Special Groups
2. ASSESSMENT
3.1. Headache Therapy
Both nonpharmacological and pharmacological therapies can effectively manage chronic headaches in children and adolescents (Table 3). Relaxation, stress management, and biofeedback are effective nonpharmacological head-ache therapies in pediatric patients (39,40). Analgesics and triptans are also effective in pediatric patients, although dose adjustments are needed (41–44).
Generally, triptans are administered at approximately half of the starting adult dose in adolescents. Orally disintegrating triptans may be particularly useful in children. Preventive therapy with antidepressants and antiepileptics is also ef-fective in children (44–48). Controlled trials have not evaluated selective sero-tonin reuptake inhibitors (SSRIs) for migraine prevention in pediatric patients.
Anecdotally, SSRIs may be effective and are generally better tolerated, with fewer cognitive effects, than other antidepressants.
4. SUMMARY
Common pain syndromes in children and adolescents include musculoskel-etal pain, headache, stomach ache, and chest pain. In general, increased overall prevalence and a female predominance develop once children reach adolescence.
Table 3
Migraine Treatments With Proven Efficacy in Pediatric Migraine Pharmacological therapies
Nonpharmacological therapies Acute care Prevention
Relaxation plus stress management Ibuprofen Antidepressants Amitriptyline Trazadone
Biofeedback Triptans Antiepileptics
Sumatriptan Valproate Zolmitriptan Topiramate Rizatriptan
Based on ref. 38.
with pain should be minimized by requiring school attendance, as well as partici-pation in physical education programs, unless significant structural pathology precludes specific activities. Psychosocial factors, including changes in family and school stress, are significant aggravating factors for pediatric pain and need to be identified and openly addressed as part of the treatment plan.
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CME QUESTIONS—CHAPTER 11
1. Common pain syndromes in pediatrics include:
a. Musculoskeletal pain b. Headache
c. Abdominal pain d. Chest pain e. All of the above
2. Which of the following statements is true?
a. Most complaints of musculoskeletal pain should be considered growing pains.
b. Musculoskeletal pain reports in elementary school children usually persist for at least 1 year.
c. Musculoskeletal pain is usually endorsed to avoid unpleasant activities or homework.
d. None of the above.
3. Which statistic is/are true?
a. About 6% of all visits to a pediatric clinic are for complaints of musculoskel-etal pain.
b. About 10% of children have migraine headaches.
c. About 25% of children with recurrent abdominal pain will report chronic ab-dominal pain as an adult.
d. All of the above e. None of the above
4. Effective therapies for pediatric migraine include:
a. Relaxation therapy b. Acupuncture c. Ibuprofen d. A and C e. All of the above
185
From: Chronic Pain: A Primary Care Guide to Practical Management Edited by: D. A. Marcus © Humana Press, Totowa, NJ
pregnancy. Her pregnancy has been uncomplicated, except for a weight gain of 40 lb. Over the last 4 weeks, she reports a pain in her left thigh. Initially, this would only occur with prolonged sitting or riding in the car, or when waiting in exceptionally long lines in the store. Now she finds that she has nearly constant pain in her upper, outer thigh. Additionally, this painful area feels prickly when she touches it. This week, she has also noticed pain and tingling in her right thumb when she wakes up in the morning or scrubs the counters at her home.
Her mother told her that these are the symptoms of multiple sclerosis, just like in a character on the mother’s soap opera television show. A distraught and tearful Ms. Rogers shares her concerns with her primary care physician, who reassures her that pain, including compressive neuropathy, occurs in a signifi-cant number of women during pregnancy and that these symptoms usually go away after delivery.
* * *
New pain, neurological complaints, or both during pregnancy are accompa-nied by special concerns for patient and doctor, both of whom worry about the risks of testing and treatment to the fetus, as well as the effects of any new health problem on the ability of the new mother to care for her baby. Alter-ations in hormones, water distribution, and weight are all important factors in changing risk for pain from new and preexisting pain syndromes during nancy. Understanding typical changes in common problems during preg-nancy—such as headache, back pain, and compressive neuropathy—can allay fears and minimize the use of unnecessary testing.
KEY CHAPTER POINTS
• Pain complaints occur in the majority of pregnant women.
• The lower back is the most common pain location during pregnancy.
• Compressive neuropathies occur more commonly during pregnancy because of changes in water retention, weight, and posture; they include Bell’s palsy, carpal tunnel syndrome, and meralgia paresthetica.
• Premorbid headache, especially migraine, improves in the majority of women in early pregnancy. Headache does persist, however, throughout pregnancy for a significant minority of women.
• Persistent pain during pregnancy may require treatment with safe nonpharma-cologic and pharmanonpharma-cological therapies to minimize disability and the need to self-medicate.
Pregnancy is associated with increased risk for a variety of musculoskeletal and neuropathic pain complaints. In a prospective study of 200 pregnant women, investigators identified pain occurring during pregnancy in 166 (85%), with new pain beginning during pregnancy in 137 (70%) (1). The most com-mon body area affected by pain was the back, especially in the lumbar and sacral areas (Fig. 1). In addition to the development of new pain during preg-nancy, preexisting pain conditions—such as low back pain and headache—are also often modified during pregnancy.
In this chapter, several commonly occurring painful conditions that occur in pregnancy are reviewed. Evaluating and treating pain during pregnancy offers unique challenges because of concerns for the effects of testing and treatment interventions on the developing baby. Increased ability of the patient to iden-tify common, self-limited, pregnancy-related pain complaints reduces the need to perform unnecessary testing during pregnancy and helps distinguish atypi-cal conditions that may warrant additional evaluations.