Characteristics and outcomes of peripheral neuropathic pain patients with repeated applications of high-concentration capsaicin cutaneous patch: Results of a retrospective chart review in Germany.

OBJECTIVE: The aim of this study was to evaluate patient characteristics, concomitant analgesic medication, and pain intensity in a real-world setting in Germany, focusing on the repeated application of high-concentration capsaicin patch (HCCP) for neuropathic pain. DESIGN: Data were collected from electronic medical records of patients who received at least two HCCP treatments between January 2011 and July 2022. Subgroup analyses were performed based on the number of HCCP treatments, age groups, and specific neuropathic pain conditions. SETTING: The study was conducted at an outpatient pain center in Wiesbaden, Germany. SUBJECTS: The study included 97 patients, primarily diagnosed with neuropathic back pain, postoperative or post-traumatic neuropathic pain, and postherpetic neuralgia. METHODS: The daily dose of concomitant medications (eg, opioids and anticonvulsants) at the start of capsaicin therapy was compared with the average within 2 years of capsaicin therapy. The last observation carried forward method was used if HCCP treatment was discontinued before the end of the 2-year period. RESULTS: The majority of patients received concomitant medications, with opioids, anticonvulsants, and antidepressants being the most common. The average daily morphine equivalent dose decreased significantly during HCCP treatment. Pain intensity at baseline was generally high, but substantial improvements were observed in patients who received at least three HCCP applications. CONCLUSIONS: This study provides evidence for the effectiveness of HCCP treatment in reducing pain intensity and concomitant opioid use in patients with neuropathic pain. Further research is needed to explore the long-term outcomes and optimal treatment regimens for different patient populations.

How different experimental models of secondary hyperalgesia change the nociceptive flexion reflex.

OBJECTIVE: In this neurophysiological study in healthy humans, we assessed how central sensitization induced by either high-frequency stimulation (HFS) or topical capsaicin application modulates features of the RIII reflex response. The ability of these stimuli to engage the endogenous pain modulatory system was also tested. METHODS: In 26 healthy participants we elicited an RIII reflex using suprathreshold stimulation of the sural nerve. Subsequently HFS or capsaicin were applied to the foot and the RIII reflex repeated after 15 minutes. Contact heating of the volar forearm served as the heterotopic test stimulus to probe activation of the endogenous pain modulatory system. RESULTS: HFS significantly reduced the pain threshold by 29% and the RIII reflex threshold by 20%. Capsaicin significantly reduced the pain threshold by 17% and the RIII reflex threshold by 18%. Both HFS and capsaicin left RIII reflex size unaffected. Numerical Rating Scale (NRS) pain scores elicited by the heterotopic noxious heat stimulus were unaffected by capsaicin and slightly increased by HFS. CONCLUSIONS: HFS and capsaicin similarly modulated the pain threshold and RIII reflex threshold, without a concomitant inhibitory effect of the endogenous pain modulatory system. SIGNIFICANCE: Our neurophysiological study supports the use of the RIII reflex in investigating central sensitization in humans.

In Vivo Calcium Imaging Visualizes Incision-Induced Primary Afferent Sensitization and Its Amelioration by Capsaicin Pretreatment.

Previous studies have shown that infiltration of capsaicin into the surgical site can prevent incision-induced spontaneous pain like behaviors and heat hyperalgesia. In the present study, we aimed to monitor primary sensory neuron Ca2+ activity in the intact dorsal root ganglia (DRG) using Pirt-GCaMP3 male and female mice pretreated with capsaicin or vehicle before the plantar incision. Intraplantar injection of capsaicin (0.05%) significantly attenuated spontaneous pain, mechanical, and heat hypersensitivity after plantar incision. The Ca2+ response in in vivo DRG and in in situ spinal cord was significantly enhanced in the ipsilateral side compared with contralateral side or naive control. Primary sensory nerve fiber length was significantly decreased in the incision skin area in capsaicin-pretreated animals detected by immunohistochemistry and placental alkaline phosphatase (PLAP) staining. Thus, capsaicin pretreatment attenuates incisional pain by suppressing Ca2+ response because of degeneration of primary sensory nerve fibers in the skin.SIGNIFICANCE STATEMENT Postoperative surgery pain is a major health and economic problem worldwide with ∼235 million major surgical procedures annually. Approximately 50% of these patients report uncontrolled or poorly controlled postoperative pain. However, mechanistic studies of postoperative surgery pain in primary sensory neurons have been limited to in vitro models or small numbers of neurons. Using an innovative, distinctive, and interdisciplinary in vivo populational dorsal root ganglia (DRG) imaging (>1800 neurons/DRG) approach, we revealed increased DRG neuronal Ca2+ activity from postoperative pain mouse model. This indicates widespread DRG primary sensory neuron plasticity. Increased neuronal Ca2+ activity occurs among various sizes of neurons but mostly in small-diameter and medium-diameter nociceptors. Capsaicin pretreatment as a therapeutic option significantly attenuates Ca2+ activity and postoperative pain.

Effect of Topical Analgesia on Desensitization Following 8% Topical Capsaicin Application.

To prevent pain associated with 8% capsaicin application, pretreatment with local anesthetics, such as EMLA (eutectic mixture of lidocaine 2.5% and prilocaine 2.5%), is considered an option. However, there is contradicting evidence regarding the effects of local analgesia on capsaicin-induced desensitization. In session 1, 2 skin areas in each forearm of 24 healthy volunteers were randomized to 2-hour pretreatment with EMLA/placebo cream. After pretreatment, 8% capsaicin patches were applied for 3 hours in 1 placebo and 1 EMLA pretreated area, obtaining the following four areas: Capsaicin + EMLA, Capsaicin + Placebo, EMLA alone, and Placebo. Pain intensity scores were assessed during the 3-hour application of capsaicin. Warmth detection, heat pain sensitivity, and microvascular reactivity were measured after the removal of capsaicin. After 24 hours, in session 2, all tests were repeated followed by histamine application in each area to examine itch intensity and neurogenic flare. Overall, EMLA caused significant reductions in capsaicin-induced pain compared with placebo (P= .007) and enhanced the capsaicin-induced increase in superficial blood perfusion immediately after the 3-hour capsaicin application (P< .01). Regardless of pretreatment, capsaicin induced heat hyperalgesia immediately after the application (P< .001). Twenty-four hours post application, heat pain sensitivity was normalized. However, WDT increased significantly (P< .001). Capsaicin tended to reduce the itch intensity and significantly reduced the neurogenic flare (P< .05) induced by histamine compared with EMLA alone. The findings suggest that pretreatment with topical analgesic cream reduces application site pain without interfering with the 8% topical capsaicin-induced desensitization. PERSPECTIVE: Pretreatment with local anesthetic EMLA cream might be considered a good therapeutic option to reduce the pain associated with 8% capsaicin application currently used for treatment of neuropathic pain syndromes. This study also suggests the existence of a synergistic effect of capsaicin and EMLA on the process of neurogenic inflammation.

Efficacy of topical capsaicin for the treatment of cannabinoid hyperemesis syndrome: A retrospective cohort study.

BACKGROUND: Cannabis Hyperemesis Syndrome (CHS) is a clinical disorder characterized by abdominal pain and intractable vomiting among patients with chronic marijuana use. We sought to assess the efficacy of capsaicin to determine whether it could reduce ED length of stay in patients with CHS. METHODS: his retrospective observational study was conducted among patients with CHS. Patients were classified based on whether they received capsaicin, which was pseudorandomized and dependent on the pharmacist available. Outcomes included time to discharge, number of medications given, bounceback rate, and admission rate. Statistical analyses included t-tests, survival analyses, and cox regressions. RESULTS: 55 patients (35 capsaicin, 20 no capsaicin) met inclusion criteria. There was no difference in time to discharge between the experimental and control groups (4.46 h vs 3.52 h, p = 0.10), rounds of medications given (2.60 vs 3.54, p = 0.09), bounceback rate within 24 h (0.11 vs 0.10, p = 0.43), or admission rate to the hospital (0.19 vs 0.05, p = 0.07). A survival analysis and cox regression showed no difference in time to discharge. A subgroup analysis between patients who received capsaicin within their first two rounds of treatment had statistically significantly shorter length of stays than patients who received capsaicin afterwards, (4.83 h vs 7.09 h, p = 0.01). CONCLUSION: Topical capsaicin was not associated with shorter length of stays than no capsaicin. When given earlier during an ED visit, it is associated with a shorter length of stay than when given later.

Topical capsaicin for the treatment of cannabinoid hyperemesis syndrome, a systematic review and meta-analysis.

INTRODUCTION: Cannabinoid hyperemesis syndrome (CHS) is a condition that is being recognized and treated more frequently in emergency departments (EDs) across the United States. Currently, ED providers rely on antiemetics, antipsychotics and benzodiazepines to alleviate the symptoms. Topical capsaicin, a transient receptor potential vanilloid 1 (TRPV1) agonist, has been proposed in recent years as a low-cost and effective alternative to the traditional antiemetic regimen when treating CHS. The aim of this systematic review and meta-analysis is to demonstrate the reliability and the gaps of what is known about this treatment modality. METHODS: Articles were extracted from PubMed, SCOPUS, and Google Scholar databases. Publication dates ranged from the inception of the databases to October 2020. Initial searches found 328 studies. After careful review and screening by two investigators, 7 studies met the inclusion criteria and were included for our meta-analysis. Variables that were evaluated included the prevalence of hospital admissions for patients treated with capsaicin, time to relief of symptoms after capsaicin administration, and ED length of stay (LOS). I-square and Q-statistic values were used to assess heterogeneity. RESULTS: Among the 7 studies, there was a total of 106 patients. Two studies reported time to resolution of symptoms following capsaicin administration and ED LOS. Means for these outcomes were 325 (95% CI 234-787) and 379 (95% CI 10-747) minutes respectively. I-square was 44%, and Q-statistic was 11 with 6 degrees of freedom, with a p-value of 0.1. DISCUSSION: With acceptable time to resolution of symptoms after topical administration and ED LOS, capsaicin appears to be an effective treatment option for symptomatic relief of CHS. Further randomized controlled trials should be conducted to examine if it is the more efficacious and efficient treatment for CHS across various care settings.

Treatment and Management of Loin Pain Hematuria Syndrome.

PURPOSE OF REVIEW: Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available. RECENT FINDINGS: LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.

Comparison of topical capsaicin and topical piroxicam in the treatment of acute trauma-induced pain: A randomized double-blind trial.

BACKGROUND: This study aimed to compare the analgesic efficacy of topical capsaicin and topical piroxicam in acute musculoskeletal injuries. METHODS: This is a prospective, randomized, controlled, double-blinded study. The data for the 67 patients in the piroxicam group and the 69 in the capsaicin group were examined. The initial visual analog scale (VAS) scores were compared with the 60th and 120th minute as well as the 24th and 72nd hour values. Differences between the VAS scores, clinical effectiveness of the treatment and side effects were evaluated. RESULTS: In the capsaicin group, the mean difference in the delta VAS scores was significantly higher at each measurement time. The mean of the percentage of reduction in the VAS scores of the topical capsaicin group was significantly higher than that in the topical piroxicam group. The highest difference in terms of both outcomes was determined at the 72nd hour VAS change. Mean differences were 1.53 (95% CI: 0.85-2.221) and 19.7 (95% CI: 12.4-27.2) respectively (p < 0.001). In the capsaicin group, the clinical effect of the treatment was found significantly higher (p < 0.01). The difference between the clinical effectiveness of the groups regarding the treatment outcomes was also statistically significant (p < 0.001). There was no significant difference between the patient groups regarding the presence of side effects. CONCLUSION: Topical capsaicin can be used as an alternative to topical piroxicam initially and at follow-up in patients presenting to the emergency department with acute pain as there were no observable differences in side-effects between the two groups.

Role of TRPV1/TRPV3 channels in olanzapine-induced metabolic alteration: Possible involvement in hypothalamic energy-sensing, appetite regulation, inflammation and mesolimbic pathway.

Atypical antipsychotics (AAPs) have the tendency of inducing severe metabolic alterations like obesity, diabetes mellitus, insulin resistance, dyslipidemia and cardiovascular complications. These alterations have been attributed to altered hypothalamic appetite regulation, energy sensing, insulin/leptin signaling, inflammatory reactions and active reward anticipation. Line of evidence suggests that transient receptor potential vanilloid type 1 and 3 (TRPV1 and TRPV3) channels are emerging targets in treatment of obesity, diabetes mellitus and could modulate feed intake. The present study was aimed to investigate the putative role TRPV1/TRPV3 in olanzapine-induced metabolic alterations in mice. Female BALB/c mice were treated with olanzapine for six weeks to induce metabolic alterations. Non-selective TRPV1/TRPV3 antagonist (ruthenium red) and selective TRPV1 (capsazepine) and TRPV3 antagonists (2,2-diphenyltetrahydrofuran or DPTHF) were used to investigate the involvement of TRPV1/TRPV3 in chronic olanzapine-induced metabolic alterations. These metabolic alterations were differentially reversed by ruthenium red and capsazepine, while DPTHF didn't show any significant effect. Olanzapine treatment also altered the mRNA expression of hypothalamic appetite-regulating and nutrient-sensing factors, inflammatory genes and TRPV1/TRPV3, which were reversed with ruthenium red and capsazepine treatment. Furthermore, olanzapine treatment also increased expression of TRPV1/TRPV3 in nucleus accumbens (NAc), TRPV3 expression in ventral tegmental area (VTA), which were reversed by the respective antagonists. However, DPTHF treatment showed reduced feed intake in olanzapine treated mice, which might be due to TRPV3 specific antagonism and reduced hedonic feed intake. In conclusion, our results suggested the putative role TRPV1 in hypothalamic dysregulations and TRPV3 in the mesolimbic pathway; both regulate feeding in olanzapine treated mice.

Laser speckle contrast imaging, the future DBF imaging technique for TRP target engagement biomarker assays.

A comparison was made between the established laser Doppler imaging (LDI) technique and the more recently developed laser speckle contrast imaging (LSCI) method to measure changes in capsaicin- and cinnamaldehyde-induced dermal blood flow (DBF) as an indicator of TRPV1 and TRPA1 activation, respectively. METHODS: Capsaicin (1000 µg/20 µl) and cinnamaldehyde (10%) solutions were applied on the forearm of 16 healthy male volunteers, alongside their corresponding vehicle solutions. Pre challenge and 10, 20, 30, 40 and 60 min post challenge application, changes in DBF were assessed with the LSCI technique, followed by LDI. The area under the curve from 0 to 60 min (AUC0-60) post capsaicin and cinnamaldehyde application was calculated as a summary measure of the response. Correlation between the LDI and LSCI instrument was assessed using a simple linear regression analysis. Sample size calculations (SSC) were performed for future studies using either the LDI or LSCI technique. RESULTS: Higher arbitrary perfusion values were obtained with LDI compared to LSCI, yet a complete discrimination between the challenge and vehicle responses was achieved with both techniques. A strong degree of correlation was observed between LDI and LSCI measurements of the capsaicin- (R = 0.84 at Tmax and R = 0.92 for AUC0-60) and cinnamaldehyde-induced (R = 0.78 at Tmax and R = 0.81 for AUC0-60) increase in DBF. SSC revealed that LSCI requires considerably less subjects to obtain a power of 80% (about 15 versus 27 subjects in case of capsaicin and 7 versus 13 for cinnamaladehyde). CONCLUSIONS: The LSCI technique was identified as the preferred method to capture capsaicin- and cinnamaldehyde-induced changes in DBF. Besides its reduced variability, the shorter scan time provides a major advantage, allowing real-time DBF measurements.

Notalgia paresthetica: treatment review and algorithmic approach.

Background: Notalgia paresthetica (NP) is a sensory neuropathy of the back characterized by a well demarcated, hyperpigmented macule or patch located medial or inferior to the scapulae. Symptoms include localized pruritus and pain, and the clinical course consists of remissions and relapses. It can be an underrecognized and difficult disease to treat since conventional treatments for pruritus in inflammatory dermatosis have variable efficacy. There are a variety of treatment modalities, but strong evidence to suggest the superiority of any one treatment is lacking.Objective: This review describes the treatments that have been used for NP in the literature and evaluates their level of evidence with respect to their efficacy. We also present a treatment algorithm based on our analysis.Materials and methods: MEDLINE search was performed using the terms 'notalgia,' 'paresthetica,' and 'treatment.' All resulting articles have been included in this review.Results: Treatment options include topical agents (capsaicin, tacrolimus, anesthetic cream, and amitriptyline/ketamine), systemic agents (gabapentin, oxcarbazepine, and amitriptyline), procedural modalities (botulinum toxin A and narrowband UVB), and physical therapy.Conclusions: Treatment should begin with topical agents or physical therapy, then systemic agents, and finally procedural modalities. We recommend combining treatment options with physical therapy for sustained treatment response.

Thermoregulatory and cardiovasculareffects of capsaicin application on human skin during dynamic exercise to temperate and warm conditions.

Thermoregulatory and cardiovascular responses during cycling in temperate and warm environments without and with application of capsaicin on the skin were investigated. We hypothesized that regardless of environmental temperature, capsaicin application would activate heat loss mechanisms attenuating exercise-induced rectal temperature (Tre) and blood pressure increase. Eight males cycled at 55% of their maximal aerobic power so long as to reach 38.2°C Tre at 20.8 ± 1.0°C and at 30.6 ± 1.1°C ambient temperatures twice: without (NCA) and with (CA) application of capsaicin patches (12 × 18 cm, 4.8 mg). Patches were applied on pectoralis major, trapezius and vastus lateralis muscles. Thermoregulatory (Tre, proximal-distal skin temperature gradient, sweating rate), cardiovascular variables and oxygen uptake were continuously recorded. In both ambient conditions, during the first 14 min of exercise, the local vasoconstrictive tone as a function of the relative change in Tre was lower in CA than NCA (p < .05, d = 0.84-1.15). Further, sweating rate was higher and occurred at a lower Tre increase in CA compared to NCA (p = .03, d = 0.6) resulting in extended time to reach 38.2°C Tre (p = .03, d = 0.9). Moreover, oxygen consumption was higher in CA than in NCA (p < .001, d = 0.8). Mean arterial pressure was lower during cycling in warm compared to temperate environment, but was unaffected by capsaicin. We conclude that activation of thermal sensors by capsaicin results in lower Tre rise during exercise, which is mediated through greater skin vasodilation along with higher rate and earlier onset of sweating. Nonetheless, capsaicin application has no extra effect on exercise cardiovascular responses.

Rapid and sensitive LC-MS/MS method for simultaneous quantification of capsaicin and dihydrocapsaicin in microdialysis samples following dermal application.

A bioanalytical LC-MS/MS method was developed and validated for the simultaneous quantification of capsaicin (CAPS) and dihydrocapsaicin (D-CAPS) in dermal microdialysis samples from rats. Capsaicinoids were separated by using a C18 column, with a mobile phase of water and acetonitrile, both with 0.1% of formic acid, eluted as a gradient. Compounds were detected by using an electrospray ionization source operating in the positive mode (ESI+) to monitor the m/z transitions of 306.1 > 137.0 for CAPS and 308.1 > 137.0 for D-CAPS. The method showed linearity in the concentration range of 0.5-100 ng/ml for CAPS and 0.25-100 ng/ml for D-CAPS, with coefficients of determination of ≥ 0.99. The inter- and intra-day precision, accuracy, and compound stability in different conditions were in accordance with the limits established by the US Food and Drug Administration guidelines. The recovery of the drugs by microdialysis were dependent on the flow rate, but independent of drug concentration. For CAPS, calibration of the in vitro microdialysis probes by dialysis and retrodialysis resulted in statistically similar drug recovery of 68.5% ± 5.9% and 77.8% ± 6.6%, respectively, at a flow rate of 0.5 µl/min. For D-CAPS, the recovery by dialysis was lower than by retrodialysis, at 51.4% ± 6.6% and 92.6% ± 2.4%, respectively. This difference was attributed to the binding of D-CAPS to the plastic tubing, which was experimentally evaluated and mathematically modeled. In vivo recoveries were 75.7% ± 6.3% for CAPS and 81.9% ± 1.5% for D-CAPS at the same flow rate. The analytical method showed high specificity, accuracy, and sensitivity, and suitability for dermatopharmacokinetic studies. These results will allow the determination of the actual free concentration of these drugs in dermatopharmacokinetic experiments, as shown in a pilot experiment with a commercial cream containing capsaicinoids.

Dry eye sensitizes cool cells to capsaicin-induced changes in activity via TRPV1.

Corneal cool cells are sensitive to the ocular fluid status of the corneal surface and may be responsible for the regulation of basal tear production. Previously, we have shown that dry eye, induced by lacrimal gland excision (LGE) in rats, sensitized corneal cool cells to the transient receptor potential melastatin 8 (TRPM8) agonist menthol and to cool stimulation. In the present study, we examined the effect of dry eye on the sensitivity of cool cells to the transient receptor potential vanilloid 1 (TRPV1) agonist capsaicin. Single-unit recordings in the trigeminal ganglion were performed 7-10 days after LGE. At a concentration of 0.3 µM, capsaicin did not affect ongoing or cool-evoked activity in control animals yet facilitated ongoing activity and suppressed cool-evoked activity in LGE animals. At higher concentrations (3 µM), capsaicin continued to facilitate ongoing activity in LGE animals but suppressed ongoing activity in control animals. Higher concentrations of capsaicin also suppressed cool-evoked activity in both groups of animals, with an overall greater effect in LGE animals. In addition to altering cool-evoked activity, capsaicin enhanced the sensitivity of cool cells to heat in LGE animals. Capsaicin-induced changes were prevented by the application of the TRPV1 antagonist capsazepine. With the use of fluorescent in situ hybridization, TRPV1 and TRPM8 expression was examined in retrograde tracer-identified corneal neurons. The coexpression of TRPV1 and TRPM8 in corneal neurons was significantly greater in LGE-treated animals when compared with sham controls. These results indicate that LGE-induced dry eye increases TRPV1-mediated responses in corneal cool cells at least in part through the increased expression of TRPV1. NEW & NOTEWORTHY Corneal cool cells are known to detect drying of the ocular surface. Our study is the first to report that dry eye induced alterations in cool cell response properties, including the increased responsiveness to noxious heat and activation by capsaicin. Along with the changes in cell response properties, it is possible these neurons also function differently in dry eye, relaying information related to the perception of ocular irritation in addition to regulating tearing and blinking.

0.075% capsaicin lotion for the treatment of painful diabetic neuropathy: A randomized, double-blind, crossover, placebo-controlled trial.

OBJECTIVE: A randomized, double-blinded, crossover, placebo controlled trial was conducted to evaluate the efficacy and safety of 0.075% capsaicin lotion for treating painful diabetic neuropathy (PDN). PATIENTS AND METHODS: PDN subjects were randomized to receive 0.075% capsaicin/placebo for 8 weeks, then crossing over to the other treatment after a 4-weeks washout period. Primary endpoint was the change in visual analog scale score of pain severity. Secondary outcomes were score changes in Neuropathic Pain Scale, short-form McGill Pain Questionnaires, and proportions of patients with pain score reductions of 30% and 50%, and adverse events. RESULTS: A total of 42 subjects were enrolled, 27 completed at least an 8-week treatment period. Intention-to-treat analysis showed no significant improvement in pain control with capsaicin lotion compared with placebo for all pain measures and proportion of patients who had 30% or 50% pain relief, respectively. Per protocol analysis were consistent. Capsaicin lotion was well tolerated but local skin reactions were common. CONCLUSION: In patients with PDN, the efficacy of 0.075% capsaicin lotion was similar to placebo but was well tolerated. More work is needed to assess different capsaicin formulations.

Amplification of glyceryl trinitrate-induced headache features by noxious craniofacial stimuli in pain-free healthy humans.

AIM: Glyceryl trinitrate (GTN) provokes an immediate migraine-like headache, followed by a delayed migraine attack in migraineurs. In healthy volunteers, only an immediate, less severe and shorter headache occurs. The presence of an already sensitized nervous system in migraineurs may underlie the more intense and prolonged GTN-evoked headaches. We tested if in healthy humans, application of noxious cutaneous and/or mechanical stimulation within craniofacial region would enhance or prolong GTN-evoked headache. MATERIALS & METHODS: Noxious stimuli with a capsaicin patch on forehead, a mechanical headband, or both were applied prior to sublingual GTN (0.5 mg) in 20 healthy volunteers. GTN-induced headache characteristics and sensory responsiveness were recorded. RESULTS: A more intense GTN-evoked headache was produced following application of headband. CONCLUSION: Noxious mechanical stimulation prior to GTN resulted in a more intense GTN-evoked headache.

Orexin-1 receptors in the rostral ventromedial medulla are involved in the modulation of capsaicin evoked pulpal nociception and impairment of learning and memory.

AIM: To investigate the role of rostral ventromedial medulla orexin-1 receptors in the modulation of orofacial nociception as well as nociception-induced learning and memory impairment in adult male rats. METHODOLOGY: Pulpal nociception was induced by intradental application of capsaicin (100 µg) into the incisors of rats. Orexin-1 receptors agonist (orexin-A, 10, 25 and 50 pmol L-1  rat-1 ) and antagonist (SB-334867-A, 40 and 80 nmol L-1  rat-1 ) were microinjected into the rostral ventromedial medulla prior to capsaicin administration. Total time spent on nocifensive behaviour was recorded by direct visualization of freely moving rats whilst learning and memory were evaluated by the Morris water maze test. One-way analysis of variance and repeated-measures were used for the statistical analysis. RESULTS: Capsaicin-treated rats had a significant increase of nocifensive behaviours (P < 0.001), as well as learning and memory impairment (P < 0.001). However, intraventromedial medulla prior micro-injection of orexin-A (50 pmol L-1  rat-1 ) significantly reduced the nociceptive behaviour (P < 0.001). This effect was blocked by pre-treatment with SB334867-A (80 nmol L-1  rat-1 ). Orexin-A (50 pmol L-1  rat-1 ) also inhibited nociception-induced learning and memory deficits. Moreover, administration of SB-334867-A (80 nmol L-1  rat-1 ) plus orexin-A (50 pmol L-1  rat-1 ) had no effect on learning and memory deficits induced by capsaicin. CONCLUSIONS: The data suggest that rostral ventromedial medulla orexin-A receptors are involved in pulpal nociceptive modulation and improvement of learning and memory deficits induced by intradental application of capsaicin.

The time course of brief and prolonged topical 8% capsaicin-induced desensitization in healthy volunteers evaluated by quantitative sensory testing and vasomotor imaging.

Topically applied high-concentration capsaicin induces reversible dermo-epidermal denervation and depletion of capsaicin-sensitive nociceptors. This causes desensitization of distinct sensory modalities and is used to treat peripheral neuropathic pain and itch. For high-concentration capsaicin, the selectivity of loss of function and functional recovery rates of various afferent fibers subpopulations are unknown. This study used comprehensive quantitative sensory testing and vasomotor imaging to assess effectiveness, duration and sensory selectivity of high-concentration 8% capsaicin-ablation. Skin areas in 14 healthy volunteers were randomized to treatment with 8% capsaicin/vehicle patches for 1 and 24 h and underwent comprehensive sensory and vasomotor testing at 1, 7 and 21 days postpatch removal. Tests consisted of thermal detection and pain thresholds, tactile and vibration detection thresholds, mechanical pain threshold and mechanical pain sensitivity as well as micro-vascular and itch reactivity to histamine provocations. The 24 h capsaicin drastically inhibited warmth detection (P < 0.001), heat pain (P < 0.001) as well as histamine-induced itch (P < 0.05) and neurogenic flare (P < 0.001), but had no impact on tactile sensitivity, cold detection and cold pain. A marginal decrease in mechanical pain sensitivity was observed (P < 0.05). Capsaicin for 1 h had limited and transient sensory effects only affecting warmth and heat sensations. Time-dependent functional recovery was almost complete 21 days after the 24 h capsaicin exposure, while recovery of neurogenic inflammatory responsiveness remained partial. The psychophysically assessed sensory deficiencies induced by the used 8% capsaicin-ablation correspond well with a predominant effect on TRPV1+-cutaneous fibers. The method is easy to apply, well tolerated, and utilizable for studies on, e.g., interactions between skin barrier, inflammation and capsaicin-sensitive afferents.

Identification of Individuals with Functional Dyspepsia With a Simple, Minimally Invasive Test: A Single Center Cohort Study of the Oral Capsaicin Test.

OBJECTIVES: The diagnosis of functional dyspepsia (FD) is challenging due to the lack of reliable biological markers to support the diagnosis. We assessed the relevance of a previously validated simple test for chemical hypersensitivity in the setting of a gastrointestinal outpatient department. METHODS: A total of 224 outpatients who were referred for evaluation of gastrointestinal symptoms in the absence of alarm symptoms swallowed a capsule containing 0.75 mg capsaicin. Severity of symptoms before and after capsule ingestion was assessed by a graded questionnaire and the difference in aggregate symptom scores (delta) was calculated. RESULTS: Sensitivity of the test was between 0.51-0.59, specificity was 0.84-0.89 and positive predictive value for the diagnosis of FD 70-71%. FD patients had significantly higher median delta symptom scores (10.0; 25% quartile: 3.0; 75% quartile: 16.0) as compared to inflammatory bowel disease (2.5; 1.0/8.5)(P=0.003), peptic ulcer disease (0.0; -1.5/4.5) (P<0.001), irritable bowel syndrome (3.0;0.5/8.5)(P=0.001), and patients classified with "other disease" (2.5;0.0/5.0)(P<0.001). Patients with gastroesophageal reflux disease had significantly lower symptom scores if FD was not concomitantly diagnosed (2.0; 0.0/6.0) than if FD was present (10.0; 4.0/15.0). CONCLUSIONS: Hypersensitivity for capsaicin discriminates functional dyspepsia from patients with other GI disorders. The capsaicin test is a simple and non invasive method to detect a large subgroup of functional dyspepsia with chemical hypersensitivity. These findings might open new diagnostic options in functional dyspepsia and possibly new therapeutic options by targeting the specific capsaicin receptor TRPV1.