MYOFASCIAL HEADACHES AND TRANSFORMED MIGRAINE Myofascial headache is a variant of tension headache and is characterized by the presence of trigger points on the scalp; constant, squeezing pain; and occasionally shooting pain. Nausea, vomiting, neck pain, and neck tenderness may be present. It is important to differentiate this disorder from common tension headache because myofascial headache may benefit from referral for injection of trigger points. "Transformed migraine" is a syndrome in which classic migraine headaches change over time and develop into a chronic pain syndrome. One cause of this change is frequent treatment with narcotics.8 In this regard, patients who initially have "vascular symptoms" eventually have predominantly muscular symptoms: nonthrobbing, squeezing, bandlike pain associated with muscle tenderness and tension. Nausea and vomiting or failure of oral antimigraine medications often prompts an ED visit.
FIBROMYALGIA AND CHRONIC MYOFASCIAL CHEST PAIN Fibromyalgia is classified by the American College of Rheumatology as the presence of 11 of 18 specific tender points, nonrestorative sleep, muscle stiffness, and generalized aching pain, with symptoms present longer than 3 months. 9 Chronic myofascial chest pain is classically a dull, constant pain associated with trigger points on the chest wall. Symptoms may mimic ischemic myocardial-type chest pain but usually is not provoked by exercise (unless the movement involves the use of chest or arm muscles) and is not completely relieved by rest.
BACK PAIN Risk factors for chronic back pain following an acute episode include male gender, advanced age, evidence of nonorganic disease, leg pain, prolonged initial episode, and significant disability at onset. 10 Chronic back pain symptoms and causes can be divided into myofascial or muscular, articular, and neurogenic types. Myofascial back pain is characterized by constant dull and occasional shooting pain that does not follow a classic nerve distribution. Pain may or may not be exacerbated by movement. Usually trigger points can be found at the site of greatest pain, and muscle atrophy is not found. Range of motion of the involved muscle is reduced, but there is no actual muscle weakness. Previous recommendations for bed rest in the treatment of back pain have proven counterproductive. 11 Exercise programs have been found to be helpful in chronic low back pain.12 Articular back pain is characterized by constant or sharp pain that is exacerbated by movement and associated with local muscle spasm. Myofascial and articular back pain may be indistinguishable from each other except by advanced imaging techniques beyond the usual scope of practice in the ED. Neurogenic back pain is classically characterized by constant or intermittent pain that is burning, shooting, or aching. The pain is usually more severe in the leg than in the back and follows a dermatome. Muscle atrophy as well as reflex changes can be seen over time.
COMPLEX REGIONAL PAIN Complex regional pain type I, also known as reflex sympathetic dystrophy, and complex regional pain type II, also known as causalgia, may be seen in the ED 2 weeks or more after an acute injury.13 These disorders cannot be differentiated from one another on the basis of signs and symptoms. Type I occurs because of prolonged immobilization or disuse, and type II occurs because of a peripheral nerve injury. These disorders should be suspected when a patient presents with classic symptoms: allodynia (pain provoked with gentle touch of the skin), and a persistent burning or shooting pain. Associated signs early in the course of the disease include edema, warmth, and localized sweating. Therefore, it may be difficult to distinguish this disorder from an underlying wound infection or osteomyelitis. Later signs include periods of edema and warmth that alternate with cold, pale, cyanotic skin and eventually atrophic changes. Complex regional pain is an important diagnosis to make, since early steroid treatment may prevent ongoing symptoms.
POSTHERPETIC NEURALGIA The classic pain of postherpetic neuralgia may follow the course of an acute episode of herpes zoster. Pain is characterized by allodynia (defined above) and shooting, lancinating (tearing or sharply cutting) pain. Often, patients have hyperesthesia in the involved dermatome. Occasionally there are pigmentation changes in the distribution of the involved dermatome, but this is not unique to postherpetic neuralgia.
PHANTOM LIMB PAIN Phantom limb pain is quite variable in presentation but is more frequent in patients who had pain in the extremity before amputation. Pain may be aching, cramping, burning, tearing, or squeezing. Failure to respond to any treatment, including narcotics, is common.
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