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HEADACHES THAT ARE NOT MIGRAINE: TENSION HEADACHES

03/07/11

Tension headaches are caused by a tightening of the muscles at the back of the neck with consequent tension of the scalp. The pain can be felt at the back of the neck, over the top of the head, or over the forehead, and is often described as a ‘vice round the head’. The tension of the muscles is in itself painful, but associated constriction of the arteries to the muscles makes the pain considerably worse. The electromyograph (a machine which picks up electrical activity in muscle) can prove that active muscle contraction occurs during this form of headache.Patient G.H., a 45-year-old housewife, said:For the past nine months, I have suffered from almost continuous headaches. It is as if I have a heavy weight on the top of my head and I notice it as soon as I wake in the morning. It lasts all day but it does not keep me awake at night although it is there when I wake up in the morning. I do not feel sick and have no trouble with my eyes. Sometimes I feel a tight band around my head and usually the back of my neck feels stiff.This is a typical tension or muscle-contraction headache. In the case of G.H., direct questioning revealed that the headaches had started after her husband had told her he was contemplating divorce but had not yet decided to leave the conjugal home. These sorts of headaches could be due to depression, coupled as they were with feelings of lack of wanting to do anything, and early morning waking.Anxiety-depressive headaches are commoner than typical migraine but the two types often occur at different times in the same sufferer.
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THE UNDERUTILISATION OF MORPHINE : OPIOPHOBIA-PROFESSIONAL OPLOPHOBIA

14/06/11

Morphine is the drug of choice for the management of severe pain in advanced cancer but opioids are frequently denied to patients who could benefit from them.
The belief that morphine should be only given when patients are dying is archaic. Morphine may be used for months or years and, correctly administered, is compatible with a normal life style. That morphine should be reserved for the ‘crescendo of pain’ which occasionally occurs before death is incorrect because the broad therapeutic range of morphine allows for increasing doses if need be.
Morphine will be ineffective in controlling pain if it is being incorrectly administered, used for morphine-insensitive pain or if matters of psychosocial concern have not been addressed. The correct dose of morphine is that which relieves the patient’s pain whilst causing acceptable side effects and must be individually titrated for each patient. Neuropathic pain is relatively
opioid-insensitive and may respond better to one of the adjuvant analgesics. Physical pain may be caused or aggravated by psychosocial problems and no amount of well prescribed analgesia will relieve this pain until the psychological and social concerns are addressed.
Side effects should not be severe. In patients with cancer, respiratory depression is very uncommon except in opioid naive patients who are commenced on parenteral therapy. Constipation occurs inevitably and requires explanation and advice about diet and laxative therapy. Patients should be warned of the possibility of somnolence and nausea and reassured that these usually improve after several days.
The most frequent reasons why morphine is withheld relate to misunderstandings about tolerance, physical dependence and psychological dependence. In contrast to intravenous drug users who develop rapid tolerance, patients with cancer rarely develop clinically significant tolerance and frequently require little increase in the dose over weeks or months. Physical dependence requires explanation and patients must be reassured that morphine can be weaned (by 25% a day) if their pain is relieved by other means. Psychological dependence occurs extremely rarely in patients with cancer and pain. Concerns about tolerance, physical dependence or psychological dependence are never a reason to delay treatment with morphine if it is indicated.
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