The Range of Headache & Pain Disorders

We are pleased to be the guest medical editors for this and the next issue of Practical Neurology, both focusing on headache and pain disorders—together, the most common reason people seek medical care. Headache disorders and chronic low back pain are also among the top 10 causes of disability globally. Although we recognize that for some neurologists, like ourselves, assessment and treatment of pain and headache are a life’s passion, other neurologists may not as warmly embrace assessing and treating the painful neurologic disorders they frequently encounter (eg, migraine and other headache disorders; neuropathies; pain associated with multiple sclerosis, Parkinson disease or other neurologic conditions; and spinal pain.) We hope to highlight the vital and positive force neurologists can be for countless people with headache and pain disorders.

Many incredible advances have been made in understanding the pathophysiology of migraine and other painful disorders, from expanding the taxonomy to improving our conceptual understanding of centralized pain and our appreciation of how powerfully cognitive-behavioral approaches can help in managing chronic pain and headache. The recognized optimal assessment and treatment of pain conditions is through a multidisciplinary approach and biopsychosocial model of care. The topics covered reflect this, and we welcome the contributions of anesthesiologists, psychologists, and others.

Steinberg and Argoff begin with a clinically relevant review of the current basic science of Understanding Pain, and how that connects both to treatments and the new pain taxonomy recently established by the International Association for the Study of Pain. From these connections, it is clear that many current treatments—from traditional pharmacotherapy to cognitive-behavioral to neuromodulation—have developed because of this improved understanding of mechanisms.

In Headache Disorders: Acute Management, Montenegro and Kissoon provide key insights into acute management in general by highlighting cases that showcase the essential practice of individualized treatment. Next, Moskatel, Mallick-Searle, Carroll, Hashmi, and Barad explore the often underrecognized and undertreated Headache Attributed to Spontaneous Intracranial Hypotension, showing the importance of integrated multidisciplinary teams for chronic pain and headache.

It is increasingly recognized just how important the integration of cognitive-behavioral and lifestyle changes are for overall care of a person being treated for chronic pain or chronic headache. This is highlighted by Martin, Schmidt, and Murphy in their overview of Chronic Pain: Behavioral Management and by Forde in Headache Disorders: Behavioral and Lifestyle Management.

As we continue addressing the COVID-19 pandemic, we also continue recognizing the importance of the opioid epidemic. Among the many observations over the last decade is that although there may be a subset of people experiencing chronic pain for whom chronic opioid therapy proves effective and safe over the long term, there are many others for whom it is neither effective nor safe. These observations underlie the timeliness and importance of Chronic Pain: Opioid Weaning by Hooten, Moman, and Hagedorn. They provide a clear discussion of how, when a decision has been made to discontinue opioid therapy, this can be completed safely and compassionately in a manner that does not increase pain for the patient. This concept is well known to neurologists, because we often adjust and taper medications when managing diverse conditions—from epilepsy to Parkinson disease—recognizing the need to taper and titrate medications in the best interest of the patient.

In the next issue, we will highlight the role of neuromodulation and other interventional treatments for pain and headache, spinal pain, potential use of cannabinoids, telemedicine, and medication-overuse headache. Although we recognize we cannot cover every relevant topic in these issues, we hope the information provided is truly helpful to you and your approach to the management of those experiencing headache and pain disorders. We have never had as many opportunities to help our patients with headache disorders and chronic pain as now.