Therapeutic strategies that act on the peripheral nervous system in primary headache disorders.

Introduction: Acute and preventive treatment of primary headache disorders is not completely resolved with regard to efficacy, safety, and tolerability. Hence, peripheral and central neuromodulation can provide therapeutic alternatives in drug-resistant cases. Peripheral targets of neuromodulation include invasive and non-invasive neurostimulation and electrical and chemical nerve and ganglion blockades. Areas covered: A PubMed search of papers published from January 2012 to October 2018 was conducted. The goal of this review was to analyze the efficacy and safety of invasive (implantable) peripheral neurostimulation methods (the occipital nerve, the cervical branch of vagal nerve, the sphenopalatine ganglion) and non-invasive (transcutaneous) peripheral neurostimulation methods (the occipital nerve, the supraorbital nerve, and the cervical and auricular branches of the vagal nerve), based on the results of published clinical trials and case series. Acting also on the peripheral nervous system, peripheral nerve (i.e. greater occipital nerve) and ganglion (i.e. sphenopalatine ganglion) blockades, botulinum neurotoxin type A-hemagglutinin complex therapies, and calcitonin gene-related peptide-related monoclonal antibody treatments in this patient population are also discussed. Expert opinion: This review summarizes the latest results on the therapeutic strategies acting on the periphery in primary headache disorders. These therapeutic options are minimally invasive or non-invasive, efficacious, safe, and well tolerated.

Resultados sobre la aplicación cráneo-facial del parche de capsaicina 8 % en una serie de 5 casos / Results of the capsaicin 8% patch in craniofacial application in five clinical cases

Los parches de capsaicina al 8 % son una alternativa de segunda línea para el tratamiento del dolor neuropático periférico. Aunque tiene pocos efectos secundarios, no tiene indicación para el tratamiento cráneo-facial debido a la posible irritación de mucosas por la capsaicina. Sólo hemos encontrado tres publicaciones que refieren la aplicación del parche en estas localizaciones, describiendo 7 casos clínicos. Hemos recogido 4 casos en los que se realizan 5 aplicaciones en total, 3 mujeres (repitiendo aplicación en una de ellas) y 1 hombre, entre 58 y 84 años, con los siguientes diagnósticos: necrosis cáustica en labio inferior tras limpieza dental, neuralgia del trigémino y neuropatía postherpética. Tras comprobar ineficacia de otros tratamientos, se propuso el parche de capsaicina al 8 %, con firma previa de los consentimientos informados de la aplicación de parche en régimen de hospital de día y de tratamiento fuera de ficha técnica. Previamente a la aplicación del parche en la zona cutánea dolorosa, se procedió a realizar protección ocular de ambos ojos con parche oftálmico quirúrgico, y de mucosas oral y nasal con mascarilla facial quirúrgica sellada. La protección se mantuvo durante toda la aplicación del parche y se quitó una vez retirado éste y limpiada la zona de aplicación. Únicamente se reportaron 3 efectos secundarios leves del total de las 5 aplicaciones: un paciente presentó piel eritematosa que cedió espontáneamente, otra paciente refirió sensación de quemazón y dolor que cedió con analgesia endovenosa, y otra paciente explicó dolor leve bien tolerado, que cedió de manera espontánea. En ninguno de los casos se apreciaron efectos secundarios a nivel de mucosas. En cuanto a resultados, dos pacientes notaron mejoría durante uno y dos meses, colocando nuevamente el parche en una de ellas, sin lograr esta segunda vez alivio. Las otras dos pacientes no notaron ningún cambio. El tratamiento con parches de capsaicina 8 % en superficies cráneo-faciales parece tener similar eficacia a su aplicación en otras áreas de la piel. Los efectos secundarios en su aplicación en estas superficies son escasos, al igual que en otras aplicaciones corporales. Creemos que con las medidas de precaución adecuadas en las regiones cráneo-faciales, la utilidad clínica observada del parche de capsaicina 8 % lo sitúa como otra opción de tratamiento para dolor neuropático, sin complicaciones añadidas. No obstante, estudios clínicos con mayor número de pacientes deberían llevarse a cabo para confirmar estos hallazgos (AU)

The capsaicin 8 % patch is a secondary line alternative to neuropathic peripheral pain treatment. Although it has few secondary effects, is not indicated in head and facial treatment due to the possibility of the irritation of mucosa. We have only found three publications related with the patch application in those locations, describing 7 clinical cases. We have analyzed 4 cases in which we have applied 5 patches in total. There were 3 women (repeating the application in one of them) and 1 man, between 58 and 84 years old, with the following diagnosis: caustic necrosis in the inferior lip after dental cleaning, trigeminal neuralgia and post-herpetic neuropathy. Inefficacy of other treatments was confirmed, and after that, the capsaicin 8 % patch was proposed. Informed consent of the application of the patch at day clinic and treatment out of technical data sheet were previously signed. Before the patch was applied to the painful cutaneous area, we proceed with ocular protection of both eyes with surgical ophthalmic patch and oral and nasal mucosa protection with surgical mask hermetically seal. That protection was maintained during the whole application of the patch, and was removed once the capsaicin patch was taken off and the application area was cleaned. There were only 3 mild secondary effects of the total 5 applications: one patient showed erythematic skin that was resolved spontaneously, another patient related burn and pain sensation which was solved with endovenous analgesia. Finally, another patient explained mild pain well tolerated, that was resolved also spontaneously. In no cases there were secondary effects in mucosa. Related with the results, 2 patients felt improvement between one and two months, applying again the patch in one of them, not reaching this time relief in the pain. The other 2 patients did not notice any change. The capsaicin 8 % patch treatment in head and facial areas seems to have similar efficacy as the application in other skin areas. Secondary effects in these surfaces are very low, the same as in other corporal locations. We believe that with the adequate preventive measures in head and facial areas, clinical utility observed with capsaicin 8 % patch places it as another treatment option for neuropathic pain, with no complications added. However, clinical studies with a higher number of patients should carry on to confirm these findings (AU)

Irritable bowel syndrome.

Questions from patients about analgesic pharmacotherapy and responses from the authors are presented to help educate patient sand make them more effective self-advocates. The topics addressed in this issue are the signs, symptoms, and treatment of irritable bowel syndrome (IBS). A discussion of pain management and complementary therapies is included.

Combinatorial treatments enhance recovery following facial nerve crush.

OBJECTIVES/HYPOTHESIS: To investigate the effects of various combinatorial treatments, consisting of a tapering dose of prednisone (P), a brief period of nerve electrical stimulation (ES), and systemic testosterone propionate (TP) on improving functional recovery following an intratemporal facial nerve crush injury. STUDY DESIGN: Prospective, controlled animal study. METHODS: After a right intratemporal facial nerve crush, adult male Sprague-Dawley rats were divided into the following eight treatment groups: 1) no treatment, 2) P only, 3) ES only, 4) ES + P, 5) TP only, 6) TP + P, 7) ES + TP, and 8) ES + TP + P. For each group n = 4-8. Recovery of the eyeblink reflex and vibrissae orientation and movement were assessed. Changes in peak amplitude and latency of evoked response, in response to facial nerve stimulation, was also recorded weekly. RESULTS: : Brief ES of the proximal nerve stump most effectively accelerated the initiation of functional recovery. Also, ES or TP treatments enhanced recovery of some functional parameters more than P treatment. When administered alone, none of the three treatments improved recovery of complete facial function. Only the combinatorial treatment of ES + TP, regardless of the presence of P, accelerated complete functional recovery and return of normal motor nerve conduction. CONCLUSIONS: Our findings suggest that a combinatorial treatment strategy of using brief ES and TP together promises to be an effective therapeutic intervention for promoting regeneration following facial nerve injury. Administration of P neither augments nor hinders recovery.

The preventive treatment of migraine.

BACKGROUND: Migraine is a common, chronic, and disabling disorder. The treatment of migraine includes a combination of nonpharmacologic and pharmacologic techniques. Pharmacologic approaches are subdivided in preventive therapies and acute care. REVIEW SUMMARY: In this review article, we review the current approaches to the preventive treatment of migraine. Preventive treatment should be initiated in those with frequent or disabling headaches. The goals include (1) reducing attack frequency, intensity, and duration; (2) minimizing headache-related disability; (3) improving health-related quality of life; (4) avoiding headache escalation and medication misuse. In this article, we also discuss the principles of migraine prevention, as well as drugs available for this goal. We divide preventive medications on those of common use, nutraceutical compounds, and medications less frequently used. We close by briefly discussing some in-development potential preventive drugs. CONCLUSION: Preventive therapies are well suitable for migraineurs with attack-related disability despite appropriate acute care.

Irritable bowel syndrome: a primer on management.

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain, bloating, and either constipation or diarrhea. Managing this chronic condition requires a coordinated effort between patient and physician. The diagnosis of IBS should be made as early as possible in the evaluation of a patient, so that treatment can be initiated as soon as possible. Treatment usually requires a multifactorial approach, including patient education, reassurance, lifestyle changes, and pharmacotherapy. In this article, medications commonly used to treat the individual symptoms of IBS are reviewed, based on evidence from the literature. In addition, new agents that affect the serotonin system and treat the global symptoms of IBS are described.