Edward Lichten, M.D.,PC
Director, Diamond Headache Clinic, Chicago, Illinois
Director, Inpatient Headache Unit, Columbus Hospital
Adjunct Professor of Pharmacology and Molecular Biology, The Chicago Medical School
Phone contact@ 1-800-HEADACH
The treatment of pain concerns every practitioner. This article is one of series alerting the physician to recent trends and theories in the management of a common problem.
If I were to choose between pain and nothing, I would chose pain. William Faulkner.
Each year 550 million workdays are lost in the United States because of pain, which is probably the principal compliant presented by patients and the major determinant in their to consult a physician. A recent survey by Louis Harris and Associates deline ated this loss according to type of pain.
Reaction to chronic pain varies greatly. I have observed patients who function well despite tremendous pain and others who are devastated or completely disabled by it. Although a plethora of methods is available for direct treatment, including analgesi cs, narcotics, tricyclic antidepressants, biofeedback, transcutaneous stimulation, surgery, and acupuncture, a reliable regime for relief of chronic pain remains elusive.
Management of patients refractory to traditional methods of pain relief is difficult. A recent study described 90 patients who were trained for 10 weeks in a mindfulness-meditation program that integrated stress reduction and relaxation approaches. On an intensive daily basis, patients practice meditation and were encouraged to employ this technique in coping with stress and pain. Various pain indexes were used to make pre- and post-innervation assessments; patient gender and type of pain were not con sidered as variables in the final results.
The following were significantly reduced as a result of training; pain outcome, mean number of symptoms during the preceding month, and incidence of mood disturbances and psychological symptomatology. The incidence of anxiety and depression decreased th e most. Of 39 patients who used drugs to control pain before starting the program of meditation, relaxation, and stress reduction, 17 reported decreased intake of medication. At the end of the treatment period, 11 of 17 patients indicated that they rare ly used medication. Interestingly, with the exception of present moment pain, improvements observed during the meditation period were maintained for up to 15 months after training was completed.
Many patients stressed the importance of continuing to practice meditation techniques. Patients who were most responsive fell into two groups of equal size. In the first group, pain was greatly reduced or eliminated. In the second group. patients repo rted that although the pain continued, their fear, self-pity, and willingness to permit pain or fear of pain to restrict their activities were decreased.
The authors compared the results in these patients to those in 21 patients who had conventional therapy and were not trained in any form of self-regulation. The comparison group reported little relief of pain or its effects.
Headache is the most common cause of lost workdays in the United States. Most generalists find that muscle contraction is the cause of headache in 90% of patients, vascular conditions (including migraine and cluster headaches) in 8%, and an organic basi s in 2%. In many of these patients, behavioral approaches offer a powerful alternative to the use of medication.
For the past 15 years, biofeedback has been employed at the Diamond Headache Clinic in Chicago, to treat headache on both an outpatient and inpatient basis. Most patients are referred by their physicians because of recurring pain or because they are hab ituated to analgesics, barbiturates, tranquilizers, or ergot alkaloids. In two retrospective studies, we reported the excellent response to biofeedback, meditation, and progressive relaxation techniques by patients refractory to traditional therapy. Thes e techniques also may augment other treatment including use of analgesics and antidepressants.
Studies of the long-term efficacy of biofeedback-behavioral programs are scarce. A recent survey conducted by the Ochsner Clinic, New Orleans, assessed results of a specific biofeedback-behavioral program for muscle contraction headaches 20 months after completion. The study examined the relationship of a personality variable (expectation of control) to alleviation of headache through self-regulation. The concept of an internal locus of control reflects the extent to which individuals perceive reinforci ng or punishing events to be related to their own actions. It was hypothesized that patients with an internal locus of control would be more likely to use self-control methods over bodily functions and rate biofeedback-behavioral programs higher than woul d persons with external orientation, who assume that reinforcing events result from chance, the acts of other, more powerful individuals, or fate.
Of 114 persons contacted, 74 (65%) completed the questionnaire. Of these 74 patients 82% achieved and maintained a significant decrease in the overall headache severity and duration for the 20 month period. Personnel who benefited from biofeedback were usually under 40 years of age, as we had also noted in our previous studies. The results of the Ochsner study was encouraging because the Pain Locus of Control Scale appears to be extremely effective in predicting which patients will be successful with biofeedback behavioral programs or other self regulation techniques.
Diamond Headache Questionnaire
1. Which statement best describes the frequency of your headaches? _____more than one a day _____one a week ____one/ month _____fewer than 1/2-3 mon _____one a day ____one per month 2. Place a check by the statement that best describes the pain level of your typical headache. _____no headache _____headache, but can be ignored _____headache, cannot be ignored, but does not interfere daily _____headache, cannot be ignored, interferes with concentration _____headache, cannot be ignored, interferes everything except basics _____headache, cannot be ignored, bed rest required 3. Which symptoms accompany your usual headache? _____loss of appetite _____dizziness _____vision problem _____Mood change _____vomiting _____nausea 4. Do any relatives have server or recurring headaches? _____Mother _____Father _____Brother/sis _____Grandparent 5. Check the appropriate box
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|Revised: January 1, 2011|