Treatments for MS Pain
Pain in multiple sclerosis is treated in a variety of ways, depending on the type and cause of the pain. Pharmaceutical management can include anti-seizure, anti-spasticity, anti-anxiety, antidepressant, and anti-pain medications. Complementary and alternative medicine (CAM) therapies such as acupuncture, acupressure, guided imagery, biofeedback, yoga, and tai chi may also help to relieve pain associated with MS.
Treatments for Specific Types of MS Pain
Treating Neurogenic Pain
This type of pain lies within the axons (nerves) of the CNS that are either inflamed or are malfunctioning after the protective layer of myelin has been damaged. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen usually won’t work well on this type of pain. The over-stimulated nerves need to be calmed, and this may best be accomplished with anti-epileptic drugs, tricyclic antidepressants, and antispasticity drugs, to treat painful spasticity and spasms.
Topical medications such as lidocaine gel or Zostrix® (capsaicin topical analgesic) may help reduce the burning and tingling. Optic neuritis is often treated with steroids to reduce the inflammation of the optic nerve. Non-pharmaceutical strategies may help to reduce the perceived severity of the pain.
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 multiple sclerosis. The most frequently prescribed drugs used to treat this type of pain were originally developed as anti-seizure medications or antidepressants.
Pharmaceutical (with Medication) Management
- Anti-Seizure Agents, including (first-line, newer drugs) Neurontin® (gabapentin) and Lyrica® (pregabalin); (second-line) Tegretol® (carbamazepam) and Dilantin® (phenytoin)
- Anti-Anxiety Agents, including Cymbalta® (duloxetine hydrochloride) and Klonopin® (clonazepam)
- Tricyclic Antidepressants, including Elavil® (amitriptyline), Pamelor™ (nortriptyline), Norpramin® (desipramine), and others
As noted in the section on opioids, the medication tramadol (brand names include Ultram®, Ultram® ER, ConZip™, and Ryzolt™) may sometimes be used as a “rescue” drug for burning dysesthesias.
Trigemenial 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. Trigeminal neuralgia can usually be treated with medications such as anti-seizure agents.
Pharmaceutical (with Medication) Management
These include anti-seizure, anti-spasticity, anti-anxiety, and anti-pain medications.
- First line: Tegretol® (carbamazepine)
- Second line: Oxtellar XR™ and Trileptal® (oxcarbazepine); Lamictal® (lamotrigine); and baclofen (formerly available as Lioresal®)
- Other options: Dilantin® (phenytoin), Klonopin® (clonazepam), Depakene® (valproic acid), Lyrica® (pregabalin), Neurontin® (gabapentin), and intranasal lidocaine
As noted in the section on opioids, the medication tramadol (brand names include Ultram®, Ultram® ER, ConZip™, and Ryzolt™) may sometimes be used as a “rescue” drug for trigeminal neuralgia.
Surgical procedures
Surgical procedures to reduce pressure on the trigeminal nerve are possible in some situations.
Lhermitte’s Sign
Lhermitte’s sign is a brief, electrical sensation 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 typically does not require specific treatment.
Non-Pharmaceutical (without Medication) Management
Lhermitte’s sign is seldom treated with medication since it usually is not painful and tends to resolve on its own. New onset of Lhermitte’s sign or a reappearance of Lhermitte’s sign may indicate a presenting sign of a cervical cord lesion, or alternatively, a cervical cord exacerbation.
Pharmaceutical (with Medication) Management
Lhermitte’s sign is not typically painful and does not require pharmaceutical (with medication) management, as the risk of side effects from medication does not outweigh the benefits. New onset of Lhermitte’s sign or a reappearance of Lhermitte’s sign may indicate a multiple sclerosis exacerbation (or a new or worsening cervical-cord lesion). If Lhermitte’s sign is an indication of a multiple sclerosis relapse, your physician may discuss prescribing steroids or other relapse treatment. An alternative to corticosteroids, highly purified forms of the adrenocorticotropin (ACTH) in gelatin, with the brand names of Acthar® Gel and Purified Cortrophin® Gel, act similarly to corticosteroids.
Treating Nociceptive Pain
This type of pain is associated with living with disability and its effects. Examples of this type of pain include musculoskeletal pain, painful spasms, pain related to urinary-tract infection, and other sources of pain not resulting from damaged nerves.
Unlike neurogenic pain, neuromuscular pain may respond to NSAIDs, which includes ibuprofen (Advil® and Motrin®) and naproxen (Aleve®). Acetaminophen (Tylenol®) may help with this type of discomfort too. Antidepressants are sometimes effective and their function is twofold: they may help to shift the perception of pain, while also elevating one’s mood, as living with chronic pain is known to increase depression, fatigue, and anxiety. Anti-spasticity medications may be used if spasticity and/or spasms are contributing to one’s discomfort.
Non-pharmaceutical (without medication) approaches include acupuncture, massage, tai chi, yoga, meditation, hydrotherapy, and physical therapy, among others. A physical therapist experienced with multiple sclerosis can be particularly useful in returning balance and good posture back to one’s movement. Warm compresses can sometimes loosen a tight muscle or reduce lower back pain, while an ice pack is normally prescribed for a recent muscle injury or injection-site reactions.
MS experts caution their patients about chiropractic care as it can potentially aggravate the nerves of the back and neck. If back pain is severe, tests should be done to see if a pinched nerve, slipped disc, or other structural problem is at fault.
Back and Other Musculoskeletal Pain
Back and other musculoskeletal pain in multiple sclerosis 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 as well. An evaluation to pinpoint the source of the pain is essential.
Non-Pharmaceutical (Without Medication) Management
A variety of strategies may prove helpful in managing musculoskeletal pain. These may include heat, massage, ultrasound, evaluation of gait and seating by a physical therapist, and treatments for spasticity.
A variety of relaxation techniques have proven helpful, as have acupressure and acupuncture. Acceptance and Commitment Therapy (ACT) may be of help. According to GoodTherapy.org, ACT uses mindfulness skills to develop psychological flexibility and helps clarify and direct values-guided behavior. Mindfulness-based interventions include therapies such as behavioral activation, hypnosis, and relaxation techniques.
Pharmaceutical (with Medication) 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 follow prescribing instructions. Too much of these medications can cause serious side effects, including liver damage.
Botox® (botulinum toxin) can be effective in treating migraine headache, which is common in multiple sclerosis. Botox also helps other pain, including pain from muscle spasms in multiple sclerosis.
When Are Opioids Prescribed?
With certain diseases and conditions involving severe pain that is not responsive to other drugs, opioids are a type of drug that is sometimes prescribed. With multiple sclerosis, opioids are not as effective, and they are typically avoided. When these drugs are prescribed for any condition, doctors are cautious, as people become dependent upon them when used for a period of time. This is not a problem if managed correctly by the prescribing doctor, and when discontinuing the drug, care is taken to do so gradually. However, some people will abuse this type of medication.
What are opioids?
Opioids are all related to morphine and include such familiar brand names as OxyContin® and Percocet® (both are brand names for the drug oxycodone), and Vicodin® (hydrocodone). Several other related drugs are members of the opioid family, including morphine, which is marketed under the brand names of Astramorph® and Avinza®. According to WebMD, “Opioid analgesics suppress your perception of pain and calm your emotional response to pain by reducing the number of pain signals sent by the nervous system and the brain’s reaction to those pain signals.”
Opioids and MS
Heidi Wynn Maloni, PhD, ANP-BC, CNRN, MSCN explains, “Opioids are used in multiple sclerosis pain, but not as a first-line drug. When are opioids indicated? When pain is moderate to severe, has significant impact on function and on quality of life, when non-opioids have been tried and failed, and very importantly, when the patient is agreeable to having opioids closely monitored.”
Dr. Maloni continues, “Those experiencing multiple sclerosis pain have the capacity to accept and manage their pain. By becoming more active, as well as seeking human interaction and support, one’s perception of pain may be reduced. Using techniques such as mindfulness, along with a careful use of medications – such as using low doses of several medications, to avoid side effects of excess drowsiness and constipation – are important strategies to help individuals who are coping with multiple sclerosis pain.”
Complementary and Alternative Medicine (CAM) Therapies
Readers are advised to consult their physician before trying any new treatment, including these types of CAM 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.
Movement
Both yoga and tai chi are based on traditional Asian medicine, and both have been shown to be of significant value in managing multiple sclerosis 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 multiple sclerosis.
Cannabis or Marijuana
The medical use of cannabis (marijuana) is controversial since it has not been legalized nationally, although most states have legalized its medical use by prescription through approved distribution centers, and some states have approved cannabis for recreational use.
Studies with multiple sclerosis patients and cannabis for symptom relief are limited and the results have been mixed. In multiple sclerosis, cannabis is most often used to reduce the symptoms of pain, spasticity, and insomnia.
Additionally, there have been reports of some individuals with multiple sclerosis experiencing adverse cognitive effects. Adverse neurological and psychiatric events have also occurred. Your healthcare professional can help you to better understand the risks versus the benefits of cannabis in treating certain multiple sclerosis symptoms.
Reviewed by MSAA Chief Medical Officer Barry Hendin, MD