.  IT is very likely that CDH, like migraine headache, is a neurovascular disorder.

Since the mechanisms underlying CDH are still not well understood, the treatment choices are open to debate.  There are both pharmacologic and non-pharmacologic treatment options available to patients. As more studies on CDH are conducted, eventually we will have a better understanding of CDH. At present, it is important for clinicians to keep in mind that CDH is a disabling disease, and that promptly recognizing and treating patients with headache(s)- as early as possible- can prevent chronicity in many cases.  What would you do if a 40-year old patient complaining of 6months of persistent headache? The patient reports he has had a headache almost everyday; he describes it as pulsating, unilateral, and aggravated by activity.  What if his hheadache is unilateral without side-shifting but with ipsilateral lacrimation and rtosis? what if the hheadache is is bilateral?  What if his daily headache seems to occur without any preceding events and there is no past medical history of headaches? Would the diagnosis be different? More importantly, would your option of treatment for this patient be different? Discussion on answers to some of these questions will be presented in this article.

  Prevalence

Chronic headache is a common disorder even through it is still not well understood. The overall worldwide prevalence is approximately 4%, and the female to male ratio is close to two to one. A population-based survey from 1998 to 2000 showed that 4.1% of Americans, 4.35% of Greeks, 3.9% of elderly Chinese, and 4.7% of Spaniards had primary chronic daily headaches.  There are two peaks of age-related prevalence: 20-24 years of age and those above the age of 64(8% for both).

 Definition/Classification

The latest diagnostic criteria for CDH were published by the International Headache Society in 2004.  According to these criteria, primary chronic daily headache ( CDH) is defined as headache that occurs for more than 15 days a month and has no structural or infectious causes.

CDH is further divided into four subtypes:

1.  Chronic tension-type headache ( Approx.  in 2-3% of the population)
2.  Chronic Migrane ( ~2%)
3.  New daily persistent headache (~0.2 %)
4. Hemicrania continua ( very rare)

The most common type of headache that a clinician encounters in practice is either chronic tension-type headache or chronic migraine. These patients usually have a history of previous episodic tension, migraine headaches, or both. 

New daily persistent headache (NDPH) is a new subtype recently created to describe headaches that suddenly appear one day and the patient distinctly remembers the onset. These patients usually do not have a previous history of headache. TO date, we still do not know much about the epidemiology pathogenesis, or treatment of NDPH. [ Editors note: See Dr. Steven Singer’s article ” New Daily Persistent Headache” in the issue for a discussion of NDPH and the latest findings.]

Hemicrania continua is a rare headache disorder that is now more frequently recognized and treated by headache clinics.  It is a continuous one-sided headache ( sometimes with autonomic gestures like tearing and rhinorrhea) that completely resolves with the administration of indomethacin. It is so perfectly treatable that this condition should be considered in every CDH patient.  An adequate trial of oral indomethacin over several days should be given if a CDH patient has only one-sided symptoms and is not responding to other treatment(s).  The dose can be increased from 25mg bid to a maximum of 300mg per day.  A single IM shot of 50mg indomethacin ( the so-called Indotest) can also be used effectively.

 Risk Factors and Chronicity

Epidemiological studies have shown that migraine has a higher prevalence in households with lower socio-economic status. This could either be a cause factor or an effect.  Having many migraines could lead to poorer health status and lower academic and social achievement since they can be quite debilitating.  Who therefore has a higher risk of having CDH? Although there are limited data on the natural course of CDH, a few risk factors for CDH have been identified.  

The risk factors that have been found to be associated with CDH include female gender, white race, lower eduational level, being previously married (e.g. divorced, widowed, or seperated), and obesity. Conversely, the factors associated with remission are non-whites, higher educational level, and being currently married. These risk factors were identified by Scher et al who surveyed 55,255 potential cases and controls in the baltimore, Philadelphia and Atlanta metropolitan areas between 1997 and 1999.  Scher et al collected information on gender, age, height, weight, current marital status, highest educational level and race– as well as duration of CDH, pre-CDH frequencey, and the speed of onset of CDH.  The authors followed up with 798 controls and 1134 cases of patients who were able to provide their headache frequency.  The one-year incidence of ew-onset CDH was reported at 3%. This study found that the likelihood of remission increased with age for women but not for men– suggesting that natural history of CDHmight be different in men and women.  THis likelihood may be explained by the fact that the majority of women stop having migraines after menopause.

Scher at al also found that control with higher headache frequency, obesity, or arthritis were all more likely to have new-onset CDH at follow-up.  Moreover, the risk of new-onset CDH was significantly higher in control subjects with more than two headaches per months.  It is therefore important for clinicians to promptly treat patients with frequent headaches to prevent progression to CDH. Scher et al, also reported that 16% of CDH subjects reported continuous headaches. Patients who had continuous headaches were often older and had experienced CDHfor a longer duration. The authors hypothesized that ” if there is such a thing as a progressive headache syndrome, then continuous headache may represent a later stage of the disorder.”          So is there such a thing as progressive headache syndrome?  Are certain patients with headache predisposed to chronicity?  The question can be partly answered by the study of Spierings et al. They interviewed 258 patients of which 230 had known onset of their daily headaches. 22% (51/230) had daily headaches from the time of onset and 78%( 179/230) initially had intermittent headaches. Of the latter 179 patients, 81% ( 145/179) developed daily headaches gradually and 19% had an abrupt transition into daily headaches.  It took an average of 10.7 years for the 145 patients to develop daily headaches from intermittent headache.  The severity of initial headaches varied among the 145 patients to develop daily headaches from intermittent headaches.  The severity of initial headaches varied among the 145 patients: 33% than the ones with mild headache. However, regardless experienced mild headache while 67% suffered from severe headache. The patients with severe headaches experienced more nausea and vomitting than those with mild headache.  However, regardless of the severity of initially intermittent headaches, these patients eventually developed the same daily headache.  In addition, of the 145 patients who gradually developed daily headaches, 69 were followed up to obtain more information on their transition of headaches. 33% ( 23/69) continued to have daily headaches whereas 67%(46/69) were having a recurrence of intermittent headaches.  Of the patients with recurring intermittent headaches, 74% (34/46)  were experiencing migraine and 26% (12/46) were experiencing tension-type headache. Of the 34 migrane patients, 88% ( 30/46) also initially had migraines but 12%( 4/34) originally had tension-type headache.  Of the 12 patients who currently experienced tension-type headache, only 25%( 3/12) had tension-type headache originally and 75% (9/12)  had migrane initially.

The transition into daily headaches has been recognized since the 1980s, but it is difficult to determine who would eventually develop daily headaches. It is also difficult to determine wheter people with certain headache types are more predisposed to chronicity.  Patients with episodic migraine or tension-type headache ultimately develop the same daily headache and, when the daily headaches become intermittent again, they seem to reassume the initial headaches.  The specific risk factors for each subtypes of CDH are still not specified and more studies need to be done in the future to answer this question.

Pathogenesis

Current theories of episodic migraine headache clearly indicate that it is a neurovascular disorder.  Migrane is now considered the result of dysfunction within the brainstem that induces changes in blood vessels within the pain-producing intracranial meningeal structures.  The exact nature of this dysfunction is still not clear.  Current theories propose that ” the local vasodilation of intercranial extracerebral blood vessels and a consequent stimulation of surrounding trigeminal sensory nervous pain pathways is the key mechanism underlying the generation of headache pain associated with migraine.”     The activation of the trigeminal pathway stimulates the release of pro-inflammatory mediators that results in sterile inflammation in the preivascular area.  The release of vasoactive sensory neuropeptides like calcitonin gene-related peptide (CGRP) results in activation of the pain pathway.  In addition to CGRP, the levels of of nitrite, neurokinin A (NKA), prostaglandin E2 (PGE2), and 6 keto PGF1 alpha are elevated during the migraine attack and decrease after the end of attacks. Once the pathway is activated by the neuropeptides, the pain signals are sent up by activated trigeminal nerves to the central neurons in the brainstem trigeminal sensory nuclei.  These signals are then relayed to higher centers where pain is perceived.

There is both central and peripheral sensitization during episodic migraines.  Sever MRI studies have demonstrated that a migraineur who is not currently have (a) headache has a state of neuronal hyperexcitability in the cerebral cortex– especially in the occipital cortex.  This finding explains the susceptiblity of the migrainous brain to headaches.  A frequent finding in migraine is the presence of high signal deep white matter foci on brain MRI– the clinical significance of which is still up for debate.  In addition to MRI, PET scanning for patients with acute migrane headaches demonstrates activation of the contralateral pons–even after the pain has been aborted by medications.

In addition to the trigeminal nervous pathway and brainstem, the hypothalamus plays a prominent role in certain headache disorders.  Hypothalamus involvement can explain some of the autonomic behaviors seen with the headaches: yawning, sweating, aggressive behavior,tearing, rhinorrhea, etc.  These behaviors are more commonly seen in trigeminal autonomic cephalalgias ( a new name given to cluster headaches and similar headaches).  Studies using functional neuroimaging with PET and anatomical imaging with a voxel-based morphometry have identified “the posterior hypothalmus grey matter as the key area for the basic fefect in cluster headache.”  The hypothalamus can also activate the trigeminal vascular pathway and thus generate a headache. 

 Do these theories that explain episodic headache also apply to CDH?  Currently it is believed that CDH is also a nurovascular disorder that occurs due to an alteration in serotonergic and monoamingergic pathways to the brainstem and hypothalamus.  We know that there is central and peripheral sensitization of the nervous system in episodic migraine.  We postulate that a mechanism similar to kindling occurs in patients with frequent episodic headache resulting in a constant state of sensitization and, therefore, persistent headaches.  

There is limited imaging data demonstrating that CDH is a neurovascular disorder. In 2004, Nagesh et al took high resolution MRI images of 17 CDH patients, 10 episodic migraine patients, and 15 controls with a 3 telsa MRI in deoxyhemoglobin and hence persistent activation of red nucleus (RN) and substantia nigra (SN) in CDH compared to control and episodic migraine groups. However, there was no significant difference between the control and episodic migraine groups.   Aurora et al assessed the excitability of the cortex by the magnetic suppression of perceptual accuracy (MSPA) profiles transcranial magnetic stimulation in 25 chronic migraine patients.  Ten of these 25 patients were studied with ( 18-FFDG PET) scans. MPSA demonstrated decreased inhibition in chronic migraine compared to control and episodic migraine.  PET evaluation in ten subjects demonstrated increased cerebral metabolism in areas of the brainstem compared to the global flow.  Certain areas in the medial frontal, parietal,  as well as the somatosensory cortex, also showed decreased cerebral metabolism. This study concluded that ” chronic migraineurs are characterized by reduced visual suppression that correlates with high cortical excitability.”  The brainstem activation and inhibition in certain areas of the cortex were observed in a cohort of these subjects suggesting ” a potential dysfunction in the inhibitory pathways.”  The cause of the activation is still unknown.  How the brainstem changes during the progression of CDH and in response to treatment needs to be investigated.

 Pharmacological Management

 There are two types of treatment- acute abortive treatment and preventive treatment.

 Acute Treatment.  Abortive treatment aims at relieving symptoms immediately.  If a CDH patient has an acute episode of migraine, triptans or ergots can be used. However, they are not very effective in controlling chronic headache(s).  The role of serotonin agonists ( i.e. triptans or ergots) is not clearly understood in the management of CDH.  Triptans (e.g. sumatriptan) are serotonergic agonists that selectively inhibit vasodilation through 5-HT1B receptors expressed in intracranial arteries and inhibit neurogenic inflammation in the dural vessels. At the present time, these agents are only warranted for short term management during exacerbation of headache.  Chronic tension-type headache can be effectively managed with analgesics such as NSAIDs. For hemicrania continua, prompt resolution of the headache with a trial of indomethacin 50mg 3 times a day, for 48 hours, will establish the diagnosis.  These agents should not be used as long-term treatment, since doing so may prolong CDH.  It is important to limit the use of acute medication to 2-3 days per week.  Clinicians need to reevaluate the treatement protocol if a patient constantly seeks medications and, perhaps, institute preventive treatment instead. 

 Preventive treatment.

 Preventive treatment is the usual approach to CDH and is quite effective in controlling chronic headache(s). The primary goal of preventative treatment is to reduce the frequence, severity, and duration of headaches.  Preventive treatment involves taking daily medication for 3-6 months or longer. Choice of prevention treatment should be based on the concomitant or co-morbid conditions.  Regardless of the type of medications, as a general rule medication should start at minimum dose and be adjusted slowly until efficacy is achieved or side effects are reported . To date, only amitiptyline, fluoxtine, gabapentin, tizanidine, topiramate, and botulinum toxin type A ( BoNTA) have been evaluated as ” prophylactic treatment of CDH in randomized double-blind, placebo controlled, or active comparator-controlled trials.   Currently, many physicians consider antidepressants as the primary choice for the treatment of CDH since they have been studied most extensively. Several double-blind placebo-controlled studies were summarized in the review by Redillas and SOlomon. Tricyclic antidepressants (TCAs) potentiate the action of 5-HT and nonrepinephrine (NE)  by inhibiting their reuptake into the CNS. The review noted the study by Gobel et al in 1994  on 24 chronic tension-type headache patients indicated a decrease in headache duration by 30% after a six-week amitriptyline treatment regimen. The review also noted that Bendsonet al in 1996 compared amitriptyline and citalopram against placebo in 34 patients and reportd that amitriptyline was effective in decreasing headache frequency and duration but that citalopram had no effect.  Selective serotonin reuptake inhibitors (SSRIs) inhibit 5-HT, NE, and platelet 5-HT uptake.  The review noted that the study by saper et all indicated an increase in headache-free days in 40% of CDH patients on fluoxetine, and there was at least 50% improvement from baseline in overall headache status. The review also noted Foster and Bafaloukos reported improvement in headache in an open-label study of 60 CDH patients treated with paroxetine. In this study, 44 patients reported a decrease in headache frequency by atleast 50%.

If antidepresants are not effective, anticonvulsants can be used. Muscle relaxants or antianxiety agents can also be used as part of a treatment regimen if muscle spasm or anxiety is co-morbid.  One interesting, atypical preventive medicaton that has been studied for CDH is botulinum toxin (BoNTA). In a placebo-controlled study consisting of over 1000 there is a statistically significant difference ( P=.038)  in headache-free days at day 180 between BoNTA ( 10 headache free) and placebo ( 6.7 days).  The study concluded that BoNTA was safe, well-tollerated, and effective in reducting the frequency of headaches.   Occasionally, outpatient treatment may fail thus neccessitating impatient admission for intractable headache. Intravenous dihydroergotamine(DHE)  can be used to break the cycle of CDH.  Opioids can be used as a treatment of last resort when all other treatment options fail.  The pros and cons of daily opioid therapy should be carefully discussed with the patient.  However, opioids are still under-used, rather than over-used, in headache management.  Clinicians need to careful but not afraid when using opioids. 

Pain Solutions Network is an interdisciplinary chronic pain management program located in Cincinnati, Ohio.

Chronic pain is defined as persisting for more than 6 months after an injury, surgery or disease process.

Chronic pain is addressed with a variety of treatment options. Each treatment option has its place depending upon where the person in chronic pain is along the continuum of care.