Dr Tadhg Lynch

Consultant Pain Specialist, Kilkenny and Dublin

Most people will in fact experience an episode of severe pain at some point in their life. For example, for 20% of adults[1], this pain is persistent and associated with loss; loss of function, identity, in some cases mental health, and in many, loss of the life they had.

Prevalence rates for Irish people suffering with chronic pain range from 13–35.5% of the population[2]. Furthermore, access to pain treatment is a fundamental human right and society needs to act collectively to provide integrated, multidisciplinary, evidenced-based care to pain sufferers.

What is chronic pain?

Chronic pain persists longer than three months, either continually or episodically and has no useful function. It can be a result of an injury, an ongoing pathology (e.g. arthritis), involvement of the nervous system (e.g. post herpetic neuralgia (shingles)) or from an unknown or uncertain cause (e.g. fibromyalgia).

Many people in Ireland suffer with severe chronic pain that in general can affect their work, daily activities and relationships. It has a huge both personal and societal impact.

Access to treatment is a fundamental human right

Access to treatment is a fundamental human right since the Declaration of Montreal (2010). We know that pain is the primary reason people seek help from healthcare providers and is the main complaint in general practice, pharmacy practice and in the emergency room.

Who treats Chronic Pain?

Generally speaking chronic pain is often challenging to treat and general practitioners are usually the first doctors to treat pain in patients.

Patients may be referred to:

• An orthopaedic surgeon with joint pain
• A rheumatologist with inflammatory or autoimmune associated pain
• A neurologist with neurological issues such as migraine/headache
• A spinal surgeon due to neck, back or radiating pain like sciatica.
• A consultant pain specialist or a pain clinic for chronic pain management.

What treatment is available for chronic pain?

Patient-centred care include for example medication, diagnostic and therapeutic  minimally-invasive procedures, and multidisciplinary care including physiotherapy and psychological therapy.

A patient who has persistent and severe pain, that has not responded to or is not suitable for surgery or medical treatment by other specialists, should in that case be referred to a pain specialist.

To clarify, pain specialists are consultant medical doctors. Their training and qualifications are approved by the Faculty of Pain Medicine of the College of Anaesthesiology.

Pain self-management

A pain self-management programme can help patients develop tools to enjoy life, such as pain education, medication management, activity pacing, graduated exercise and psychological tools including cognitive behavioural therapy, relaxation techniques and others.

Diet and nutrition advice from a dietitian and work and activity advice from an occupational therapist can also be very helpful.

Under-resourced

However, unfortunately Irish pain treatment’s under-resourced. For example, with prolonged waiting times for sufferers to gain access to specialised pain clinics. [3].

Pain healthcare annually costs €5.34 billion (or 2.86% of GDP) in Ireland.[4]. This poses a markedly significant burden on the individual and on the economy.

[1] Breivik et al., 2006; Raftery et al., 2011 | [2] Breivik et al. 2006 | [3] Fullen et al., 2006 | [4] Raftery et al., 2012

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Physiotherapists commonly encounter people with migraine and neck pain. In fact, more than three quarters of people with migraine experience neck pain. This is due to anatomical connections between upper neck nerves, and nerves from the head and face.

The physiotherapist will ask questions about your neck pain and migraine. Similarly. they will use hands-on assessment to determine if the neck stiffness and pain may be a potential migraine trigger.

Neck pain may be one trigger of many

The treatment of migraine is unique. The physiotherapist will take into account that your neck will only ever be one trigger of many. The management of neck-related symptoms in migraine usually involves hands-on treatment and exercises. However, all other triggers and lifestyle factors such as hormonal changes, sleep patterns, stress, skipping meals, and dehydration, obesity and not exercising need to be recognised and managed for overall successful migraine management.

Keeping a migraine diary can pinpoint triggers

A physical assessment will raise the physiotherapist’s suspicion that the neck may be acting as a trigger, but it is only through a trial of treatment that the physiotherapist will be sure.

The best thing to do is to keep a detailed headache and migraine diary for at least one month before you start physiotherapy, and then to continue to record your symptoms during your treatment. If there is no significant change in the number of days you are getting headache or the severity of your symptoms, then physiotherapy is not working for you.

Focusing on lifestyle changes and medication is often an essential addition to treatment, and again a detailed diary will show the areas of management that are most beneficial.

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Dr Mary Kearney

GP and co-author of the Migraine Quick Reference Guide

Doctors often see headache disorders, with migraine being one of the most common. For this reason, it is estimated to cost the Irish economy €252 million a year[1]. A migraine diary can be hugely beneficial to patients and their healthcare providers.

Dr Ruttledge, Dr Mary Kearney and Ms Esther Tomkins co-authored The ICGP Migraine Quick Reference Guide. In fact, this reference guide was developed to “help give doctors a greater understanding of migraine, and improved tools in the assessment of headaches which will help them identify cause of headache,” says GP Dr Mary Kearney.

The peak prevalence is for women between the ages of 15-49 years. Additionally, the life-time prevalence is 42% in females[2]. Some patients experience relatively infrequent attacks during their lifetime, while the average patient gets one to two attacks per month. Additionally, approximately 10% of all patients get weekly attacks.

The diary should include, at the least, symptoms, duration, severity, medication taken and its effect for each attack.

Underdiagnosed and undertreated

Furthermore “migraine is a very common and often debilitating neurological disorder. Although sadly, doctors and healthcare professionals worldwide underdiagnosed/undertreated migraine.” says Dr Martin Ruttledge, Consultant Neurologist at Beaumont Hospital.

At the launch of the ICGP Migraine Quick Reference Guide, Dr Ruttledge said: “Our statistics are getting worse and worse as time goes on. We think there’s probably about three quarters of a million migraine patients in Ireland”. It was co-authored by which was co-authored by Dr Ruttledge, Dr Mary Kearney and Ms Esther Tomkins.

The more detailed the diary, the better

“When a patient presents to a general practitioner with recurrent headaches, they should be advised to keep a detailed daily diary. However, ensure that these include details about the severity of the headaches, associated features, acute treatments used, effect on lifestyle and possible triggers.” ICGP Migraine Quick Reference Guide says.

Furthermore, this provides very useful clinical information and can help confirm the diagnosis. In addition, the diary often demonstrates the benefits of acute and/or other therapies. In short, the diary should include, at the least, symptoms, duration, severity, medication taken. Similarly it’s to reference its effect for each attack.”[3]

Generally speaking, Dr Ruttledge concludes. “It’s all about just sitting and talking to the patients”.

[1] Steiner TJ, Stovner LJ, Vos T, Jensen R, Katsarava Z. Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain 2018 Feb 21; 19(1):17-018-0846-2.
[2] Frederick IO, Qiu C, Enquobahrie DA, Aurora SK, Peterlin BL, Gelaye B, et al. Lifetime prevalence and correlates of migraine among women in a pacific northwest pregnancy cohort study. Headache 2014 Apr; 54(4):675-685.
[3] Migraine Diagnosis & Management from a GP Perspective Quick Reference Guide

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A focus on the importance of understanding your pain, with its impact on your life; and therefore the role of the physiotherapist in implementing coping strategies to help manage your pain.

Everyone has an understanding of pain, which is usually based on our own experiences, the experiences of those close to us, as well as ideas and information we get from wider society. When it comes to pain we often have a clear expectation of how much an injury or impact should hurt, where we should feel it and long it should last.

However, for many people this expectation is not met and pain does not behave they way we expect.

The cost of persistent pain on Irish society

There are a rare few people who are born insensitive to pain which can lead to an accumulation of injuries and problems that as a result in some cases can reduce life expectancy.

For a much larger group of people pain can become a constant feature in their lives by and large arriving without warning, affecting many areas of their body and lasting for a long time. This type of pain is called persistent pain and in Ireland a 2008 study found that over 20% of the population have had persistent pain for over 10 years.

Persistent pain has a huge impact on peoples’ lives affecting their mood, work, family relationships and moreover finances. It is also a very costly problem for the health service with the the same 2008 study estimating the total cost of persistent pain at €4.7bn per year, which at the time was 2.55% of GDP.

Learning how to manage your condition

We now know that pain is multimodal with a number of factors affecting our experience. The complexity of persistent pain as a condition can seem like the greatest hurdle in both assessing people looking for help with their pain, and working with them to improve their symptoms.

However, our understanding of how the body works in relation to how we experience pain is developing all the time. This new understanding is placing neuroscience education for people in pain as a core part of recovery. Allied to this are developments in exercise physiology and prescription in persistent pain. Along with management strategies for mood and sleep, these strategies offer a solid platform upon which to base recovery. Physiotherapists also play an important role in helping people with persistent pain.

A multi-disciplinary approach to treating your pain

The best framework to understanding and managing persistent pain is the bio-psychosocial framework. By understanding this very complex condition from a biological, psychological and social perspective we have the best chance of planning a successful recovery.

Acknowledging this complexity is very important because, in my opinion, there are usually no quick fixes for persistent pain; there are slower paced solutions, which involve planning and teamwork between the physiotherapist and the person in pain.

Implementing pain management strategies with your physiotherapist

The role of a physiotherapist is to listen to the person in front of them and identify the factors affecting the person in pain. Using their knowledge of pain biology, exercise, goal setting and problem solving a physiotherapist can help the person in pain understand their condition and develop a recovery plan.

It is important for a physiotherapist to explain the significance of the many tests and scans people may have had, ensuring that the management plan in place is the right one. Developing fitness, education and management strategies take time for people in all walks of life and it is no different for those suffering with persistent pain. A strong relationship between the person in pain and the physiotherapist is key to a positive outcome.

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Life with chronic pain can worsen our mental health; and in turn, poor mental health can worsen our perception of pain.

“Chronic pain can impact every facet of everyday life resulting in low self-esteem and loss of meaning. Patients often question what this new life with chronic pain will look like. Research shows a high comorbidity of chronic pain with depression and anxiety, but one, often overlooked issue, is grief. 

Many of those we support mention what they ‘used to’ be able to do and compare life with chronic pain with life before. For example, “Well, I was always the one everyone came to for help. How will I ask them?”, or, ”I used to be able to weed the whole garden, but now I can only manage 10 minutes, then I can’t do anything else for the rest of the day”.

There are huge losses associated with any chronic pain or health condition. Loss of hopes and dreams of the future. Similarly loss of identity or role in the family or at work. This loss of physical capacity and dignity are just a few.

While treating the physical problem is usually the main approach, life with chronic pain is complex and usually involves a psychological component. Often, what patients hear is that it’s, ‘all in their head’.

But what we think and feel impacts how we perceive pain, and life with chronic pain will impact our mental health. It’s vital that anyone with chronic pain addresses their mental health and allows themselves the time to grieve and adjust to life with a chronic condition. 

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The importance of pharmacists working with patients, doctors and hospital pain teams to ensure the most suitable pain care treatment pathway.

Pharmacists have a central role in counselling and educating patients in pain management. When pain killers are taken correctly, they can provide a useful option for responsibly managing pain. Pharmacists are experts in medicines. They are one of the first ports of call should be your local pharmacy if you are experiencing pain.

The ‘Pain Ladder’ recommends that patients always begin with the lowest form of appropriate pain-relief for the shortest amount of time for their symptoms in order to reduce the incidence of side effects and dependence, for example a simple paracetamol in the first instance.

Pharmacists can advise on pain relief medication

Pharmacists can provide advice on the strength and type of painkiller that is best for you. Depending on the type of pain you are experiencing.

They can also provide advice on your condition, the directions for use, the recommended dose, the precautions for use, if it is suitable with your current medicines and when the product should not be taken for both over the counter and prescription medicines.

Your pharmacist can help if you are not experiencing any relief from your symptoms after a number of days. Or, if you are experiencing side effects from taking painkillers you can revisit your pharmacist who will recommend a suitable alternative or refer you to the doctor.

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“I’ve found that many people see migraine as a ‘female condition’. While it is more prevalent in women (8:1 ratio), men do suffer migraine and it has an equally debilitating effect on our lives. Some individuals have even said quite disapproving things to me about it, basically questioning my manliness.”

“There are friends in my life who simply do not understand. By a comment or look you sort of know that is one barrier that won’t ever come down.”

The migraine aura makes me feel nauseous just to think of

“In my younger days, the migraine aura looked like a colourful version of ‘TV static’ – flickering, colourful snowy blotches that I would see in my peripheral vision. In adulthood, it more accurately resembles zigzag, pulsating lines, expanding from the centre of my vision outwards. Just thinking about it here is making my stomach feel sick. It’s absolutely horrible.

“Once a migraine has set in, the pain is so bad, I can only text, ‘Migraine’ if people try to get in touch. Then it’s several hours of nausea and vomiting.”

Teenage hormones can increase the intensity and frequency of migraines

“The years between ages 7-15 were the worst of my life in terms of migraine attacks. Very few people understood what I was going through, which caused a lot of additional stress. In hindsight, I realise, I was depressed.”

Even onions can trigger a migraine!

“Triggers for me include extreme changes of weather or barometric pressure, humidity, lack of routine, long gaps between meals, dehydration and, bizarrely, the smell of onions.

“Thankfully, I’ve had fewer severe migraines since 2017.”

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“I’ve suffered ‘headaches’ since I was about three years old. I used to complain to my mother about pains in the back of my head. It was alarming for her since I was so young and, being adopted, I had no family medical history to work with.”

“In my early 20s, I contacted my birth family and discovered a strong genetic link to migraine. It was only then that I was formally diagnosed at the Migraine Clinic in Beaumont Hospital. The wait to access this clinic was over a year at the time, but the care I received there was second to none. And once you’re in the system, it seems easier to access follow-up care.”

There seems to be a migraine-shaped gap in GPs’ knowledge

“Unfortunately, many GPs seem either uninterested or uneducated about the finer aspects of migraine. It leaves many patients in the dark about the condition in general and how to manage it.

“Organisations like The Migraine Association of Ireland (MAI) are vital to help sufferers understand more about the condition. They also connect with others who can give hints and tips on how best to manage your migraines.

“I now have a really good GP who helps me manage with prophylactic and acute treatments, but migraine sufferers desperately need more migraine clinics made available to them. And there definitely needs to be more neurologists who have an interest in migraine in public hospitals – all over the country.”

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“Fear, panic, nausea, numbness and throbbing pain. For me: what my first migraine felt like.”

“It took me a long time to understand the connection between the mind and the body, and how it can help me deal with my migraines. I’ve battled with intense anxiety for most of my life, but I’ve learned to manage it with counselling and yoga. The knock-on effect this has had on my migraine has been hugely beneficial.”

You have no control when a migraine hits

“You have very little – if any – control of when a migraine will strike. You could be in work, driving or in a social setting. That would immediately make me panic: ‘How will I cope? How will I get home? What about the task I need to finish for work? My anxiety raced all the while my body was trying to process the migraine itself.”

My migraine routine

“However, many migraines later, I’ve managed to level off my fear at the onset of attacks with a ritual that I stick to.

“Once I feel the visual aura starting, I immediately take my medication. I get plenty of water and find as quiet and private a space as possible. Once I’ve managed this much, I sit down, close my eyes and very simply try to breathe deeply in and out.

“I reassure myself, sip water, and just breathe to distract myself as much as possible from the physical symptoms. Once my mind is calm I find that I’m far better equipped to manage the migraine itself.

“Although focusing your attention away from the physical symptoms is challenging, with practice it can become a powerful skill and one I definitely recommend integrating into in the battle against migraine.”

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