Pain

Clavicle fractures in the pediatric population are very common. Clinical manifestations include decreased movement of the arm on the affected side, crepitus, and/or bony irregularity at the fracture site. In neonates, the Moro reflex may be absent on the affected side.

A 48-year-old woman with a history of hypertension and mild asthma has been transferred to the medical service because of an abnormal postoperative ECG. She had been admitted 2 weeks earlier to the gynecology-oncology service for local recurrence of a previously resected uterine sarcoma and underwent laparotomy for debulking of the pelvic mass and resection of the rectosigmoid colon. She did well until postoperative day 14, when sudden chest pain and dyspnea developed.

A 39-year-old man complains of severe daily headaches that he describes as throbbing and "burning," with a sensation of pressure. He rates the severity of his pain as 8 to 10 on a 10-point visual analog scale (VAS) in which 10 is the most severe. The mean duration of the headaches is 12 hours, and the mean frequency is 5 days per week. Between the episodes of severe headache, he has constant "minor" headaches that are not as severe (mean severity, 3 to 5 on a 10-point VAS). Within the past 5 months, he has never been totally free of headache.

ain management is a common and challenging aspect of caring for elderly patients. The principles that guide therapeutic pain management in these persons are different from those used in the treatment of younger persons.

The patient is a 56-year-old man who presents with daily headaches that occur behind the right eye, right temple, and occasionally on the right side of the forehead. He has never experienced this type of headache on the left side. He describes the pain as “stabbing,” “throbbing,” and occasionally “burning.” He rates the intensity of the pain a 7 on a 10-point visual analog scale on which 10 is the most severe.

A 69-year-old man with an acute severe headache and nausea was brought to the emergency department. The patient was neurologically intact; an intracerebral hemorrhage was suspected.

The Geriatric Depression Scale is the most widely validated screening tool. The questionnaire has been reduced to a single question that is as sensitive and as specific as the 15-item shortened form of the original 30-item scale. The question is: "How often do you feel sad or depressed?' This is certainly something that is easy to ask in the course of a general physical examination or routine office visit.

Many patients who present to the emergency department (ED) with severe headache request a narcotic to relieve the pain.

You recently diagnosed migraine without aura in a patient who complains of headaches of moderate intensity. Is a migraine-specific prescription agent warranted?

A 34-year-old woman complains of headaches that interfere with work. Her first headache episode, approximately 6 years earlier, was relatively mild. Initially, she experienced attacks only once every 3 to 4 months and managed them effectively with over-the-counter (OTC) agents. However, in the last 6 months the attacks have become more frequent—they occur at least twice a month—and are so severe that she misses work.

Patients with ankylosing spondylitis are at increased risk for fractures (particularly extension fractures of the cervical and thoracolumbar spine) and spinal cord injury. Fractures in these patients are extremely unstable; in fact, they are among the most complication-prone of all cervical spine injuries likely to be seen in the primary care setting.

In their case report, “Sudden Headache in a Woman With Hypertension” (CONSULTANT, July 2002, page 1049), Drs Gary Quick and Maggie Law describe a patient with uncharacteristically severe headache and very high blood pressure.

Calcium channel blockers are commonly prescribed to treat several cardiovascular diseases and may be helpful in other conditions, such as migraine and bipolar disorder.1 These agents are associated with numerous clinically significant drug interactions.1-3 While some of these interactions, such as the effect of verapamil on serum digoxin concentrations, are well-known, others are not widely recognized— yet warrant attention.

A 69-year-old retired accountant presents with a 2-month history of daily headaches. The pain is moderate, constant, global, pressure-like, and occasionally pulsating; it is sometimes exacerbated when the patient lies down. He denies nausea or vomiting, ocular symptoms, weakness, or sensitivity to light. His wife reports that years ago he experienced throbbing headaches regularly.

A 64-year-old woman with a history of diabetes, hypertension, and lymphoma was admitted to the hospital with a dull headache, conjunctival congestion, and slight dyspnea. Her pulse rate was 96 beats per minute; blood pressure, 146/68 mm Hg; and respiration rate, 22 breaths per minute. She also had increased jugular venous distention; cardiovascular and chest examination findings were normal. Edema of both arms and dilated blood vessels on the anterior chest wall were noted.

In many patients, episodic migraines increase in frequency and transform into a refractory pattern.

What are the factors that underlie the transformation of episodic migraine to refractory migraine? Dr Susan Hutchinson explains.

When a patient presents to a primary care physician with a bad headache and organic cause is ruled out, 94% of the time the diagnosis is migraine.

Once you've decided that an opioid analgesic is indicated, what can you do to ensure that your patient uses the medication safely?

Highlights from the International Headache Congress are presented by Stephen D. Silberstein, MD, professor of neurology at Jefferson Medical College and director of the headache center at Thomas Jefferson University, Philadelphia, as well as chair of the congress organizing committee.