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article is from the WebMD Feature
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article is from the WebMD Feature
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PAIN and Multiple Sclerosis
When
most people think of multiple sclerosis, they think of a disease that causes
symptoms of weakness and motor problems — not pain.
most people think of multiple sclerosis, they think of a disease that causes
symptoms of weakness and motor problems — not pain.
“About
10 or 20 years ago, there was a saying that MS causes all kinds of trouble but
doesn’t cause pain, which really isn’t true,” says Francois Bethoux, MD,
director of rehabilitation services at the Mellen Center for Multiple Sclerosis
Treatment and Research at The Cleveland Clinic.
10 or 20 years ago, there was a saying that MS causes all kinds of trouble but
doesn’t cause pain, which really isn’t true,” says Francois Bethoux, MD,
director of rehabilitation services at the Mellen Center for Multiple Sclerosis
Treatment and Research at The Cleveland Clinic.
“In
a national survey of more than 7,000 MS patients, 70% of them had experienced
some kind of pain, and at least 50% were experiencing some kind of pain at the
time of the survey,” Bethoux says.
a national survey of more than 7,000 MS patients, 70% of them had experienced
some kind of pain, and at least 50% were experiencing some kind of pain at the
time of the survey,” Bethoux says.
The
National Multiple Sclerosis Society reports that almost half of all people with
MS are troubled by chronic pain.
National Multiple Sclerosis Society reports that almost half of all people with
MS are troubled by chronic pain.
MS pain
differs from the kind of pain you might get with a headache, a joint injury, or
muscle strain. “It’s often more diffuse, affecting several areas of the
body at a time. It often changes over time, getting worse or better for no
apparent reason. It tends to fluctuate a lot,” says Bethoux. “People
often find it hard to describe: It’s sometimes described as like a toothache,
other times like a burning pain, and sometimes as a very intense sensation of
pressure. It’s very distressing for patients because they have a hard time
explaining what their pain experience is.”
differs from the kind of pain you might get with a headache, a joint injury, or
muscle strain. “It’s often more diffuse, affecting several areas of the
body at a time. It often changes over time, getting worse or better for no
apparent reason. It tends to fluctuate a lot,” says Bethoux. “People
often find it hard to describe: It’s sometimes described as like a toothache,
other times like a burning pain, and sometimes as a very intense sensation of
pressure. It’s very distressing for patients because they have a hard time
explaining what their pain experience is.”
So
what’s causing this baffling, complex, often debilitating pain? Bethoux
describes it as “an illusion created by the nervous system.”
Normally, he explains, the nervous system sends pain signals as a warning
phenomenon when something harmful happens to the body. “It’s a natural
defense mechanism telling us to avoid what’s causing the pain,” he says.
“But in MS, the nerves are too active and they send pain signals with no
good reason — they’re firing a pain message when they shouldn’t be.”
what’s causing this baffling, complex, often debilitating pain? Bethoux
describes it as “an illusion created by the nervous system.”
Normally, he explains, the nervous system sends pain signals as a warning
phenomenon when something harmful happens to the body. “It’s a natural
defense mechanism telling us to avoid what’s causing the pain,” he says.
“But in MS, the nerves are too active and they send pain signals with no
good reason — they’re firing a pain message when they shouldn’t be.”
Some of the most common types
of pain experienced by multiple sclerosis patients include:
of pain experienced by multiple sclerosis patients include:
Acute MS pain. These come on suddenly and
may go away suddenly. They are often intense but can be brief in duration. The
description of these acute pain syndromes are sometimes referred to as burning,
tingling, shooting, or stabbing.
may go away suddenly. They are often intense but can be brief in duration. The
description of these acute pain syndromes are sometimes referred to as burning,
tingling, shooting, or stabbing.
Trigeminal
neuralgia or “tic doloureux.” A stabbing pain in the face that can be
brought on by almost any facial movement, such as chewing, yawning, sneezing,
or washing your face. People with MS typically confuse it with dental pain.
Most people can get sudden attacks of pain that can be triggered by touch,
chewing, or even brushing the teeth.
neuralgia or “tic doloureux.” A stabbing pain in the face that can be
brought on by almost any facial movement, such as chewing, yawning, sneezing,
or washing your face. People with MS typically confuse it with dental pain.
Most people can get sudden attacks of pain that can be triggered by touch,
chewing, or even brushing the teeth.
Lhermitte’s sign. A brief, stabbing,
electric-shock-like sensation that runs from the back of the head down the
spine, brought on by bending the neck forward.
electric-shock-like sensation that runs from the back of the head down the
spine, brought on by bending the neck forward.
Burning,
aching, or “girdling” around the body. This is called dysesthesia by
physicians.
aching, or “girdling” around the body. This is called dysesthesia by
physicians.
There
are also some types of pain related to MS that are described as being chronic
in nature — lasting for more than a month — including pain from spasticity
that can lead to muscle cramps, tight and aching joints, and back or
musculoskeletal pain. These chronic pain syndromes can often be relieved by
anti-inflammatory drugs, massage, and physical therapy.
are also some types of pain related to MS that are described as being chronic
in nature — lasting for more than a month — including pain from spasticity
that can lead to muscle cramps, tight and aching joints, and back or
musculoskeletal pain. These chronic pain syndromes can often be relieved by
anti-inflammatory drugs, massage, and physical therapy.
Anticonvulsant
Drugs Offer Relief
Drugs Offer Relief
Anticonvulsant
Drugs Offer Relief
Drugs Offer Relief
For the
most part, however, acute MS pain can’t be effectively treated with aspirin,
ibuprofen, or other common OTC pain reliever medications or treatments.
“Since most MS pain originates in the central nervous system, it makes it
a lot more difficult to control than joint or muscle pain,” says Kathleen
Hawker, MD, an assistant professor of neurology in the multiple sclerosis
program at the University of Texas Southwestern Medical Center in Dallas
(UTSW).
most part, however, acute MS pain can’t be effectively treated with aspirin,
ibuprofen, or other common OTC pain reliever medications or treatments.
“Since most MS pain originates in the central nervous system, it makes it
a lot more difficult to control than joint or muscle pain,” says Kathleen
Hawker, MD, an assistant professor of neurology in the multiple sclerosis
program at the University of Texas Southwestern Medical Center in Dallas
(UTSW).
So
what’s the alternative? In many cases, the treatment of choice is one of a
range of anticonvulsant medications, such as Neurontin and Tegretol. “The
main thing that links them all up is that we’re not quite sure how they work —
either for seizures or for pain,” says Hawker. Since the FDA hasn’t
officially approved these anticonvulsants for the treatment of pain, they’re
all being used “off-label,” but Neurontin, for example, is prescribed
five times more often for pain than for seizures, says Hawker.
what’s the alternative? In many cases, the treatment of choice is one of a
range of anticonvulsant medications, such as Neurontin and Tegretol. “The
main thing that links them all up is that we’re not quite sure how they work —
either for seizures or for pain,” says Hawker. Since the FDA hasn’t
officially approved these anticonvulsants for the treatment of pain, they’re
all being used “off-label,” but Neurontin, for example, is prescribed
five times more often for pain than for seizures, says Hawker.
“In
the vast majority of patients, these medications do work,” says George
Kraft, who directs the Multiple Sclerosis Rehabilitation, Research, and
Training Center and the Western Multiple Sclerosis Center at the University of
Washington in Seattle. “There’s a problem, though, in that most of them
can make people sleepy, groggy, or fatigued, and MS patients have a lot of
fatigue anyway.”
the vast majority of patients, these medications do work,” says George
Kraft, who directs the Multiple Sclerosis Rehabilitation, Research, and
Training Center and the Western Multiple Sclerosis Center at the University of
Washington in Seattle. “There’s a problem, though, in that most of them
can make people sleepy, groggy, or fatigued, and MS patients have a lot of
fatigue anyway.”
The
good news: Most pain in MS can be treated. There are more than half a dozen of
these anticonvulsants, and they all have a slightly different mechanism of
action and different side effects. The side effects of these drugs can also
include low blood pressure, possible seizures, and dry mouth. They can also
cause some weight gain.
good news: Most pain in MS can be treated. There are more than half a dozen of
these anticonvulsants, and they all have a slightly different mechanism of
action and different side effects. The side effects of these drugs can also
include low blood pressure, possible seizures, and dry mouth. They can also
cause some weight gain.
Anticonvulsant
Drugs Offer Relief continued…
Drugs Offer Relief continued…
“Some
drugs are so similar to each other that if one drug in the class fails, another
is unlikely to work,” says Hawker. “That’s not the case with these.
Which one you use for which patient depends on the side effect profile.”
drugs are so similar to each other that if one drug in the class fails, another
is unlikely to work,” says Hawker. “That’s not the case with these.
Which one you use for which patient depends on the side effect profile.”
Finding
the right anticonvulsant is all about trial and error, says Bethoux.
“We’ll start them at the lowest possible dose of one medication and
increase it until the person feels comfortable or until side effects aren’t
tolerable. If one medication doesn’t work, we’ll try another,” he says.
“It’s a process that can take a long time, but it’s the only way we have
to do this.”
the right anticonvulsant is all about trial and error, says Bethoux.
“We’ll start them at the lowest possible dose of one medication and
increase it until the person feels comfortable or until side effects aren’t
tolerable. If one medication doesn’t work, we’ll try another,” he says.
“It’s a process that can take a long time, but it’s the only way we have
to do this.”
New
Frontiers in Treatment
Frontiers in Treatment
Some
patients, however, still haven’t found the right drug and the right dosage to
control their pain. “About 1% to 2% of patients have extremely refractory
pain that’s very hard to manage,” says Kraft. So MS experts are still
looking for options to add to their treatment arsenal.
patients, however, still haven’t found the right drug and the right dosage to
control their pain. “About 1% to 2% of patients have extremely refractory
pain that’s very hard to manage,” says Kraft. So MS experts are still
looking for options to add to their treatment arsenal.
One
intriguing possibility: Botox. The anti-wrinkle injections popular with Park
Avenue socialites have shown promise in helping to control some types of MS
pain. Botox, which acts locally to temporarily paralyze a nerve or muscle, has
been used for years at some multiple sclerosis clinics, including Hawker’s, to
manage spasticity and bladder problems. “Serendipitously, we found that it
also seemed to have an effect on pain,” she says. “It’s far from
being a known treatment for pain in MS at this point, but it’s an exciting
possibility.”
intriguing possibility: Botox. The anti-wrinkle injections popular with Park
Avenue socialites have shown promise in helping to control some types of MS
pain. Botox, which acts locally to temporarily paralyze a nerve or muscle, has
been used for years at some multiple sclerosis clinics, including Hawker’s, to
manage spasticity and bladder problems. “Serendipitously, we found that it
also seemed to have an effect on pain,” she says. “It’s far from
being a known treatment for pain in MS at this point, but it’s an exciting
possibility.”
UTSW,
along with two other centers, will soon be launching a small study involving
about 40 patients with MS to assess whether Botox can indeed relieve the
stabbing pain of trigeminal neuralgia. “There are no systemic side effects,
only mild local facial weakness. The biggest drawback is that you can only
inject it in a limited area, so even if we do find that it’s effective against
MS pain, Botox will certainly not replace any of the medications we currently
have. But it may be used in very specific conditions like trigeminal
neuralgia,” Hawker says.
along with two other centers, will soon be launching a small study involving
about 40 patients with MS to assess whether Botox can indeed relieve the
stabbing pain of trigeminal neuralgia. “There are no systemic side effects,
only mild local facial weakness. The biggest drawback is that you can only
inject it in a limited area, so even if we do find that it’s effective against
MS pain, Botox will certainly not replace any of the medications we currently
have. But it may be used in very specific conditions like trigeminal
neuralgia,” Hawker says.
……..
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