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Postdural puncture headache
15. There is no evidence that bed rest is beneficial in the treatment and prevention of
postdural puncture headache (U) (Level I [Cochrane Review]).
16. The incidence of postdural puncture headache is reduced by using small‐gauge spinal
needles and/or a non‐cutting bevel (U) (Level I).
17. Further high quality trials are required to determine the efficacy of epidural blood patch
administration in the treatment of postdural puncture headache (U) (Level I), however
benefit is likely (N) (Level II).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Opioids should be used with extreme caution in the treatment of headache (U).
Frequent use of analgesics, triptans and ergot derivatives in the treatment of recurrent
acute headache may lead to medication overuse headache (U).
9.6.6 Acute pain associated with neurological disorders
Pain associated with neurological disorders is usually neuropathic in nature, although
nociceptive pain due to problems such as muscle spasms may also occur. Neuropathic pain
may be acute or chronic and may be due to a lesion or dysfunction of the peripheral nervous
system (PNS) (eg painful peripheral neuropathy) or the CNS (central pain, eg poststroke pain)
(Loeser & Treede, 2008).
Treatment of acute neuropathic pain is based largely on evidence from trials for the treatment
of a variety of chronic neuropathic pain disorders. Effective treatments for neuropathic pain
include TCAs, anticonvulsants, membrane stabilisers, NMDA‐receptor antagonists, opioids or
tramadol (see Sections 4.1 and 4.3.2 to 4.3.6).
Associated psychosocial problems and physical disabilities must also be managed within a
multidisciplinary framework.
Multiple sclerosis
CHAPTER 9 Chronic pain is experienced by 49% to 73.5% of patients with multiple sclerosis (Osterberg et al,
2005; Hadjimichael et al, 2007; Khan & Pallant, 2007; Brochet et al, 2009) and the type of pain may
vary. In one survey, central pain was reported in 27.5% of patients (17.3% of these had
trigeminal neuralgia); another 20.9% had nociceptive pain and 2.2% described peripheral
neuropathic pain (Osterberg et al, 2005). In another survey, of those patients with chronic pain,
60.7% had dysaesthetic pain and just 6.6% reported nociceptive pain (Khan & Pallant, 2007).
Pain related to trigeminal neuralgia responds to carbamazepine (Wiffen et al, 2005 Level I).
Cannabinoids reduced the intensity of neuropathic pain associated with multiple sclerosis by
approximately 1.5/10 (VAS or verbal numerical rating scale [VNRS]), compared with placebo;
there were significant side effects, particularly dizziness (Iskedjian et al, 2007 Level I). Safety
concerns regarding cannabinoid use need to be considered. There was no evidence to guide
the use of antispasticity agents such as baclofen in the treatment of multiple sclerosis‐related
acute pain (Shakespeare et al, 2003 Level I). Nortriptyline was as effective as transcutaneous
nerve stimulation in reducing pain intensity and/or sensory complaints in patients with
multiple sclerosis (Chitsaz et al, 2009 Level II). Levetiracetam was effective in reducing pain in
multiple sclerosis (Rossi et al, 2009 Level II).
272 Acute Pain Management: Scientific Evidence
