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The most common chronic pain syndromes. Symptoms and methods of treatment of chronic pain syndrome. Causes of Chronic Pain and Risk Factors

chronic pain is extremely common and underestimated. According to the Russian Association for the Study of Pain, the prevalence of chronic pain syndromes in Russia varies from 13.8% to 56.7%, averaging 34.3 cases per 100 people (Yakhno N.N. et al., 2008). A patient with chronic pain syndrome often ceases to pay attention to pain, begins to perceive it as something for granted and inevitable, and continues to carry out his normal daily activities. In many cases, patients with chronic pain, on the contrary, become overly subordinate and dependent: they demand more attention, feel seriously ill, begin to rest more and relieve themselves of responsibility for performing some duties. This hinders the healing process and delays it. The following will list additional characteristic features of chronic pain syndrome: 1. his/her attention is constantly focused on pain; 2. he/she constantly complains of pain; 3. the patient dramatizes his pain and demonstrates with all his appearance that he is sick (for example, he grimace, groan, groan, limp); 4. he/she uses a wide variety of medicines; 5. he/she seeks more medical care; and 6. his/her family relationships change for the worse. The spouse of a CPS patient also experiences anxiety, depression and fear. Consider the basic principles of diagnosing chronic pain syndrome.

Diagnostics chronic pain syndrome includes several provisions. Exclusion of possible somatic (organic) factors that cause pain. So, in the case of chronic pain in the left half of the chest, coronary heart disease is excluded. With pain in the pelvis, gynecological, urological and other causes of pain are excluded; in case of headaches - volumetric processes in the cranial cavity, anomalies of the craniovertebral junction, pathology of the cervical spine, etc. In cases where organic pathology is excluded or its presence cannot explain the duration and nature of pain, the diagnosis of chronic pain syndrome is carried out using the following criteria:

1. clarification of the temporal characteristics of pain: for 3 (three) months or more, the patient experiences pain that lasts most of the day and at least 15 days within 1 month;

2 . qualitative characteristics of pain: 2.1. pain of a monotonous nature, periodically increasing to an attack; 2.2. the use of other terms to describe pain, for example, “stale”, “cotton” head, “congestion” in the left half of the chest, “heaviness” in the abdomen, “unpleasant tickling” in the lumbar region, etc .; 2.3. senestopathic coloration of pain: when questioned, patients report that they feel “difficulties in passing blood through the vessels”, “as if something is moving or overflowing in the head” and other similar phenomena;

3 . localization of pain always much wider than the patient presents; thus, in patients with chronic back pain, headaches, pains in the heart, abdomen, etc. are often found; on palpation, such patients experience pain much wider than in the initially presented area;

4 . pain behavior: depending on the location of the pain, it includes different behavioral patterns, for example, marking the "sick" organ - its immobilization, constant rubbing of the skin in the region of the heart or restrictive behavior, for example, avoiding normal physical activity, a rigid diet to prevent abdominal pain, regular intake analgesics in the absence of the effect of them, calling an ambulance, etc.);

5 . psychogenesis of pain: when studying the anamnesis of patients, it often turns out that in childhood one of the close relatives suffered from pain, and more often in the same localization as that of the patient; often the patient himself experienced pain or observed them in emotionally intense situations, for example, the death of a parent from myocardial infarction with severe pain or headaches that led to a stroke, etc .;

6 . beaten paths: debut or exacerbation of chronic pain after injuries, surgical interventions, infectious diseases; for example, chronic "post-traumatic" headaches for many years after a mild traumatic brain injury or chronic post-operative abdominal pain, usually flowing under the guise of "adhesive" disease;

7 . syndromic environment includes psychovegetative and motivational disorders; with active and purposeful questioning in these patients, it is possible to identify sleep disorders, appetite, changes in body weight, decreased libido, constant weakness and fatigue, difficulty breathing, palpitations and other symptoms that indicate a violation of the autonomic nervous system.

To assess multifactorial pain syndrome most often use a specially designed McGill questionnaire. This questionnaire contains 20 groups of adjectives that describe pain. The patient is asked to underline one word from each group that best describes his/her pain. The McGill scale allows you to measure the sensory, emotional and quantitative components of the pain syndrome; the data obtained, although not expressed in absolute terms (i.e., they are not parametric), however, are amenable to statistical interpretation. The difficulty in assessing the McGill questionnaire arises only when the patient is not familiar with the language.

To assess the psychological component of chronic pain in patients with chronic pain, the Minnesota-based Multiphasic Personalized Inventory (MMPI) is most commonly used. Patients with chronic pain syndrome have elevated scores in the following three categories of the MMPI scale: hypochondria, hysteria, and depression. The combination of these pathological conditions, which is called the neurotic triad, quite well reflects the psychological status of patients with chronic pain syndrome.

At the initial stages of the examination of a patient with chronic pain syndrome, depression (according to the questionnaire and the Beck depression scale) and anxiety (according to the questionnaire and the Spielberger anxiety scale) are sometimes assessed. When examining patients with chronic pain syndrome, special attention is paid to such clinical signs as the individual's excessive attention to his somatic state, depressed mood and helpless/hopeless outlook on life. Listed below are some specific characteristics of pain that indicate poor psychological tolerance to nociceptive stimuli:

1 - pain does not allow a person to perform their daily duties, but nevertheless does not prevent him from going to bed peacefully;
2 - the patient vividly and vividly describes the pain sensations experienced and demonstrates with all his behavior that he is sick;
3 - he / she experiences pain constantly, pain sensations do not change;
4 - physical activity increases pain, and increased attention and care from others soften it.

treatment a patient with chronic pain syndrome should be treated by specialists of various profiles, since chronic pain is polyetiological. If taken at a minimum, then the treatment and rehabilitation team should be represented by an anesthesiologist, psychologist, paramedical personnel and a social worker; in large pain centers, this team also includes a neurologist, orthopedist, neurosurgeon, acupuncturist, and authorized vocational rehabilitation person. If necessary, assistance from other specialists may be required.

© Laesus De Liro

The purpose of this publication is to set out clearly the challenges facing chronic pain professionals: what are the logistical and physical costs for health administrators and practitioners, what are the economic and moral gains. We emphasize that we are talking about chronic pain syndrome, about pain-disease, and not about acute pain-symptom, with which anesthesiologists-resuscitators are currently coping quite successfully.

The needs of society and understanding of the importance of the problem of pain have contributed to the emergence in some developed countries of specialized "pain clinics", specialized departments in medical centers and university clinics.

The treatment of patients with chronic pain syndromes carried out in these clinics allows them to provide them with much more effective and well-structured specialized care, significantly increases the positive effect of treatment, and contributes to the speedy recovery of patients' working capacity or their social adaptation.

Unfortunately, the problem of chronic pain is completely ignored by Russian insurance companies and healthcare as non-existent. We still don't have official statistics on this, although based on the proportions of the population, it's not difficult to calculate that millions of people in Russia suffer from various types of chronic or often recurrent pain. And given the current state of the state economy, apparently, in the foreseeable future, one should not hope for any significant budget funding to solve this problem.

The multidisciplinary scientific center “Integrative Medicine” was established in 1993 at the Russian Scientific Center for Surgery of the Russian Academy of Medical Sciences on the basis of the Scientific Advisory Department (polyclinic) and the Department of Pain Syndrome Therapy. The purpose of the center is to provide an opportunity for patients suffering from various types of pain syndrome, comorbidities and functional disorders to receive specialized medical care, and for medical workers to have additional income on a completely legal basis.

The organizational and legal form of the new structural subdivision of the RNCH is a closed joint stock company, where its only founder is a state institution that owns 51% of the shares. The remaining shares are distributed among the employees of the RNCH and cannot be transferred (sold) to third-party individuals or legal entities. All financial and economic activities are controlled and determined by the general meeting. Profits from commercial activities are mainly used to purchase medicines, equipment and consumables for research; specific items of expenditure are approved at the annual general meeting of shareholders.

The Integrative Medicine Center has a license for almost all types of medical activities (from the medical control commission and all types of medical and diagnostic practice to testing and developing new medical equipment), which largely determines the success of financial and economic activities in the current economic conditions.

As a result of a long-term scientific study of the problem of diagnosing and treating chronic pain and practical achievements in this area, the Center has formed the following staff of specialists working in the relevant laboratories:

• main specialists: anesthesiologists, neuropathologists, psychoneurologist, orthopedic traumatologist, physiotherapists, reflexologists, chiropractor, exercise therapy doctor, massage therapists, nurses and junior medical staff;
• consultants: neurosurgeon, microsurgeon, vascular, thoracic and other surgeons, therapists (cardiologist, gastroenterologist, etc.), urologist, gynecologist, ENT, ophthalmologist, endocrinologist, dermatologist, specialists in functional diagnostics;
• diagnostic laboratories: express diagnostics, clinical, functional, immunology, radioisotope, ultrasound, endoscopic, X-ray diagnostics and computed tomography, thermal mapping, prevention and treatment of infections.

The center uses the latest diagnostic and treatment methods (Tables 1 and 2). Of course, such a selection of specialists, with a wide range of diagnostic and therapeutic methods, is only possible for fairly large research centers and multidisciplinary clinical hospitals. In practical medicine, at first, 25-33% of the specified list of specialists and methods can be completely dispensed with, and as skills, work experience, appropriate equipment and equipment are acquired, the amount of assistance can also be expanded. The following composition of specialists should be considered the minimum sufficient: two anesthesiologists (one of them must be trained in performing therapeutic blockades, and the second must be proficient in the methods of reflexology in the amount necessary for the treatment of pain, including elements of manual therapy), a psychoneurologist (or a neuropathologist and a psychiatrist) and a physiotherapist. These specialists ex consilio determine the strategy and tactics of treatment for each patient, as well as the need for additional research and consultations. More often you have to resort to the consultations of specialists available in each clinic or hospital (surgeon, gynecologist, dentist, etc.).

Table 1. Methods for diagnosing chronic pain

It should be specially noted that at present (orders of the Ministry of Health of the Russian Federation No. 364 and 365 of December 10, 1997) reflexology and manual therapy for the first time received the status of officially existing specialties in Russia. Nursing staff are involved as necessary to perform specific work (massage, physiotherapy, manipulations, blockades, etc.). The medical registrar copes well with the function of a cashier.

The experience has shown that the organization of the work of the pain center is successfully undertaken by anesthesiologists, who are the most proactive, informed about the inpatient and outpatient activities of the hospital, people who, as a rule, get along well with management, colleagues and staff. If your medical institution has all of the above prerequisites, then a group of like-minded people can take the initiative to organize an analgesic center in order to provide additional LEGAL earnings to ALL hospital or polyclinic specialists. Further organizational actions do not present big problems. The management of the medical institution or an initiative group submits to the general meeting of employees the issue of creating a closed joint-stock company (or another structure more convenient for the team), the charter is adopted and a new legal entity is registered, an agreement is concluded under which the institution transfers the necessary areas to the pain center or the same jobs and the necessary equipment. It remains to fulfill one condition - to introduce a single full-time position - an accountant, as well as to purchase and register a cash register.

Currently, there are already regulations on the pricing of medical services. All employees, whose advisory and medical activities will be in demand among the population, work in the center under a contract in their free time from their main activities. The percentage of deductions from the total amount of incoming funds for wages, as well as for development, is determined by the general meeting of shareholders, taking into account taxes and so on.

Table 2 Treatment options for chronic pain

The pain center should build its work, focusing mainly on outpatients, which, however, does not exclude, if necessary, hospitalization for more detailed examination and treatment, as well as the possibility of servicing enterprise teams on a contractual basis.

The scope of services depends on the level of professional skills of the staff. Based on the principle of minimum sufficiency, economic profitability can be achieved if the following items are included in the list of medical services:

• classical acupuncture;
• manual therapy;
• therapeutic blockades and pharmacopuncture;
• therapeutic massages: vacuum, segmental, acupressure;
• integrative methods of influence (TENS, EHF, etc.);
• combined reflexology with psychotropic drugs;
• physiotherapy procedures.

The above list of effects can be mastered and applied by any specialist of the pain center - training in these methods today in Russia is carried out in many specialized institutions.

A group of patients with chronic pain of oncological origin stands somewhat apart, that is, patients who are within the competence of the palliative and hospice service of the oncological dispensary. According to modern criteria, the methods listed above are equated to physiotherapeutic procedures, and therefore are not applicable in oncology, although there are results of studies conducted in many university clinics around the world that show the effectiveness of integrative medicine methods in relieving cancer pain. At the same time, in our opinion, any method that relieves pain in the terminal stage of cancer deserves the most careful attention and study.

Patients come to the Center with various conditions and diseases. Pain syndromes are presented in table. 3 in decreasing progression.

As mentioned above, we divide all methods of exposure into invasive and non-invasive, pharmacotherapeutic and non-drug methods. The choice of optimal complex methods of treatment and their integration was based on the use of more than 150 classic traditional and modern treatment methods.

At each stage of treatment, the choice and sequence of application of the methods were determined individually, depending on the etiological and symptomatic manifestations of the pain syndrome and the severity of the accompanying functional disorders.

Table 3. Pain syndromes in decreasing order of pain intensity

Usually, patients came to us after undergoing treatment in many instances, but with the same complaints, so most often we had to start treatment with pain relief using the following pharmacotherapeutic methods.

• With a pronounced excruciating pain syndrome caused by malignant neoplasms of the abdominal cavity and small pelvis, phantom and causal pains, epidural analgesia was used. Puncture and catheterization of the epidural space was performed in accordance with generally accepted recommendations. Analgesia was carried out by introducing the narcotic analgesic morphine (0.1 - 0.3 ml of a 1% solution in 10 ml of saline) once a day. The advantages of this methodological solution are that a good analgesic effect is achieved with minimal administration of the drug, there is no need for frequent repeated injections, which reduces the risk of infection of the epidural space. The method was used both in inpatient and outpatient settings. Side effects such as hypotension, orthostatic collapse, respiratory depression were not observed.
• The method of regional analgesia was used to treat almost all types of pain syndromes. Analgesia was carried out by introducing 0.75-1% solutions of local anesthetics (bupivocaine, lidocaine). For the upper extremities, Kulenkampf blockade, axillary nerve blockade with a tourniquet were used; for the lower extremities - blockade of the femoral, sciatic, external cutaneous, obturator nerves. Treatment sessions were prescribed as needed, but not more than once every two days, both in inpatient and outpatient settings.
• The essence of the pharmacopuncture technique is the introduction of microdoses of modern pharmaceuticals into the classical acupuncture points. The method was used to treat all types of pain syndromes, comorbidities and functional disorders, such as bronchial asthma, intestinal motility disorders, urination disorders, pruritus, neuralgia, including herpes, neuropathies, neuritis. Non-narcotic analgesics (tramal, butarphanol tartrate, analgin, baralgin) and local anesthetics were administered. In combination with them, depending on the cause of the pain syndrome, hormones and other anti-inflammatory drugs and antihistamines, vitamins of group B were prescribed. The drugs were injected into the classic acupuncture points according to an individually selected recipe, based on the most painful (trigger) zones. It can be considered optimal to administer drugs using original sets of disposable syringes with two or three successively located containers in the tube containing a local anesthetic, B vitamins and hormonal agents. The introduction of drugs is carried out by means of a single injection, which reduces trauma, increases the accuracy of administration and optimizes dosing of drugs. We also used a sequential nozzle on one injection needle of two or three syringes containing drugs selected according to an individual prescription. Both methods can be performed according to the principle of polytopic administration of drugs.

The choice of integrative methods of reflexology for the treatment of patients with chronic pain syndrome is based on the severity of its manifestations, that is, the intensity and duration, psycho-emotional exhaustion of patients associated with the low effectiveness of long-term use of traditional analgesics (narcotic and non-narcotic). We also proceeded from the fact that the traumatic nature of integrative methods of clinical reflexology should not exceed the severity of the manifestations of the pain syndrome and should not be subjectively burdensome for the patient.

An objective characteristic of the effectiveness of integrative reflexotherapy techniques based on the impact on biologically active points and zones was made on the basis of an analysis of the results of computer thermal mapping and the calculation of the amount of analgesics consumed before and during treatment. Good subjective tolerance by patients of these techniques is confirmed by the study of hemodynamic parameters and cyclic nucleotides before and after exposure. All methods of reflexology used by us reduce adrenergic stimulation, due to which arteriolospasm is eliminated and tissue microcirculation improves.

The results of the introduction of integrative methods of clinical reflexotherapy into the practice of pain clinics in the treatment of severe pain syndromes from traumatic surgical (destruction of the anterior pituitary gland and frenotomy) and radiation methods testify in favor of integrative reflexotherapy.

For citation: Spirin N.N., Kasatkin D.S. Modern approaches to the diagnosis and treatment of chronic daily headache // BC. 2015. No. 24. S. 1459-1462

The article presents modern approaches to the diagnosis and treatment of chronic daily headache.

For citation. Spirin N.N., Kasatkin D.S. Modern approaches to the diagnosis and treatment of chronic daily headache // BC. 2015. No 24. S. 1459–1462.

Headache is one of the most common symptoms in the population, significantly reducing the quality of life and performance. In 2007, data from a population-based study conducted under the auspices of the World Health Organization to identify the prevalence of headache in the world were published, including a meta-analysis of 107 publications from 1982 to 2011. Analyzing the prevalence of headache in the world, it was found that it is significant more common in the populations of developed countries in Europe and North America (60%), compared with the world average (45%), while there is a significant predominance of the prevalence of headache in women - 52% versus 37% in men. In Russia, the prevalence of headache among those who applied for an appointment at a polyclinic is about 37%.
The most socially significant and disabling is chronic daily headache (CDHA), which combines various types of headaches that occur 15 or more times a month for more than 3 months. The prevalence of this type of pain in developed countries is 5–9% of the entire female population and 1–3% of the male population. An important aspect is the fact that 63% of patients with chronic headache are forced to take analgesics for 14 or more days a month, while in most cases there are signs of drug overdose, which further increases the risk of complications.
To simplify the differential diagnosis, CEHD is divided into pain with a short duration, lasting up to 4 hours, and long-term pain, lasting more than 4 hours. The 1st group includes the actual primary short-term headaches and headaches associated with the involvement of the autonomic nervous system of the face and head. The 2nd, more common group includes migraine, including transformed, chronic tension headache (CHTN) and continua hemicrania (hemicrania continua).
The key to effective treatment of CEHD is accurate differential diagnosis, which makes it possible to exclude the secondary nature of headaches and confirm the nosological affiliation of this type of pain. When assessing the anamnesis, neurological and somatic status, special attention should be paid to potential predictors of secondary pain, conventionally called "red flags".
These include, in particular:
- a clear clino-orthostatic dependence - the appearance or intensification of a headache when moving to a vertical or horizontal position;
- headache is provoked by the use of the Valsalva test - forced exhalation with the nose and mouth closed;
- sudden onset of intense or unusual headache;
- first appeared headache over the age of 50 years;
- the presence of focal neurological symptoms;
- the presence of a head injury in the immediate anamnesis;
- signs of a systemic disease (fever, weight loss, myalgia);
- edema of the optic disc.
The most common causes of secondary headaches are an increase in intracranial pressure due to a violation of CSF circulation (Arnold-Chiari anomaly) or volumetric formation, the presence of obstructive sleep apnea, giant cell arteritis, a condition after a traumatic brain injury and vascular anomalies (aneurysms and malformations), less often intracranial hematomas. The use of additional diagnostic methods is justified only if "red flags" are detected in patients, while magnetic resonance imaging (MRI) is more sensitive in identifying the secondary nature of pain. In the absence of contraindications, MRI with contrast enhancement is recommended to improve the efficiency of detecting volumetric processes. The use of neuroimaging methods in the case of obviously primary nature of headaches is impractical due to the absence of specific symptoms of brain damage. The use of electroencephalography in the diagnosis of headache is also not justified.
After excluding the secondary nature of CEGB, it is recommended to use the criteria recommended by the International Classification to confirm the nosological form of headache.
CEHD with a short duration are relatively rare, but the correct diagnosis of these conditions can significantly improve the patient's quality of life. Headaches associated with the involvement of the autonomic nervous system of the face and head include chronic cluster headache, paroxysmal hemicrania, and short-term unilateral neuralgic headaches with conjunctival injection and lacrimation (SUNCT). Experimental and functional neuroimaging studies have shown that these conditions are accompanied by activation of the trigemino-parasympathetic reflex with clinical signs of secondary sympathetic dysfunction. A distinctive feature of this group is the presence of lateralization (pain is predominantly unilateral), localization in the orbit, less often in the forehead and temple, as well as a combination with ipsilateral injection of the conjunctiva and/or lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead sweating or face, miosis and/or ptosis.
Other primary headaches with a short duration are hypnic pain (occurs during sleep, continues after waking up in the morning, more often over the age of 50 years), cough pain (headache occurs when coughing and performing a Valsalva maneuver), headache of physical tension (throbbing pain , sharply aggravated by physical exertion) and primary stabbing headache (acute pain in the temple, crown or orbit). All nosological forms of this group have signs of the presence of "red flags", which means that they can be set as a "diagnosis of despair" only after the complete exclusion of the secondary nature of the process, but even in this case they are subject to further dynamic observation.
HEGB with a duration of more than 4 hours includes the main primary headaches: tension headache (THN), migraine, continuum hemicrania and new daily persistent headache (new daily-persistent headache).
Chronic migraine usually develops in patients with a long history of migraine that has rapidly or gradually transformed into CEHD. Patients in this case describe their condition as persistent moderate headache with intermittent episodes of exacerbation of the type of classic migraine. Often, inadequate migraine therapy leads to such a situation, while there is a so-called "abuse headache" associated with a change in the activity of analgesic systems against the background of abuse of analgesics.
Diagnostic criteria for this nosological form are: the presence of a headache that meets criteria C and D of migraine without aura, characterized by one of the following signs: 1) unilateral localization, 2) pulsating character, 3) moderate to significant intensity, 4) worsens from ordinary physical activity ; in combination with one of the following symptoms: 1) nausea and/or vomiting, 2) photophobia or phonophobia; at the same time, the duration and frequency of occurrence correspond to CEHD (15 or more times a month for more than 3 months). An important aspect is to exclude the presence of an overuse headache in a patient by discontinuing the used analgesics for 2 months, if symptoms persist beyond this period, chronic migraine is diagnosed, while the presence of improvement indicates an overuse headache.
Hemicrania continuum is a moderate pain of a unilateral nature, without changing sides, with the absence of light gaps and a periodic increase in pain; like the partial form of hemicrania, it is accompanied by signs of autonomic activation: ipsilateral conjunctival injection and/or lacrimation, nasal congestion and/or rhinorrhea, miosis and/or ptosis. An additional diagnostic criterion is the good efficacy of indomethacin.
A new daily persistent headache is a type of CEHD that proceeds from the very beginning without remissions (chronization occurs no later than 3 days from the onset of pain). The pain, as a rule, is bilateral, pressing or squeezing in nature, of mild or moderate intensity, is not aggravated by ordinary physical activity and is accompanied by mild photo- or phonophobia, slight nausea. The diagnosis is established if the patient can accurately indicate the date of onset of the headache. In case of difficulty of the patient in determining the time of onset of symptoms, a diagnosis of CHTH is made.
CTH is the most common type of CTH in the population and accounts for more than 70% of all headaches. The duration of the pain is several hours, or the pain is constant, combined with the presence of 2 of the following symptoms: 1) bilateral localization, 2) compressive or pressing (non-pulsating) character, 3) mild to moderate intensity, 4) not aggravated by ordinary physical loads; and is accompanied by mild photo- or phonophobia, slight nausea. In the presence of excessive use of analgesics at the time of diagnosis, abuse headache should be excluded. In rare cases, a patient may have a combination of migraine and chronic tension headache, which can be a problem in developing patient management tactics.
The treatment of chronic headache is an indicator of the quality of the work of a doctor as a diagnostician and, at the same time, as a psychologist and psychotherapist, since adequate rational psychotherapy, including in the form of informing the patient about the causes and risk factors for the development of his headache, is an important condition for reducing the severity and frequency of seizures, improving the patient's adherence to treatment and improving the quality of his life. In addition, a number of non-pharmacological measures should be included in the treatment program for a patient with CEHD, which can have a significant effect, despite the absence of a serious evidence base at the moment. These, in particular, include a change in the daily regimen with the allocation of sufficient time for night sleep: full sleep is one of the important conditions for the restoration of the antinociceptive systems of the brain, as well as systems that regulate the psycho-emotional status and are directly involved in counteracting chronic pain (raphe nuclei, blue a place). The second important aspect of non-drug therapy is diet correction: it is necessary to limit or completely eliminate the use of alcohol, caffeine, as well as potentially headache-causing foods (containing sodium monoglutamate). Compliance with a full-fledged diet (with the avoidance of long periods of fasting) is also an important condition for effective treatment. It is also necessary to completely eliminate smoking.
Headache is one of the common side effects of drug therapy with almost any drugs, however, some groups of drugs have a specific "cephalgic effect" associated with the mechanism of their action (in particular, NO donors and phosphodiesterase inhibitors), which must be taken into account when planning the treatment of comorbidities .
A number of studies have demonstrated a good effect from osteopathic effects on the neck area and the use of a set of exercises for the neck muscles, however, the effectiveness of this method is probably determined by the presence of concomitant pathology of the cervical spine and craniovertebral junction. The use of acupuncture, according to the meta-analysis, is effective if the patient has HDN, in other cases it can be used as part of complex therapy.
The drug therapy of CEHD has significant differences depending on the nosological form diagnosed in the patient, but the most significant is the adequate use of analgesic therapy (avoidance of drug abuse, including taking drugs strictly on time, regardless of the presence or absence of headache, and the inadmissibility use of the drug "on demand"). An effective method may be a radical change in the group of drugs used, especially if you suspect the abuse nature of the pain.
From the point of view of evidence-based medicine, the most justified is the use of drugs such as antidepressants, anticonvulsants, α2-adrenergic receptor agonists for the treatment of CEHD.
Antidepressants are an important component of the treatment of chronic pain syndromes in neurology, rheumatology and therapy. A feature of the pathogenetic action of this group of drugs is the effect on the metabolism of brain monoamine systems directly involved in antinociception, in particular, norepinephrine and serotonin. Clinical trials demonstrated a moderate clinical efficacy of amitriptyline compared with placebo - a decrease in the frequency of pain by more than 50% from the initial one in 46% of patients after 4 months. therapy, but after 5 months. no statistical significance of differences was demonstrated, which may be due to the general nature of the study population (any types of CEHD). According to the Cochrane meta-analysis, the effectiveness of selective serotonin reuptake inhibitors (fluoxetine) has not been demonstrated.
Among the anticonvulsants used in the treatment of CEHD (chronic migraine), valproic acid, topiramate and gabapentin demonstrated the greatest effectiveness in reducing the frequency of attacks by 50% or more, according to RCTs. In the case of a patient with chronic migraine, a justified tactic is the use of local injections of botulinum toxin A. The effectiveness of the use of beta-blockers (propranolol) in the treatment of chronic migraine is not supported by clinical trial data.
Another important group of drugs for the treatment of CEHD are centrally acting myolytics, which have an effect on monoamine structures, while the effect of the drugs is associated with the activation of presynaptic 2-adrenergic receptors both at the spinal and supraspinal levels. The activity of this type of receptor is associated with the regulation of the release of norepinephrine in the synapse. Thus, their activation leads to a decrease in the release of norepinephrine into the synaptic cleft and a decrease in the influence of the descending noradrenergic system. Norepinephrine plays an important role in the mechanisms of regulation of muscle tone: its excessive release increases the amplitude of excitatory postsynaptic potentials of the alpha motor neurons of the anterior horns of the spinal cord, increasing muscle tone, while the spontaneous motor activity of the motor neuron does not change. An additional factor in the action of noradrenaline is its participation in the mechanisms of antinociception, while its direct effect on the gelatinous substance of the nucleus of the trigeminal nerve and the posterior horns of the spinal cord, and participation in the regulation of the activity of the endogenous opiate system: intrathecal administration of an α2-adrenergic receptor antagonist that increases the content norepinephrine in the synaptic cleft, leads to a decrease in the analgesic activity of morphine.
To date, data have been obtained from a randomized, simple, blind, placebo-controlled clinical trial on the efficacy of using the 2-adrenergic receptor agonist drug, tizanidine ( Sirdaluda) in the treatment of CEHD, which demonstrated good efficacy of the drug in relation to both chronic migraine and CGTN. The duration of this study was 12 weeks. In total, 200 patients with chronic migraine (77%) and CTHN (23%) were included. All patients underwent dose titration of tizanidine during the first 4 weeks. up to a dose of 24 mg or the maximum tolerated dose divided into 3 divided doses per day. The mean dose achieved by patients was 18 mg (range 2 to 24 mg). The primary endpoint of the study was the Headache Index (HBI) score, equal to the product of the number of days with headache, mean severity, and duration in hours, divided by 28 days (i.e., the total severity of CEHA during the month).
Tizanidine (Sirdalud) demonstrated a significant reduction in GPI compared to placebo during the entire follow-up period. Thus, improvements were observed in 54% in the active treatment group and in 19% in the control group (p=0.0144). At the same time, both the decrease in the number of days with a headache per month was significant - 30% versus 22%, respectively (p=0.0193), and the number of days with severe headache per month - 55% versus 21% (p=0.0331) and overall duration of headache - 35% versus 19% (p=0.0142). There was also a decrease in the average (33% vs. 20%, p=0.0281) and peak (35% vs. 20%, p=0.0106) severity of pain intensity during the use of tizanidine. Patients in the active treatment group noted a more significant decrease in the severity of pain on a visual analog scale (p=0.0069). It is very significant that there were no significant differences in the effect of tizanidine on both chronic migraine and CTHN, which probably reflects the features of the pathogenetic effect of the drug. The most common side effects of therapy were drowsiness, noted in varying degrees (47% of respondents), dizziness (24%), dry mouth (23%), asthenia (19%), but there were no significant differences in the prevalence of side effects. in the tizanidine group and the control group. Thus, tizanidine (Sirdalud) can be used as a first-line drug in the treatment of CEHD.
Accurate differential diagnosis of the CEHD type and adequate use of complex analgesic therapy can reduce the severity and frequency of pain attacks and improve the quality of life in this category of patients. If a patient has chronic migraine, the use of anticonvulsants (valproic acid, topiramate, gabapentin) and antidepressants (amitriptyline) is indicated. In CTH and its combination with other types of pain, α2-adrenergic agonists, in particular, tizanidine (Sirdalud), have the most pathogenetically and clinically proven effect at the moment, which is confirmed both by clinical research data and personal clinical experience.

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The doctors of the neurology clinic of the Yusupov hospital are engaged in the diagnosis and treatment of all types of chronic pain syndrome: neurogenic, psychogenic, which appeared after courses of chemotherapy, radiation therapy, and surgical interventions.

Specialists select individual therapy to relieve the patient of phantom pain after surgery, joint pain, asthenia after bedsores. In each case, a separate comprehensive program is developed, including drug therapy, palliative care, rehabilitation, after which the pain symptoms in patients are significantly reduced or completely disappear.

Our specialists

Prices for the treatment of chronic pain syndrome *

*The information on the site is for informational purposes only. All materials and prices posted on the site are not a public offer, determined by the provisions of Art. 437 of the Civil Code of the Russian Federation. For exact information, please contact the clinic staff or visit our clinic.

Treatment of chronic pain in the Yusupov hospital

Pain is a symptom that signals that not everything is in order in the body, performs protective functions. But when the pain syndrome becomes chronic, painful, it does not carry any meaning and benefit. In addition to suffering, it limits the functionality of a person, interferes with leading a full life, doing work. In fact, this is an independent disease that needs to be fought.

Not so long ago, a special specialty appeared in the global clinical practice - pain medicine.

In the Yusupov hospital, this area is handled by neurologist Ekaterina Dmitrievna Abramtseva. Together with other medical specialists, she identifies the cause of the patient's pain and prescribes treatment in accordance with modern international recommendations. We use original preparations of the latest generations, physiotherapy, psychotherapy, kinesio taping, manual techniques, physical therapy and other modern methods.

Pain management at the Yusupov Hospital aims to achieve the following goals:

• Relief of the patient from pain syndrome.
• Improvement of general well-being, functionality.
• Normalization of the psycho-emotional state.
• Return to a full, active life, if possible - restoration of working capacity.
• Ensuring maximum physical and psychological comfort.

Pain is a symptom of many diseases, and with the right approach, it can be controlled. Don't be patient. Contact a specialist at the Yusupov hospital.

Principles of the Yusupov Hospital

Currently, the concept of chronic pain has been significantly revised. Modern doctors perceive it not just as certain unpleasant, painful sensations, but as a complex process in which changes occur in the work of the nervous, endocrine, cardiovascular systems, the muscular apparatus, and the psychological sphere.

In order to effectively treat pain, the specialists at our clinic follow some key principles:

• Chronic pain is an independent disease that needs to be treated. You can’t say to the patient: “we are treating the underlying disease, and you just need to endure the pain.” There is a symptom that makes a person suffer, reduces the quality of life, and this symptom must be properly dealt with. In modern medicine, there is even such a principle: "without pain." The patient should not experience discomfort associated with the disease or any procedures.
• There may be more than one reason. Often, in addition to the main condition that causes pain, there are accompanying ones. They need to be found and eliminated.
• Subjective perception of pain is different. Each person perceives pain in his own way, depending on the characteristics of his nervous system, psychology. We always take this into account when prescribing treatment.

• Multidisciplinary approach. Each patient is treated by a pain specialist and a team of other specialized doctors, depending on the nature of the disease.
• Complex treatment. We use drug therapy, blockades, physiotherapy, manual techniques, kinesio taping and other techniques. The doctor makes an individual program for each patient.
• Pain cannot be tolerated. Therefore, in the Yusupov hospital, the patient receives treatment in the right amount as soon as the need arises.
• Psychological factors are important. The Yusupov Hospital has all the conditions to make patients feel as comfortable as possible. Cozy rooms, respectful and caring attitude, "home" atmosphere - all this helps to reduce the subjective sensation of pain.

Types of pain we treat

According to some reports, pain syndrome is accompanied by up to 90% of all diseases. The nature of pain is also very different. In the Yusupov hospital, a thorough diagnosis is carried out to understand the causes of the symptom, and each patient receives optimal treatment.

Pain in the neck, back, spine

This is one of the most common reasons for visiting doctors, temporary disability, in severe cases - disability. Most often, pain in the spine is disturbed due to intervertebral hernias and other pathologies in which nerve roots are pinched.

In the early stages, these diseases can be treated conservatively with pain medications, muscle relaxants, physiotherapy, manual techniques, therapeutic exercises and proper lifestyle. With severe persistent pain, our doctors perform blockades: they inject the medicine next to the damaged nerve root. A course of rehabilitation helps to prevent exacerbations in the future.

Headaches

Almost every adult has experienced this type of pain at least once in their life. If this happens occasionally, you can get by with an anesthetic pill. Chronic headaches require complex treatment. Doctors at the Yusupov Hospital treat migraine, tension headaches, cluster headaches, rare varieties. We always conduct a thorough differential diagnosis, because the treatment regimen will depend on this.

Pain in cancer

Excruciating chronic pain is a common symptom in advanced cancer. At the Yusupov Hospital, treatment is carried out in accordance with the three-step "pain relief ladder" recommended by the World Health Organization. If the drugs at one stage do not help, the doctor proceeds to the next stage:

• For mild pain - drugs from the group of NSAIDs (ibuprofen, diclofenac, etc.).
• For pain of moderate severity - NSAIDs in combination with weak narcotic analgesics.
• With severe pain - powerful narcotic analgesics.

If necessary, the patient receives other drugs. Antitumor, palliative treatment is carried out.

Pain due to damage to the nerve roots and peripheral nerves

Our doctors treat pain syndromes that occur when nerve fibers are damaged as a result of various diseases:

• Various types of polyneuropathy, neuritis, neuralgia;
• Diabetic polyneuropathy;
• Neuralgia of the trigeminal, occipital nerve;
• tunnel syndromes;
• Intercostal neuralgia;
• Postherpetic neuralgia.

Some of these diseases are accompanied by movement disorders, sensitivity. Our doctors provide comprehensive treatment that helps to restore these functions.

Pain after surgery and trauma

After surgical interventions, especially extensive ones, patients often experience pain, so it is important to provide high-quality anesthesia. The Yusupov hospital has everything you need for this. We treat patients suffering from chronic pain syndrome after injuries of the spine and spinal cord, joints, craniocerebral injuries.

phantom pains

Chronic phantom pain occurs in the missing part of the body after its amputation or loss due to trauma. They are sharp, burning, resembling an electric shock, often becoming unbearable. Currently, there are many effective ways to deal with phantom pain, including drugs, blockades, biofeedback. The Yusupov hospital uses the most modern methods with proven effectiveness.

Vascular diseases of the brain

Headaches often disturb patients after a stroke, with vascular pathologies. In a bedridden patient, degenerative changes occur in muscles and joints, which can also lead to pain. Comprehensive treatment at the Yusupov Hospital helps to get rid of excruciating pain, improve nervous function, prevent complications and recurrent acute cerebrovascular accidents.

Ways to treat chronic pain in our clinic

At the moment, there are many ways to deal with chronic pain. The Yusupov hospital uses all available options:

• Medications: NSAIDs, glucocorticosteroids, muscle relaxants, antidepressants, anxiolytics, etc.
• Narcotic analgesics.
• Blockades, during which anesthetics, glucocorticosteroids are injected into the area of ​​\u200b\u200bdamaged roots or nerves.
• Various physiotherapy.
• Therapeutic massage, manual therapy, osteopathy.
• Biofeedback method.
• Injections of botulinum toxin preparations help in the fight against headaches.
• Kinesio taping is a method of dealing with pain in the musculoskeletal system using adhesive tapes. They help relieve tense muscles, improve blood circulation, lymph outflow, activate metabolic processes in tissues.
• In cancer patients, long-term pain relief can be provided through intravenous infusion port systems.
• For malignant tumors, we provide antitumor, palliative, symptomatic treatment - they can also be considered as part of a complex therapy to combat pain.
• Electroneuromiostimulation.
• Psychotherapy.
• Comprehensive rehabilitation therapy helps to consolidate the effect and prevent exacerbations in the future.

After discharge, the patient receives detailed recommendations from the doctor on how to keep the pain syndrome under control, prevent exacerbations, what to do if severe pain begins to bother you again.

Enduring Chronic Pain Is Dangerous

Any pain signals that pathological processes are occurring in the body. Even if you "endure", in the future the symptoms may return with greater force. Many diseases accompanied by chronic pain progress over time, it becomes more and more difficult to fight them. Complications develop that may require surgical intervention, emergency care.

Five steps to get rid of chronic pain in the Yusupov hospital:

1. The doctor talks with you, evaluates your complaints, general condition, determines how much you subjectively evaluate pain. If necessary, you will receive immediate emergency assistance.
2. Thorough examination using modern diagnostic methods. The doctor discovers the underlying and any associated conditions that are causing you pain.
3. You are prescribed a comprehensive treatment, optimal in your individual case, in accordance with international recommendations. Your condition is constantly monitored, the doctor corrects prescriptions.
4. A course of rehabilitation treatment is carried out, which helps to consolidate the result and return you to an active life.
5. After discharge, you will receive detailed recommendations from the doctor.

Don't wait and be patient. There are professionals in the Yusupov hospital who will understand the causes of the pain syndrome and take it under control. We know how to help, and we use all the possibilities of modern medicine for this. Contact us.

Bibliography

• ICD-10 (International Classification of Diseases)
• Yusupov hospital
• Abuzarova G.R. Neuropathic pain syndrome in oncology: epidemiology, classification, features of neuropathic pain in malignant neoplasms // Russian journal of oncology. - 2010. - No. 5. - S. 50-55.
• Alekseev V.V. Basic principles of treatment of pain syndromes // Russian Medical Journal. - 2003. - T. 11. - No. 5. - S. 250-253.
• Pain syndromes in neurological practice / Ed. A.M. Wayne. - 2001. - 368 p.