Treatment

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Since pain is a complicated combination of emotional, chemical and physical components, treating and managing it often requires several approaches. Over-the-counter (OTC) or prescription medications, physical therapy, lifestyle changes, including quitting smoking, and learning coping skills may all be recommended.

Other treatments include ice, meditation, self-hypnosis, acupuncture, chiropractic, electrical stimulation, trigger point injections, nerve blocks, epidural steroid placement, spinal cord stimulators and intrathecal pumps, which deliver small doses of pain-relieving medication directly to the pain receptors in the spinal cords, blocking the message to the brain.

There are many types of pain medications, both prescription and OTC remedies, to help you manage your pain.

OTC remedies include:

• Acetaminophen and most nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, are pain-relief medications available without a prescription. Tylenol, which contains acetaminophen, reduces pain and fever and is usually safe to use with other medications if necessary, although caution should be used when taking with alcohol because of potential for serious liver damage. (Always check with your health care professional if you are taking other medications.)

  Motrin, Advil and Aleve are examples of nonprescription NSAIDs that help reduce aches and pains. However, NSAIDs can cause stomach irritation and affect kidney function. Plus, there is the potential for cardiovascular events associated with the use of NSAIDS. The longer you use NSAIDs, the more likely you are to have side effects, and the more serious those effects can be. Many other drugs cannot be taken with NSAIDs, and these medications are associated with serious gastrointestinal problems, including ulcers, bleeding and perforation. NSAIDs should be used with caution in people over 65 and in those with any history of ulcers or gastrointestinal bleeding, congestive heart failure, renal insufficiency and hypertension. It's important to ask your health care professional for safety information associated with pain relievers with your personal health history in mind. Higher-strength forms of ibuprofen (and other NSAIDS) are available by prescription. Aspirin, available as Bayer, Bufferin and Ecotrin brands, is also an NSAID but is used primarily for relieving short-term pain.

Prescription pain medications include:

• NSAIDs such as Naprosyn, Nalfon, and Trilisate, which are useful for moderate to severe pain

• Narcotic analgesics (opioids or opiates), a wide-range of medications that are typically used for acute pain after an injury or surgery.

• Antidepressants, medications used to treat depression, which also affect pain pathways in the brain

• The COX-2 specific inhibitor (cyclooxygenase inhibitor) celecoxib (Celebrex), a type of NSAID.

• Topical pain relief agents applied directly to the skin, some available without a prescription.

Narcotics

Narcotics, such as morphine, also are used to treat cancer pain and other types of moderate to severe pain. Most people who take narcotics as prescribed by their health care professional for pain do not get high or become addicted to these drugs. Their bodies may become adapted to the narcotic, however, so they experience withdrawal if the narcotics are stopped abruptly.

Narcotic analgesics may be taken orally, by injection (intramuscularly), through a vein (intravenously) or by rectal suppository. There also are other methods of giving pain medicines for more continuous pain relief. Not all narcotics are available in each of these forms. Frequently prescribed narcotic pain relievers include:

• Codeine

• fentanyl (Sublimaze)

• hydromorphone (Dilaudid)

• levorphanol (Levo-Dromoran)

• meperidine (Demerol)

• methadone (Dolophine)

• oxycodone (OxyContin)

• oxymorphone (Numorphan)

• morphine (Avinza, Kadian, MS Contin)

OxyContin, a form of oxycodone, was approved in 1996 for the treatment of moderate to severe pain associated with musculoskeletal conditions, and by 2001 it became the most frequently prescribed brand name narcotic medication for treating moderate to severe pain in the United States. The narcotic has come under intense scrutiny by the U.S. Food and Drug Administration (FDA) and the U.S. Drug Enforcement Agency due to widespread abuse. Abusers can bypass the time-release aspect of the drug by crushing, chewing, snorting or shooting OxyContin pills to get a quick morphine-like high. The abuse of OxyContin is associated with serious consequences including addiction, overdose and death. Therefore, the FDA requires the manufacturer of OxyContin to include the agency's highest level of safety warning on the label. In addition, the FDA has collaborated with the manufacturer to develop and implement a risk management plan to help detect and prevent abuse and diversion of OxyContin.

Antidepressants

Antidepressants affect pain by changing the levels of neurotransmitters (brain chemicals) and altering the pain messages reaching the brain. When a woman is depressed and also in pain, these medications can both reduce pain and improve mood. The tricyclic antidepressants help to restore the body's normal perception of pain and may be recommended as a treatment option even when a patient is not depressed.

COX-2 specific inhibitors

The COX-2 specific inhibitor (cyclooxygenase inhibitor) celecoxib (Celebrex) is in a class of nonsteroidal anti-inflammatory prescription medications. Celebrex is indicated for the relief of symptoms caused by arthritis, such as inflammation, swelling, stiffness and joint pain and is designed to cause fewer gastrointestinal side effects (such as ulcers and bleeding) than other types of NSAIDs. Celebrex is also approved for the treatment of nociceptive pain, including pain following surgery.

Celebrex is currently the only COX-2 inhibitor on the market. Celebrex can increase the risk of heart attack and stroke; discuss these risks with your health care professional. And if you are currently taking Celebrex and think you are having an allergic reaction or have other severe or unusual symptoms while taking any NSAID, call your health care professional immediately. For more information on the risks associated with Celebrex, visit www.fda.gov

Combination Drugs

Some medications used for pain are actually combinations of acetaminophen and either oxycodone (for example, Vicodin or Percocet), a relaxant (for example, Fioricet) or an opioid (for example, Ultracet).

Topical agents

These increasingly popular pain-relief products are applied to the surface of the skin. Some are prescription while others can be purchased over the counter. Examples include: capsaicin and lidocaine.

Some alternative or holistic pain management approaches include:

• Acupressure:

  The stimulation of healing sites (as in acupuncture) with finger pressure, rather than fine needles.

• Acupuncture:

  An ancient Chinese health practice that involves therapeutic insertion of thin, solid (generally metallic) needles in specific points along your nerve pathways, called acupuncture points. While Western researchers are not sure how acupuncture works to ease pain (and some doubt that it does work), several theories suggest that acupuncture may stimulate the release of endorphins, the body's natural pain relievers.

• Biofeedback:

  A technique used to gain control over a function that is normally automatic (such as blood pressure or pulse rate); the function is monitored, and relaxation techniques are used to change it to a desired level. Biofeedback uses electronic or electromechanical instruments to monitor, measure, process and feedback information about blood pressure, muscle tension, heart rate, brain waves and other physiologic functions.

• Cranial sacral therapy:

  This hands-on treatment involves gentle massage or manipulation of all bones of the skull (including the face and mouth), vertebral column, sacrum, coccyx and pelvis to ease restrictions to physiological motion. It's a spin-off of chiropractic and osteopathic medicine but differs because instead of adjusting the musculoskeletal and nervous systems, gentle massage is used to increase the flow of cerebrospinal fluids.

• Electrical stimulation:

  This therapy involves attaching a small transmitter to the skin around a painful area and emitting electrical impulses that block pain signals, giving you a tingling feeling rather than pain. It may work by stimulating the release of endorphins.

• Homeopathy:

  A natural, noninvasive system of medical treatment based on the theory that substances that cause certain symptoms in a healthy person can—in diluted amounts—cure those symptoms in an unhealthy person. The logic is that the similar substances promote healing by stimulating your body's natural healing mechanisms.

• Hydrotherapy:

  Also called hydropathy and aquatic therapy, hydrotherapy literally means using water in the treatment of disease. Using water for pain management typically involves hot and cold compresses or tub soaks to relieve pain and decrease swelling. Aquatic therapy also refers to the use of a heated therapeutic pool for exercising without stress on the joints. It does this by relieving the pull of gravity.

• Hypnosis:

  A technique that induces a deeply relaxed and focused state of mind—a form of intense receptive concentration. While often used to modify behavior, hypnosis also helps reduce pain and may speed healing.

• Massage:

  Massage involves rubbing or kneading muscles and other areas of the body to stimulate blood circulation, relieve pain and promote a sense of well-being.

• Meditation:

  A process to increase concentration and awareness and create a more relaxed state.

• Osteopathic medicine:

  This discipline focuses on the unity of all body parts, with special consideration to the musculoskeletal system. It recognizes the body's ability to heal itself and stresses preventive medicine, eating properly and keeping fit.

• Reflexology:

  This technique is based on the belief that pressure applied to specific points on the extremities benefits other parts of the body. Massage of the hands or feet is typically used.

These approaches may be used as alternatives to medication or in conjunction with them.

Lifestyle changes may be necessary to help you relieve your pain.

• Exercise helps:

  • relieve pain

  • increase muscle mass, which reduces stress on joints

  • promote weight loss, which also reduces stress on joints

• A healthier diet may:

  • reduce swelling in joints and lead to better circulation

  • lower cholesterol levels and blood pressure.

  • assist in pain relief by providing a healthier body upon which medications can work

While exercise and modifying your diet and eating habits may be difficult lifestyle changes, they may help you to manage your pain. Always consult your health care professional before beginning a new diet or exercise program, especially if you are experiencing pain. Your health care professional may advise you not to exercise at all. However, if he or she recommends exercise, you should know that it might make your pain feel worse when you start. You may be afraid to exercise because of this increased pain. One strategy for managing this pain is to begin exercising slowly and gradually increase your activity.

When to Consider Using a Pain Clinic

You might consider visiting a pain clinic if your pain does not go away after medical treatment within the expected timeframe provided by your practitioner. Persistent nociceptive or neuropathic pain, in addition to causing physical suffering, alters a person's ability to function, which, without intervention, may lead to depression.

Pain clinics specialize in the prevention, evaluation, diagnosis and treatment of painful disorders. Treatment may include prescribing medication, physical and rehabilitative services, teaching and performing pain-relieving procedures such as massage and meditation, and counseling patients and their families.

Just as physicians differ by specialty, so do pain clinics. Some offer residential programs, where you stay at the facility. Others have outpatient programs. Generally, programs include a team of health care professionals from the disciplines of psychology, medicine, nursing, physiotherapy, occupational therapy, pharmacy and vocational counseling.

Most pain clinics will review your medical records and perform a medical evaluation, which includes a complete medical history, a physical examination and possibly medical testing, such as x-rays, if appropriate.

To treat your pain symptoms, choose a pain center that:

• offers a wide range of treatments; massage, acupuncture and other options should be considered along with conventional therapies because a variety of choices offer better chances of successful pain relief.

• has health care professionals who are specialists in pain management and pain medicine. They should be Diplomates of the American Board of Pain Medicine or members of the American Pain Society or International Association for the Study of Pain.

• is staffed by caring, qualified people. If possible, get a list of references from the pain clinic of former or current patients. If possible, interview some of the staff—either in person or by phone

• includes physical therapy and exercise programs.

• is conveniently located.

• is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). CARF is a private, not-for-profit organization that accredits programs and services in adult day services, behavioral health, employment and community services and medical rehabilitation

A list of pain specialists who are Diplomates of the American Board of Pain Medicine is available from the American Board of Pain Medicine: abpm.org.

Common Pain-Causing Conditions

Women who feel they can do nothing to relieve their discomfort are more likely to be disabled by their pain and make more trips to a health care professional than those who feel they have some measure of control. Their lives may spiral to a point where daily routines revolve around their bed, the health care professional's office and the pharmacy.

Here are some typical health conditions that cause pain, along with some treatment options. Consultation with a health care professional is recommended for persistent nociceptive and neuropathic pain that doesn't subside.

Back Pain

The majority of back pain is muscular, caused by sprains, spasms and muscle imbalance. However, many women experience back pain during or before menstruation or during pregnancy.

Although it can be nagging (and even debilitating), most back pain clears up on its own. It can be eased or treated by modifying activity, using moist heat, such as hot showers and doing exercises that strengthen the abdominal muscles to provide more support for the back.

Other keys to back pain relief include:

• using over-the-counter (OTC) medications such as ibuprofen, acetaminophen or aspirin for mild or moderate symptoms

• applying a cold pack five to 10 minutes at a time within 24 hours after back symptoms start or using a heating pad or hot shower if symptoms last longer

• limiting bed rest to two to three days (prolonged bed rest weakens the back and hasn't been shown to be any more effective than shorter intervals)

• wearing comfortable, low-heeled shoes

• using a chair with lower back support and working at a comfortable height

• keeping objects close to your body when lifting

• exercising to keep your muscles flexible and strong

• controlling your weight

• avoiding prolonged sitting in cars, at desks, and in front of computers or televisions

If you experience numbness in your hands and feet, or if the pain worsens or doesn't respond to OTC pain relievers, consult a health care professional.

Knee injuries

If you are athletic, you may be more prone to certain types of injuries that cause pain, especially in the knee. Anterior cruciate ligament (ACL) injuries, for example, are common in women who play sports that involve stops and starts and quick turns, such as basketball, skiing, soccer and tennis. Both a sedentary lifestyle and a vigorous exercise program can aggravate weakened knees.

Managing knee or ligament pain is often the same as the treatment for relieving back pain:

• use OTC medications such as ibuprofen, acetaminophen or aspirin for mild or moderate symptoms

• use ice to reduce swelling

• rest

• avoid squatting and kneeling

• wear comfortable, low-heeled shoes

If pain shoots down your leg or is associated with numbness, weakness or tingling, see a health care professional.

Headaches

Muscle tension, stress, anxiety, sinus infections and allergies can cause headaches. Certain foods, weather changes, hormonal cycles and emotions can also cause headaches. Although headaches can't always be prevented, there are things you can do to reduce their frequency, including:

• sleeping and waking up at regular times

• not skipping meals

• maintaining a healthy lifestyle that includes eating a balanced diet and exercising

Over-the-counter analgesic medications, like acetaminophen, ibuprofen or aspirin, can help relieve occasional headache pain. OTC pain-relief medications generally are safe when taken as directed, but if you drink alcohol or have specific medical conditions, be sure to tell your health care professional when discussing how to manage your headache pain.

If you want an alternative to medication, relaxation techniques, such as biofeedback, can be useful alternatives to drugs for both preventing and relieving headaches.

Biofeedback is a learned skill and, with practice, it can help you relax deeply when pain increases. Biofeedback may be used to relax muscles, restore circulation and redirect attention from the source of pain.

Occasional headaches are examples of acute pain—they generally don't debilitate you. These types of headaches may be caused by lack of caffeine (if you generally use a lot of caffeine-containing products and for some reason decrease your intake), tension or unknown sources. These headaches typically respond to OTC medication and stress reduction.

Migraines

Migraines are more than headaches—they can be completely disabling. Lasting from hours to days, they may be accompanied by such symptoms as throbbing pain, nausea and visual symptoms, such as flashing lights, zigzag lines or partial loss of vision. Sensitivity to sound and smells can be another symptom experienced by migraine sufferers.

Up to 17 percent of women and six percent of men have experienced a migraine. Migraines are an example of neuropathic pain. These severe headaches are a biologically based disorder. Symptoms are the result of changes in brain chemistry; they are not caused by an inability to manage stress.

There are many types of migraines including: hemiplegic migraines, in which patients suffer temporary paralysis on one side of the body; ophthalmoplegic migraines, which cause pain around the eyes and is associated with a droopy eyelid, double vision and other sight problems; basilar artery migraines, which include vertigo, double vision and poor muscular coordination; menstrual migraines, which are caused by fluctuating hormone levels; and several others.

When discussing your migraines with your health care professional, ask these questions about your migraines and getting treatment for them:

• What can I reasonably expect from treatment?

• What drug and non-drug treatments do you recommend?

• Will I have to be on medication indefinitely?

• What are the possible triggers of my migraines?

• Could my migraines be a symptom of other illnesses? If so, what are they?

• Will they get worse or better as I get older?

• How can I alter my diet or lifestyle to reduce my migraines?

Infrequent migraines—occurring once or twice a month—are usually treated with a fast-acting, acute-type medication that responds to the headache once it has developed. This type of medication relieves head pain, nausea and sensitivity to bright light or sound.

Women who have migraines more frequently need a different strategy; a preventive medication is often recommended. If you have frequent headaches—two or more times a month—a daily medication aimed at preventing the migraine may be recommended. Migraine-specific analgesics, as well as antidepressants, which adjust serotonin levels, are often prescribed. Heart medications such as beta blockers and calcium channel blockers are commonly used for migraine relief. Sometimes seizure-controlling medications may be used to minimize migraine occurrences. The exact reason these drugs work is unclear. Your health care professional can advise you.

Triptans are one of the most commonly used class of drugs for migraines. These drugs act on the artery-constricting chemical serotonin. Another drug that provides relief of migraine symptoms is ergotamine, a drug that constricts blood vessels, helping to counteract the painful blood dilation stage of the headache. For optimal benefit, the drug is taken during the early stages of an attack.

Other drugs used to prevent migraine include:

• propranolol (Inderal), which stops blood vessel dilation

• amitriptyline, an antidepressant

• cyproheptadine, which counteracts serotonin

If you experience a headache unlike anything you've ever had or if you get a "thunderclap" headache that starts and becomes extremely intense within a few seconds or minutes, get medical attention immediately. You should also see a health care professional if there's a change in the character of a headache or if you experience new headache symptoms.

It is also common to have "rebound" headaches. These occur in people who have daily headaches and who take medications, even OTC medications such as aspirin, acetaminophen and ibuprofen, regularly because they seem to provide relief. In actuality, this constant cycle of medication is causing the next headache. Frequently, stopping all medications for about two weeks or gradually reducing the dose until you're taking the drug no more than twice a week gets rid of rebound headaches. Also, the NSAIDS, including the COX-2 inhibitor Celebrex, do not cause rebound headaches, whereas other analgesics and the triptans do. So you shouldn't take any medication more than two days per week. If this doesn't relieve the headache, see a headache specialist.

Arthritis

Arthritis, one of the more prevalent chronic health problems, affects more women than men, according to the Arthritis Foundation. The term arthritis comprises more than 100 diseases that affect the joints, causing pain, loss of movement and sometimes swelling.

Two types of arthritis include osteoarthritis and rheumatoid arthritis.

Osteoarthritis

Osteoarthritis is the most common form of arthritis. It is the source of pain for more than 21 million Americans, and it affects women more than men, according to the Arthritis Foundation. The main symptom is stiffness and achiness in the joints, especially first thing in the morning, or after using a joint for a long time. The hips, knees, back and fingers (especially closest to the tip), are the joints most likely affected.

Osteoarthritis usually begins in women between the ages of 45 and 60 and develops slowly over a year or more. Most commonly, osteoarthritis begins in joints on one side of the body and affects only some joints. Unlike other forms of arthritis, it doesn't cause inflammation or nausea.

Other risk factors include a family history of osteoarthritis, being overweight, joint injury or overuse and inactivity, which causes joints to lose flexibility and weakens supporting muscles.

Treatment options for osteoarthritis include OTC acetaminophen and NSAIDs, the prescription Cox-2 inhibitor Celebrex, topical creams such as capsaicin, use of hot and cold, lidocaine patches, exercise, weight loss, and in extreme cases, joint replacement surgery. Acetaminophen is less likely than aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) to irritate your stomach, and acetaminophen causes fewer negative drug interactions than NSAIDs, a consideration for older women who may take a variety of medications. However, long-term use of acetaminophen may be associated with liver damage or inflammation of the kidneys (nephritis). It's important to ask your health care professional for safety information associated with pain relievers with your personal health history in mind.

In terms of exercise, be sure to avoid high-impact activities, such as jogging; instead, try walking, swimming and biking. Walking is especially good, because it helps keep bones strong. Don't forget to stretch, to keep joints flexible.

Losing weight can make a significant difference in pain caused by osteoarthritis. Excess body weight stresses joints, making osteoarthritis pain worse.

Joint replacement surgery is recommended only for severe, disabling osteoarthritis that interferes with your ability to carry out ordinary activities, such as dressing, bathing or climbing stairs.

Rheumatoid Arthritis

More than 2.1 million Americans have rheumatoid arthritis (RA), and most of them are women; in fact, women are two to three times more likely to have the disease as men. RA generally affects women in their 40s and 50s, but can strike women in their 20s and even children. It is an autoimmune disease,a disease in which the immune system attacks healthy tissues. Lupus, arthritis, scleroderma, Sjögren's syndrome and insulin-dependent diabetes are examples of autoimmune diseases. RA is characterized by the inflammation of the membrane lining of the joint, called the synovium. Inflammatory cells release enzymes that may digest bone and cartilage.

Many people confuse osteoarthritis and rheumatoid arthritis. Although both are more common in women than in men, osteoarthritis may appear as early as age 40 but usually does not develop until age 55 or 60. Osteoarthritis only affects joints and not internal organs. Rheumat