Likeable patients may receive better care for their pain, according to a study by Belgian researchers. The researchers asked 40 doctors to look at photos of six different patients. Each photo was accompanied by a description such as friendly, egoistic, arrogant, honest, faithful, hypocritical, or reserved. Then the doctors were asked to evaluate the severity of pain in these six patients after they watched a video in which the patients were being evaluated for shoulder pain. Patients with positive descriptions were thought to have more pain than those with negative ones. Most doctors are probably convinced that they treat all patients equally, but this is clearly not true. Doctors and medical students should be informed of these findings so that they constantly remind themselves of the potential bias.

Hypertension appears to increase the risk of trigeminal neuralgia, according to a new study published in Neurology by Taiwanese researchers. They looked at 138,492 people with hypertension and compared them to 276,984 people of similar age and sex who did not have hypertension. The risk of trigeminal neuralgia was one and half times higher in those with high blood pressure. Trigeminal neuralgia is an extremely painful condition with electric-like pain in one or more branches of the trigeminal nerve, which supplies sensation to the face. The likely cause of trigeminal neuralgia is compression of the trigeminal nerve by a blood vessel at the site where the nerve is coming out of the brainstem. Persistently elevated blood pressure tends to make blood vessels harder and more tortuous. Hypertension has been show to be a factor in a similar condition – hemifacial spasm, which results from the compression of the facial nerve by a blood vessel. The usual treatment of trigeminal neuralgia starts with medications, such as oxcarbazepine (Trileptal), carbamazepine (Tegretol), phenytoin (Dilantin), baclofen (Lioresal) and other. If medications are ineffective, invasive treatments are recommended. Botox injections have been reported to provide some patients with good relief, although Botox is probably more effective for hemifacial spasm. ANother procedure is the destruction of the tigeminal nerve ganglion with heat from a radiofrequency probe. This is done under X-ray guidance. Radiofrequency ablation is often effective, but the pain may recur and the procedure may need to be repeated. A more drastic but also more effective approach involves opening the skull and placing a Teflon patch between the nerve and the offending blood vessel. Obviously, this procedure carries a higher risk of serious complications, but in experienced hands it is relatively safe. You can determine the experience of the neurosurgeon by asking how many procedure he or she has performed. Ideally, pick a surgeon who has done it hundreds of times.

At the NYHC, just like at all headache clinics, we see many patients with severe disability. A very interesting study just published in the journal Pain seems to tell us how to predict which of these disabled patients will respond to treatment. Researchers at the Ohio University compared patients whose severe disability improved with treatment and those whose did not. They carefully examined a wide variety of possible factors, including race/ethnicity (African American versus Caucasian American), psychiatric comorbidity, headache management self-efficacy, perceived social support, locus of control, number of headache diagnoses, migraine versus tension-type headache diagnosis, chronic versus episodic headache diagnosis, headache days per month, headache episode severity, and whether the patient attended all scheduled treatment appointments. The only factor that seemed to predict whose disability will improve and whose will not was the attendance of the 3 follow-up visits. Those who came for follow-up visits were much more likely to improve than those who did not – showing up is half the battle.

Botulinum toxin, which most people know as Botox is produced by a bacteria – Clostridium botulinum.  This bacteria actually produces 7 different type of this toxin: A, B, C, D, E, F, and G.  Botox is botulinum toxin, type A, while another commercial product, Myobloc is botulinum toxin, type B.  Researchers, Drs. Dolly, Aoki and their colleagues managed to combine type A and E, according to a report in The Journal of Neuroscience.  Test tube experiments suggest that this combination could prove to be more effective for the treatment of pain than type A alone.  This is a very promising discovery, since Botox is effective for only about two thirds of chronic migraine sufferers.  The combined toxin could be also effective for other types of pain.

It appears that women respond better to morphine than men and men respond better to a different opioid (narcotic) drug, butorphanol.  This was the conculsion of a study presented at the American Pain Society.  The next step that the researchers plan is to look at possible genetic factors which may explain this difference.  Although the study was small and needs to be confirmed, such knowledge could have an important practical impact.  Opioid drugs are rarely used for the treatment of headaches, but when necessary it would be useful to know which one has a better chance of success.