Chronic pain syndromes

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

The approach to treatment of chronic pain syndromes includes treatments:

Designed to alleviate or minimize long-term pain
To prevent future occurrences/recurrences of pain
For severe increases in the level of pain.

These treatments require a multidisciplinary approach, and a biopsychosocial perspective, taking into account how pain affects the patient’s quality of life, and how aspects of their life may affect their pain. A clear care management plan should be discussed and agreed with the patient.[42][54][55][56] The primary care physician should consider specialist referral for patients with:

Persistent, disabling pain despite treatment
Progressive pain
A history of alcohol or drug abuse
Requirement for high doses or prolonged use of opioid analgesics
Patients causing dissent among staff
Concerning symptoms of headache
Eye involvement with postherpetic neuralgia.

Pharmacotherapeutic dose adjustments are often needed in older patients because of reduced drug metabolism, polytherapy (with associated risk of drug:drug interactions), and sensitivity to adverse effects. Recommended starting doses for common pain medications have been published by the American Geriatric Society.[57]

The American Chronic Pain Association resource guide to chronic pain treatment incorporates a multimodal approach with reliance on medical, interventional, behavioral, pharmacologic, and rehabilitation therapies to manage chronic pain.[55]

Nonpharmacologic and nonopioid pharmacologic therapies are preferred to manage chronic pain. Opioid therapy should only be considered once other options have been tried, and if the expected benefits are anticipated to outweigh risks to the patient.[42]

See Management approach in: Osteoarthritis, Rheumatoid arthritis, Musculoskeletal lower back pain, Complex regional pain syndrome, Diabetic neuropathy, Herpes zoster infection, Fibromyalgia, Migraine headache in adults, Cluster headache, and Tension-type headache.

Nonpharmacologic therapies

Nonpharmacologic therapies may be used on their own or in combination with other treatments for patients with chronic pain.[55]

Physical therapy and physical activity

Therapies should be tailored to the particular condition (see below); these include posture training, stretching exercises, active range of motion (ROM) exercises, weight reduction, and pool hydrotherapy.
Exercise programs should be tailored to the patient’s physical ability and lifestyle.[55][58]

Occupational therapy

Patients with difficulty with daily living, work, or social activities due to pain may benefit from pain management training and work modifications.

Pain management psychology

Patients with chronic pain may benefit from psychological therapies such as cognitive behavioral therapy (CBT; including internet-delivered CBT), acceptance and commitment therapy, behavioral therapy, relaxation therapy, stress management, and coping skills.[55][56][59][60][61][62] [ ]

Myofascial pain treatment

All patients with myofascial pain should be treated primarily with physical therapy, with the addition of nonsteroidal anti-inflammatory drugs (NSAIDs) as required (particularly during exacerbations of symptoms).

Patients will likely need to meet several times weekly with a physical therapist initially for instruction in techniques (such as posture training, stretching, and active ROM exercises), with requirements for home practice between appointments. The goal of the therapy is for the patient to develop a home program that may continue independently twice daily on a long-term basis.

Occupational therapy and psychological therapy for pain management should be provided for all patients whose myofascial pain has a negative impact on daily activities or mood.

Additional medication, such as acetaminophen, may be required for patients who do not obtain satisfactory pain relief from physical therapy and NSAIDs. Codeine or tramadol may be used (at the lowest effective dose) for a limited duration if benefits are anticipated to outweigh risks to the patient.[42] Trigger-point injections may be used as an option for treating myofascial pain in some patients; systematic reviews that include myofascial pain studies indicate that outcomes are similar, regardless of type of injectate used.[63][64] Techniques such as acupuncture and dry needling are useful for release of trigger points and may be used in the wider context of a rehabilitative/pain management approach.[65] Patients with severe myofascial pain that does not respond to physical therapy may benefit from additional use of a muscle relaxant such as tizanidine.[66]

Musculoskeletal pain treatment

Physical therapy is the cornerstone of treatment for mechanical pain. All patients should be considered for weight management (as appropriate) and physical therapy with or without additional pool hydrotherapy, as available. Patients whose pain impacts on daily living, work, or social activities should be evaluated by an occupational therapist and a pain psychologist. Acetaminophen and NSAIDs, alone or in combination, can be used for exacerbations of musculoskeletal pain.[67]

Osteoarthritis patients with pain flare-up (see Osteoarthritis):[67]

Medications are provided as needed with topical and/or oral analgesia (e.g., capsaicin, NSAIDs, acetaminophen)
Intra-articular corticosteroid injections may be useful.

Rheumatoid arthritis (RA) patients (see Rheumatoid arthritis):[68]

All patients with RA should be initially assessed by a rheumatologist and offered treatment with disease-modifying antirheumatic drugs (DMARDs) to minimize long-term joint destruction. Patients with mild to moderate disease are usually started on a single DMARD, unless there are specific contraindications
Patients who do not obtain sufficient benefit from conventional synthetic DMARDs may be started on a biologic agent (such as a TNF-alpha inhibitor) or a targeted synthetic DMARD, either alone or combined with a conventional synthetic DMARD.[68]

Neuropathic pain treatment

Medications are used as first-line treatment for neuropathic pain, with a goal of reducing the distressing symptoms. Membrane-stabilizing anticonvulsants (e.g., gabapentin, pregabalin) and tricyclic antidepressants (TCAs; e.g., amitriptyline) are effective.[69][70][71][72] The serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine may be beneficial in patients unable to tolerate TCAs.

Second-line therapy includes topical capsaicin (cream or patch) or a lidocaine patch.[73] Evidence for low-dose capsaicin (i.e., 0.025% or 0.075%) is poor, but it may be considered in some cases.[74]

All patients with significant impairment in daily living, work, or social activities, or mood due to neuropathic pain should be evaluated by physical, occupational and psychological therapists. Physical therapy should include posture training, stretching exercises and active ROM exercises.[75]

Noninvasive and invasive neurostimulation may be used to treat chronic neuropathic pain. Techniques with some evidence of benefit include spinal cord stimulation, epidural motor cortex stimulation, repetitive transcranial magnetic stimulation, and transcranial direct electrical stimulation.[76][77][78] Transcutaneous electrical nerve stimulation (TENS) is also sometimes used to treat neuropathic pain, but it is unclear whether it is effective, due to the low quality of the evidence.[79] There is insufficient evidence to support or refute the use of acupuncture for treating neuropathic pain.[80]

Neuropathic pain due to diabetic neuropathy requires glucose control. See Diabetic neuropathy.

Postherpetic neuralgia occurs in about 30% of patients with herpes zoster, and the risk may be minimized by early treatment with antiviral agents.[19] Patients with postherpetic neuralgia and eye involvement should be referred to an ophthalmologist. See Herpes zoster infection.

Complex regional pain syndrome (CRPS) is managed with aggressive physical therapy and drug therapy. Patients with CRPS should be referred early to a pain clinic. See Complex regional pain syndrome.

Fibromyalgia treatment

Due to the multisymptom nature of fibromyalgia and high disability in this population, the majority of fibromyalgia patients have comprehensive, multidisciplinary treatment, with the predominant aim of improving health-related quality of life.[81] Referral to a psychologist is appropriate at initial diagnosis.

Nonpharmacologic therapies with some evidence of benefit include exercise therapy, hydrotherapy, psychological pain management skills (e.g., cognitive behavioral therapy), and occupational therapy.[81][82][83][84][85] [ ]

Pharmacologic therapies with some evidence of benefit include TCAs, SNRIs, and tramadol. NSAIDs and selective serotonin-reuptake inhibitors (SSRIs) have not been shown to be effective for treating fibromyalgia pain. Strong opioids should not be used because of the high risk of adverse effects.[42][81]

See Fibromyalgia.

Chronic headache treatment

Headache treatment varies, based on diagnosis. Infrequent, acute attacks occurring no more than 3 days per week are managed using acute therapy with oral analgesics.

Ensure that the headache diagnosis is accurate before starting treatment.[2]

Post-traumatic headache (i.e., headache from trauma or injury to the head and/or neck) is treated in the same way as chronic tension-type headache.
Cluster headache: specialist referral is often required, to discuss treatment options. Chronic cluster headaches are primarily managed with preventive therapy (e.g., calcium-channel blockers). Rescue therapy (e.g., a subcutaneous triptan or oxygen) may be tried during the cluster headache episode.
Migraine headache: avoidance of triggers (e.g., alcohol, caffeine) is important; this can be facilitated by keeping a migraine diary. Drug treatment for symptom relief (e.g., NSAIDs, acetaminophen, triptan) should be started as soon as the patient recognizes that a typical migraine attack is beginning, even if symptoms are mild. Preventive treatments (e.g., anticonvulsants, beta-blockers, antidepressants, calcium-channel blockers, calcitonin gene-related peptide antagonists) should be considered for people with disabling, frequent migraine attacks, when acute treatments are ineffective or contraindicated, or when attacks lead to neurologic sequelae.
Drug overuse headache: treated with withdrawal of the overused drug, supported by symptomatic management, preventive treatment for the primary headache disorder, and patient and family education.

See Migraine headache in adults, Cluster headache, Tension-type headache, and Medication overuse headache.

Opioids

Opioids (such as codeine and tramadol) have been commonly used in pain management. However, in many cases the analgesic effect diminishes over time, and the patient requires higher doses of opioid to maintain the same level of pain relief. Higher doses come with increased risks of adverse events, including overdose, misuse, fractures from falls, hormonal changes, and increased sensitivity to pain. Therefore nonopioid therapies are preferred for treating chronic pain.[42]

Evidence on the effectiveness of long-term opioid therapy for chronic pain is very limited, but data suggest an increased risk of serious harms that appears to be dose-dependent.[42][86][87][88] Clinicians should consider not only the daily dose prescribed but also the duration of opioid action (which is related to risk of unintentional overdose injury), and favor short-acting and immediate-release agents whenever possible, especially during the first 2 weeks of therapy.[42][89]

Centers for Disease Control and Prevention guidance for prescribing opioids for chronic pain addresses patient discussions, setting treatment goals, initiation, drug selection and dosages, follow-up, continuation, risk assessment, addressing potential harms, and discontinuation. The guidance emphasizes that opioids are not first-line or routine therapy for chronic pain.[42] The UK Medicines and Healthcare products Regulatory Agency recommends that, before prescribing opioids, clinicians must discuss the risks and features of tolerance, dependence, and addiction with patients, and jointly agree a treatment strategy and plan for the end of treatment.[90]

If opioids are prescribed, they should be started at a low dose. The dose should be increased gradually, with frequent monitoring of effectiveness and adverse effects. If adverse events are unacceptable or effectiveness is insufficient, the opioid treatment should be stopped (with tapering if appropriate).[42][90]

Primary care physicians should refer patients who require high doses of opioids and/or prolonged opioid therapy for specialist assessment.

Concurrent prescription of benzodiazepines with opioids should be avoided because of an increased risk of death from drug overdose in a dose-response fashion.[42][91]

See Opioid use disorder.

Considerations in pregnancy

Nonpharmacologic therapies are especially appropriate for women who are pregnant or attempting pregnancy.

No medication is completely free of risk in pregnancy, and decisions should be made on an individual basis, balancing the risk of the chronic pain as a threat to the health of the mother and unborn child against the risk of the treatment.

Acetaminophen is the preferred pharmacologic option for the treatment of pain during pregnancy.[92][93]

Valproate medicines are contraindicated during pregnancy, due to the risk of congenital malformations and developmental problems in the infant/child.[94] In both the US and Europe, valproate and its analogs must not be used in female patients of childbearing potential unless there is a pregnancy prevention program in place and certain conditions are met.[94] The safety of other anticonvulsant drugs during pregnancy has been reviewed by the UK Medicines and Healthcare products Regulatory Agency.[95] Use of antidepressants with effects on serotonin reuptake during pregnancy to treat depression has been associated with risk of major congenital malformations.[96]

Measurement of treatment outcomes

Treatment outcome can be readily assessed by comparing pre- and post-treatment pain drawings and pain severity scores. An 11-point pain severity score (0 = no pain, 10 = excruciating) is readily understood by patients and correlates with global improvement assessments.[97] A reduction in pain of at least 2 on this scale signifies significant improvement, rated by patients as much or very much improved.

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