Management of pain in multiple sclerosis: a pharmacological approach

Abstract

About half of patients with multiple sclerosis (MS) report pain; treatment for pain alone accounts for nearly 30% of the total use of medications for the management of all MS-related symptoms. Patients with MS can experience more than one type of pain simultaneously and at any point during the disease course, even in newly or recently diagnosed cases. Pain in MS can be associated with other symptoms, including spasticity, fatigue and mood disorder. Pain sufferers experience disruption in daily life activities, work, mood, recreation and general enjoyment of life, and report low satisfaction with pain management. Many clinical features of pain are often unrecognized by clinicians and are difficult for patients to describe. The majority of clinical evidence regarding treatment stems from small pilot and open-label studies; therefore, treatment of pain associated with MS is often based on anecdotal reports and clinicians' experience. The open-label design of the majority of studies, the unavailability of large samples and the difficulty of performing placebo-controlled studies because of ethical considerations result in insufficient evidence to support or refute the effectiveness of pain medications. This Review presents available data regarding pharmacological approaches for addressing pain in MS and highlights the shortcomings in pain management research.

Diffusion tensor imaging of the trigeminal nerve in patients with trigeminal neuralgia due to multiple sclerosis

“…Besides TN due to NVC, there are other known causes for symptomatic TN, e.g., multiple sclerosis [6,9,17]. MS is a chronic inflammatory disease of the central nervous system characterized by demyelination, axonal dysfunction, and neuronal loss [18].…”

Therapeutic Management of Severe Relapses in Multiple Sclerosis

“…Care must be taken to identify and manage relapse-related symptoms during both the acute and recovery phases. Management of symptoms like pain, spasticity, or urinary symptoms can greatly increase a patient's quality of life and allow the patient to participate in physical therapy and regain functional independence more quickly [79][80][81][82]. A number of detailed reviews of symptom management strategies in patients with MS have been published and are worthy of study [83][84][85].…”

Neuropathic Pain in Multiple Sclerosis–Current Therapeutic Intervention and Future Treatment Perspectives

“…However, due to its poor tolerance, with side effects including leg muscle weakness and micturition problems that can mimic MS relapses, treatment often has to be discontinued (34,37,71). Oxcarbazepine, the keto derivative of carbamazepine, has a similar therapeutic efficacy like carbamazepine for treatment of trigeminal neuralgia but shows an improved tolerance compared to carbamazepine (72).…”

“…Estimates on the prevalence of pain in MS vary considerably depending on the population of patients sampled, the definition of MS-associated pain used, and the survey methods employed. Pain prevalence in MS ranges from 25-90% (8,36,37), depending upon the assessment protocols used and the definition of pain being applied (34). MS-induced chronic neuropathic pain is typically associated with significant MS-related disability and depression (38) and pain syndromes can be divided into primary pain caused directly by demyelination, neuroinflammation, and/or axonal damage in the CNS from disease, or into secondary pain due to an indirect consequence of the CNS lesion (8,39).…”

“…Furthermore, in general chronic pain and in MS-associated chronic neuropathic pain in particular, the conventional analgesics only insufficiently relieve or do not relieve pain at all (8,46). Adjuvant drugs such as the tricyclic antidepressants (TCAs), serotonin/norepinephrine reuptake inhibitors (SSRIs), and some anticonvulsants, for example, gabapentin or topical lidocaine are utilized as first-line drug therapy for alleviation of MS-associated neuropathic pain (34,37,46). Opioid analgesics (e.g., morphine, oxycodone, methadone, and fentanyl) and tramadol (alone or in combination with a firstline agent) are generally regarded as second-line treatments (34,63,64).…”