1. Acute pain is short-term pain lasting less than 6 months resulting from injury or illness, while chronic pain lasts longer than 6 months and can be malignant (cancer-related) or non-malignant. 2. Pain management aims to relieve pain and associated physiological changes through pharmacological methods like opioids, NSAIDs, and local anesthetics or interventional methods like epidural anesthesia. 3. Migraine headaches commonly affect females and present with prodromal symptoms before an aura of visual disturbances and severe headache, while tension headaches equally affect both sexes with constant non-pulsatile pain.

1. CLINICAL
MANAGEMENT OF PAIN

2. INTRODUCTION
TYPES OF PAIN
PATHWAYOF PAIN
MANAGEMENT OF PAIN

3. PAIN
Pain can be defined as an unpleasant sensory and
emotional experience that is associated with
actual or potential tissue damage.
Accurate assessment of pain is necessary if pain
management is to be effective. Patients with pain
are often undertreated.

4. Types of Pain
Acute Pain Chronic Pain
Malignanted chronic Pain Non malignanted chronic Pain

5. Acute pain is of short duration and lasts less
than 3 to 6 months. Intensity of acute pain is
from mild to severe.
Causes of acute pain include postoperative
pain, procedural pain, and traumatic pain.
Acute pain usually sub-sides when the injury
heals.

6. Malignanted chronic pain:
Chronic pain associated with malignancy includes the
pain of cancer, acquired immunodeficiency syndrome
(AIDS), multiple sclerosis, sickle cell disease, and
end-stage organ system failure.
Non malignanted chronic pain:
The exact cause of this pain is unknown but it is
associated with various musculoskeletal disorder
rheumatoid arthritis, and osteoarthritis ect

8. Different types of stimuli
Chemical stimuli Exogenous
Endogenous
Thermal
Mechanical

9. Physiologic Signs of pain
Result of catecholamine release and activation of the
sympathetic nervous system.
Systemic Changes
Cardiovascular system - heart rate & BP.
Pulmonary sys - resp. rate, shallow breathing.
Musculoskeletal sys - tense muscles, M. tremors.
Immune sys - resistance, stress leukogram.
Neuroendocrine sys - catabolism, anabolism.
Digestive sys - vomiting, diarrhoea.

10.  Degree of Pain
 Mild pain.
 Moderate pain.
It is the common degree of pain that is treated.
 Severe pain
it is intolerable
unprovoked vocalization
chance of self mutilation

11. Why pain management ?
 Feel better
 Physiologic changes that accompany
pain.
 Should be able to eliminate pathologic
pain
 Pain free sleep
12 – 24 hr. post operative pain
management is important.

12. Types
Pharmacological Interventional

13. Non pharmacologic approach
1. Keep patient clean & dry.
2. Keep the patient warm.
3. Room with moderate temperature and
humidity.
4. Well padded place to sleep.
5. Patients surrounding should be pleasant &
quiet.
6. Human contact
7. Acupressure, acupuncture, massage,
manipulation stimulate A-beta nerve fibers.

14. Classification
Local
Anaesthetics
Opioids Salicylates
Non
salicylates

15. Lidoderm:
5% Lidocaine Patch
Each Patch Contains 700 mg of Lidocaine
Should be Applied to Intact Skin
About 3% is Absorbed
1-3 Patches Once a Day for 12 hrs

17. Bind to Opioid Receptors:
Mu, Delta and Kappa
Meperidine,
Oxycodone,
NSAIDs to
Morphine, Hydromorphone,
Fentanyl, Codeine, Methadone,
Hydrocodone, Tramodol
Opioids may be Combined with
Enhance the Opioid Analgesic Effect

18. Drugs IV Dose (mg) Oral Dose (mg)
Morphine 10 15-30
Hydromorphine 1.5 4-8
Methadone 10 5-10
Codeine 8 5-10
Oxycodone 5-10 15-30
Hydrocodone 5-10 15-30

19. Small Doses of Analgesic Drug (Usually
Opioids), are Administered (IV) by Patient.
Allows Basal Infusion and Demand Boluses
Over Dosage is Avoided
by Limiting the Amount
and Number of Boluses
in a Set Period of Time

20. The salicylates include aspirin (acetylsalicylic
acid) and related drugs, such as magnesium
salicylate and sodium salicylate. The salicylates
have analgesic (relieves pain), antipyretic(reduces
elevated body tem-perature), and anti-
inflammatory effects.
Eg . Aspirin
Buffered aspirin
Magnesium salicylates
Sodium salicylates

21. The major drug classified as a non salicylate is
acetaminophen , (Panadol).
It is the most widely used aspirin substitute for
patients who are allergic to aspirin or who
experience extreme gastric upset when taking
aspirin.

22. Nonsteroidal anti-inflammatory
drugs(NSAIDs)
Inhibition of prostaglandin synthesis by
inhibiting cyclooxygenase enzyme (COX).
NSAIDs vary in their ability to inhibit COX 1 &
2
COX 2 inhibition will provide enhanced
analgesia.
Eg. Ketoprofen, Meloxicam, Flunixin
meglumine.

23. Types
Epidural
Anaesthesia
Spinal
Anaesthesia

30. COMMON CAUSES
• Viral Rhinitis (Common Cold)
• Sinusitis
• Fevers
• Hypertension
• Refractive Error
• Tension Headache
• Hypoglycemia
• Post ictal headache

31. SPECIFIC CAUSES
• Migraine Headache
• Cluster Headache
• Temporal Arteritis
• Post traumatic Headache
• Thunderclap Headache
(Subarachnoid Haemorrhage)

32. Specific Causes
Contd..
•Intracerebral Haemorrahage
•Subdural Haematoma
•Brain Abscess
•Primary Brain Tumor
•Metastatic Brain Tumor
•Meningitis
•Hydrocephalus
•Glaucoma

33. CRANIAL STRUCTURES
SENSITIVE TO PAIN
• The scalp
• Scalp blood supply
• Head and neck muscles
• Great venous sinuses
• Arteries of the meninges
• Larger cerebral arteries
• Pain –sensitive fibers of the fifth, ninth and tenth
cranial nerves
• Parts of the dura mater at the base of the brain

34. • Migraine occurs commonly in
– Females – 70%
– Males – 30%
• Cluster Headache occurs almost
entirely in men – 90%
• Tension Headache seen equally in
both sexes

35. Location of Headache
• Hemicranial
• Bi-Temporal
• Occipital
• Frontal
• Peri-Orbital
• Vertex

36. Nature of Headache
• Constant
• Paroxysmal
• Lancinating
• Throbbing

38. MIGRAINE HEADACHE
• Familial Disorder characterised by
periodic, Commonly unilateral , often pulsa
tile headache.
• Age of onset
– Begins in childhood , adolescents in early adult
life and diminishes in frequency and severity
during advancing years. (Typically begins in
teenage years and seldom begins after 40yeras
of age)

39. TYPES
• Classic Migraine or Neurologic Migraine
– Is characterised by aura
• Common Migraine
– Migraine without aura
• Ratio
– Classic Migraine : Common Migraine 1: 5

40. CLASSIC MIGRAINE
• Prodrome :
– Occurs hours to days before headache and consists
of change in mood, behavior, apetite and cognition.
• Aura :
– Occurs within 1 hour of headache, and is most
commonly visual or sensory
– Visual Aura
• Most Common
• Consist of photopsias, bright flashing lights, scintillating
scotomas, field cuts and fortification spectra (zigzag lines /
Teichopsia)