Management of Specific Pain Syndromes

Cancer Pain


  • ~1.75 million people are diagnosed with cancer every year
  • Up to 90% of patients with advanced cancer have pain that significantly impacts function, mood, sleep
  • In 1984, WHO stepladder was introduced for management of cancer pain

Traditional WHO Step Ladder try 2.png

  • Pain management typically relies on the WHO stepladder, but analgesia may be inadequate for 10-25% of cancer patients
  • Interventional options such as nerve blocks and intrathecal therapy may be appropriate
    • Celiac plexus block/neurolysis for abdominal pain
    • Superior hypogastric plexus block/neurolysis for pelvic pain
    • Intrathecal therapy for regional cancer-related nociceptive or neuropathic pain

Sickle cell pain

  • In sickle cell disease, a mutation in the beta globin gene leads to production of sickle cell hemoglobin.  A prominent clinical feature is vaso-occlusion by sickle hemoglobin, resulting in tissue ischemia.
  • The term “sickle cell crisis” is frequently used to refer to an acute painful episode, although this term is not ideal, as it implies aggressive pain management, including with opioids, should be brought forth only when a patient is in “crisis.”  There may also be an unintentional associate of catastrophizing or emotional instability associated with patients when using the term “crisis.”  
  • Extremities, back, chest, and abdomen are common locations for vaso-occlusive pain



Migraine is the most common headache condition prompting a visit to the physician’s office.  They are recurring headaches that are unilateral, pulsating, moderate to severe, aggravated by routine physical activities, and are associated with nausea and/or photophobia and phonophobia.  When these are associated with fully reversible, gradually occurring, neurologic symptoms such as visual changes, it is diagnosed as migraine with aura.  Migraine without aura is more common than migraine with aura, and many patients have both types.  Chronic migraine is diagnosed when there are 15 or more headache days per month.


There are overlaps between various headache disorders, and some patients may present with multiple headache disorders or even a combination of primary and secondary headaches.   Migraine aura can also mimic transient ischemic attacks (TIAs). In addition, migraine is comorbid with multiple psychiatric (eg, depression, post-traumatic stress disorder) and medical conditions (eg, stroke, epilepsy). Patient history need to be carefully explored to ensure accurate diagnosis and appropriate treatment.  

Overuse of acute pain medications is common.  In addition, migraine patients may be taking opioids to treat other pain conditions.  Medication weans are often required for the treatment of migraine. 

Chronic Abdominal Pain

Abdominal pain is oftentimes elusive for the practitioner as even after dangerous and other treatable pathologies are ruled out, some patients continue to suffer from chronic pain with no clear etiology.  This has generally been referred to as Functional Abdominal Pain (FAP) and more recently referred to as Central Abdominal Pain Syndrome (CAPS) in GI literature. Understandably, without an etiology, the treatment options are oftentimes limited at best.

Facial Pain

Trigeminal Neuralgia (TN), characterized by paroxysmal lancinating or electric shock-like pain in the distribution of one or more divisions of trigeminal nerve, is one of the most devastating neuropathic pain conditions. TN can be triggered by innocuous stimuli on the face or intraoral trigeminal territory. The incidence of TN is estimated to be 12.6-28.9 per 100,000 person-years¹,  higher among women than among men, and tends to increase with age. 

TN pain symptoms are most common in the V2 (maxillary) and V3 (mandibular) divisions.  Etiologies of TN can be idiopathic or secondary to underlying vascular or tumor impingement, multiple sclerosis, post-herpetic neuralgia, trauma, or dental injury². Although paroxysmal facial pain is the hallmark of trigeminal neuralgia, 24 to 49% of patients report continuous or long-lasting pain between paroxysmal attacks with unclear etiology². Facial pain in the areas that are not innervated by the trigeminal nerve suggests an alternative pathology under the category of “atypical facial pain” or “painful trigeminal neuropathy.”

Neuropathic pain

Most treatment for neuropathic pain is symptom management. Many neuropathic pain patients do not respond well to acetaminophen, NSAIDs, or weak opioids like codeine. 

Pain in Palliative Care

All principles of pain management could be included as palliative care as it addresses managing symptoms to improve function and quality of life.  From the perspective of palliative care and its focus on quality of life, moderate to severe pain is considered an emergency.  Pain is one of patients’ greatest fears at the end of life and unrelieved pain is common among patients with nearly all serious illnesses, including cancer, chronic lung disease, and chronic heart disease.

Myofascial Pain

  • Definition
    • Chronic Pain Syndrome
    • Characterized by multiple tender points in muscles 
    • These tender points have also been characterized at “taut bands” known as trigger points
  • Pathophysiology
    • Occurs from repetitive contraction of a muscle
    • This repetitive contraction can be a result of sports, work, hobbies, or stress
    • Muscle Injury: Strained muscles can get tight and form trigger points
    • Stress: Theory is under stress individuals can clench their muscles leading to muscle strain
  • Diagnosis: 
    • Physical Exam- The examiner must palpate painful muscle regions and feel for taut bands consistent with trigger points