Pain Management

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 widelyvalidated screening tool. The questionnaire has beenreduced to a single question that is as sensitive and as specificas the 15-item shortened form of the original 30-itemscale. The question is: "How often do you feel sad or depressed?'This is certainly something that is easy to ask inthe course of a general physical examination or routine officevisit.

A 47-year-old woman who wasseropositive for HIV-1 presented tothe emergency department with severemaculopapular, erythematouseruptions. Her antiviral regimen hadrecently been changed from zidovudine, 300 mg bid; lamivudine, 150 mgbid; and saquinavir, 600 mg tid, tolamivudine, 150 mg bid; stavudine, 40mg bid; and nevirapine, 200 mg/d.

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

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

A 32-year-old previously healthywoman presents to the emergencydepartment with skin lesions, suprapubicpain, and generalized myalgia of1 week’s duration. Trimethoprim-sulfamethoxazolefor a presumed urinarytract infection is prescribed, and thepatient is discharged. The symptomspersist; she is hospitalized 2 days later.

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

Patients with ankylosing spondylitis areat increased risk for fractures (particularlyextension fractures of the cervicaland thoracolumbar spine) and spinalcord injury. Fractures in these patientsare extremely unstable; in fact, they areamong the most complication-prone ofall cervical spine injuries likely to beseen 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 apatient with uncharacteristically severe headache and very high blood pressure.

Calcium channel blockersare commonly prescribedto treat severalcardiovascular diseasesand may be helpful inother conditions, such as migraineand bipolar disorder.1 These agentsare associated with numerous clinicallysignificant drug interactions.1-3While some of these interactions,such as the effect of verapamil onserum digoxin concentrations, arewell-known, others are not widely recognized-yet warrant attention.

A 77-year-old man is brought to the emergency department after severaldays of illness that began with fever, nausea, emesis, and headache. Muscleweakness and associated myalgia developed; the weakness became so severethat the patient needed help to get out of bed and walk to the bathroom.The day before he came to the hospital, he slept much of the time and wasdifficult to arouse.

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 nauseaor vomiting, ocular symptoms, weakness, or sensitivity to light. His wife reports that years ago he experienced throbbingheadaches 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.

A bright, active 10-year-old boy has been experiencing recurrent bouts ofabdominal pain with nausea and occasional vomiting for 3 years. Although hehas had 1 or 2 attacks at school, the pain usually occurs at home-frequentlyon weekends. His mother has been unable to correlate these episodes with particularfoods or activities. She notes that her son has experienced motion sicknessduring long auto trips and during a family holiday in the mountains ofColorado.

A 65-year-old woman with a long history of hypertension treated with metoprolol and felodipine complained of dizziness, headache, nausea, and vomiting of acute onset. Her blood pressure was 220/110 mm Hg. She was drowsy and unable to stand or walk.

A 28-year-old man presents tothe emergency departmentwith high fever; progressive, severe,generalized, throbbing headache;blurred vision; and increasingconfusion. These symptoms started3 days earlier.

A 37-year-old woman presents to the emergency departmentwith a diffuse, sharp, pounding headache,which started 2 hours earlier. She rates her discomfort as4 on a scale of 1 to 10. Neck muscle soreness is also present,but the pain does not radiate.

Is there a meaningful percentage of patients who contract Lyme disease but havenone of the early symptoms-neither the rash nor the flu-like symptoms (eg, fever,myalgia, headache, and stiff neck)-and in whom the disease only becomes clinicallyevident in a later stage when it is much harder to treat?

Migraine is an episodic, often debilitatingcondition that affects women moreoften than men. Twenty-eight millionAmericans suffer from migraineheadaches-and nearly 75% of theseare women.1 Unlike other chronic painconditions, migraine has its peakprevalence during the years of greatestproductivity, when most women arejuggling family responsibilities andcareers.2 Many women are particularlysusceptible to migraine attacks justbefore and during menses.