SECTION 7: PAIN

MS may be associated with a variety of symptoms characterized as "pain." In addition to the types of pain experienced by everyone - with or without MS - some types of pain are directly related to the MS process itself. Other pain may be the result of the physical effects of MS, such as the stress on joints produced by problems such as imbalances associated with walking difficulties. More than 50 percent of all people with MS will experience pain in one form or another during the course of their disease. A recent Canadian study indicated that pain is the second most common symptom of MS, with fatigue being the most common.

A. DYSESTHESIAS

Dysesthesias are types of pain that are experienced as a burning or aching sensation. They are the most common types of pain seen in MS. The most frequently prescribed drugs used to treat this type of pain were originally developed as anti-seizure medications or antidepressants.

PHARMACOLOGIC MANAGEMENT

Anti-Seizure Agents
including Neurontin® (gabapentin), Tegretol® (carbamazepam), and Keppra®(levetiracetam)

Please refer to the Spasticity section for details on these oral medications.

Anti-Anxiety Agents
including Cymbalta ® (duloxetine hydrochloride), Valium® (diazepam), and Klonopin®(clonazepam)

Please refer to the Spasticity, Depression, and Anxiety sections for details on these oral medications.

Tricyclic Antidepressants
including Elavil® (amitriptyline), Pamelor®(nortriptyline), and others

Please refer to the Depression section for details on these oral medications.

Dilantin®(phenytoin)

This is an oral medication in tablet form. The dose normally ranges from 100 to 400 mg per day. Dilantin is an anti-seizure medication that is commonly used to manage the pain of trigeminal neuralgia, but it may be helpful for other pain conditions as well.

Side effects include dizziness, drowsiness, and balance problems.

Lyrica®(pregabalin)

This is an oral medication in tablet form. The dose normally ranges from 150 to 600 mg per day.

This agent was approved by the FDA in 2004 for the treatment of neuropathic pain associated with diabetes, fibromyalgia, and certain types of seizures. It has not specifically been approved for MS, but has proven effective for many people.

Side effects include drowsiness, constipation, and balance problems.

B. TRIGEMINAL NEURALGIA

Trigeminal neuralgia is a "lightning-like" stabbing pain in the face. It is the result of damage to the trigeminal nerve, which innervates (provides the nerve supply to) the side of the face.

PHARMACOLOGIC MANAGEMENT

Trigeminal neuralgia can usually be treated with medications such as anti-seizure agents.

Neurontin® (gabapentin), Tegretol® (carbamazepine), and Dilantin®(phenytoin)

Please refer to the Spasticity and Pain sections for details on these anti-seizure medications.

SURGICAL MANAGEMENT

Surgical procedures to reduce pressure on the trigeminal nerve are possible in some situations.

C. LHERMITTE'S SIGN

Lhermitte's sign is a brief, stabbing pain that occurs when the neck is bent forward. It moves from the head down the spine, and usually lasts for less than a second. It may go away without specific treatment, as inflammation in the spinal cord decreases with other types of treatment or simply over time.

NON-PHARMACOLOGIC MANAGEMENT

Soft neck collar

A soft neck collar is often used to prevent the forward movement that triggers the pain.

PHARMACOLOGIC MANAGEMENT

Medications such as anti-seizure drugs may help to prevent the pain. Pharmacalogic treatment is usually accompanied by physical therapy.

D. BACK AND OTHER MUSCULOSKELETAL PAIN

Back and other musculoskeletal pain in MS can have many causes, including spasticity. Pressure on the body caused by immobility, incorrect use of mobility aids, or the struggle to compensate for gait and balance problems may all contribute. An evaluation to pinpoint the source of the pain is essential.

NON-PHARMACOLOGIC MANAGEMENT

A variety of strategies may prove helpful in managing musculoskeletal pain. These may include heat, massage, ultrasound, physical therapy, and treatment for spasticity. A variety of relaxation techniques have proved helpful, as have acupressure and acupuncture.

PHARMACOLOGIC MANAGEMENT

Tylenol® (acetaminophen), or non-steroidal anti-inflammatory drugs (NSAIDs) such as Advil ®(ibuprofen), may be helpful in managing a variety of types of musculoskeletal pain. Individuals taking these pain relievers should check with their doctor and be sure to follow prescribing instructions. Too much of these medications can cause serious Side effects , including liver damage.

COMPLEMENTARY AND ALERNATIVE MEDICINE THERAPIES

Acupuncture

Acupuncture has been studied as a possible therapy for a number of MS symptoms. Pain is the one symptom that has shown a consistent positive response to this approach, and it may be effective when provided by an experienced practitioner. The technique involves inserting and manipulating fine needles in specific points on the body. According to traditional Chinese medical theory, acupuncture points are located along meridians through which chi (vital energy) flows. There is no known anatomic basis for the existence of acupuncture points or meridians, but the technique may work in certain specific situations.

Acupressure

Acupressure is essentially a variation of acupuncture, but involves applying physical pressure to acupuncture points. As with acupuncture, the points to which pressure is applied may or may not be in the same area of the body as the targeted symptom.

Guided Imagery

Guided imagery is a meditative process focused on self-healing, relaxation, and self-awareness. It is a relaxation technique that is based on the concept that the mind and body function as a single entity, and may help manage stress and reduce tension.

Biofeedback

Biofeedback involves measuring bodily functions such as blood pressure, heart rate, skin temperature, sweat gland activity, and muscle tension. In theory, this ultimately allows you to increase your conscious control of what are normally unconscious physiologic activities. By providing you with information about physiologic functions that are normally not perceived at a conscious level, it is believed by some to allow people to achieve control over these functions.

Yoga and Tai Chi

Both yoga and tai chi are based on traditional Asian medicine, and both have been shown to be of significant value in managing MS by allowing individuals to increase strength, flexibility and balance. Several excellent books and videos are available that can help people develop a program that will assist in an overall management program for MS.

Cannabis

The use of cannabis (marijuana) is illegal in the United States and cannot be recommended. Additionally, there have been reports of adverse cognitive effects on people with MS.