Are you suffering from migraine or neuropathic pain? Why? #MSBlog #MSResearch
“I have posted before on the link between migraine and MS. It appears that people with any brain disease have a higher incidence of migraine. Why? It appears brain damage lowers the threshold for the abnormal activation of a group of cells in the brain that trigger migraine. Is migraine important? Yes, it is one of the most disabling conditions to afflict man; those of you who have migraine headaches know what I mean.”
“Neuropathic pain is another form of pain and is typically due to damage of central sensory pathways. When these sensory nerves recover they insert a different type of sodium channel into their membranes to restore electrical conduction; these sodium channels open spontaneously and activate the nerve. Your brain then interprets that electrical signal from these nerves as being a pain; signal. The intermittent activation of these nerves leads to sharp-shooting or lancinating pains; this often called neuralgia. This pain is treated with drugs that block or modulate sodium channels, for example carbamazepine, oxcarbazepine, phenytoin, gabapentin, pregabalin, etc.”
“Another pain that is more difficult to treat is the gnawing tooth-ache type pain MSers get in their backs from spinal cord disease. The exact mechanism of this pain is unknown, but probably relates to abnormal firing of sensory nerves, reduced modulation of the sensory nerves from the spinal cord and altered central processing of the pain signal. We tend to treat this pain with drugs that alter central modulation or perception of pain, for example tricyclic anti-depressants, e.g. amitriptyline, nortriptyline. I have found by trial and error that anti-depressants synergise with gabapentin or pregabalin to make this type of pain bearable. This is why I often use the combination. The latter is not evidence-based. Yes, before you criticise me I do practice non-evidence based medicine when I have back against the wall. At the end of the day MSers with chronic pain are often desperate for some relief so a trial-and-error approach may work. I also spread the hope telling MSers that this drug may not work, but there are others that may. Until we have tried them all we won’t know, which ones work or not.”
“Other strategies that may work are TENS and anti-depressants. People with pain are often depressed and depression makes the handling of pain worse. To break the vicious cycle you need to tackle both the pain and mood.”
“Finally there are surgical and interventions that work for pain, including spinal cord stimulators and functional neurosurgery. The bottom line is that if you have MS and are just living with migraine or neuropathic pain. You shouldn’t be accepting of it; ask your neurologist for help. We have medications and strategies that can take the edge off pain.”
“Neuropathic pain is another form of pain and is typically due to damage of central sensory pathways. When these sensory nerves recover they insert a different type of sodium channel into their membranes to restore electrical conduction; these sodium channels open spontaneously and activate the nerve. Your brain then interprets that electrical signal from these nerves as being a pain; signal. The intermittent activation of these nerves leads to sharp-shooting or lancinating pains; this often called neuralgia. This pain is treated with drugs that block or modulate sodium channels, for example carbamazepine, oxcarbazepine, phenytoin, gabapentin, pregabalin, etc.”
“Another pain that is more difficult to treat is the gnawing tooth-ache type pain MSers get in their backs from spinal cord disease. The exact mechanism of this pain is unknown, but probably relates to abnormal firing of sensory nerves, reduced modulation of the sensory nerves from the spinal cord and altered central processing of the pain signal. We tend to treat this pain with drugs that alter central modulation or perception of pain, for example tricyclic anti-depressants, e.g. amitriptyline, nortriptyline. I have found by trial and error that anti-depressants synergise with gabapentin or pregabalin to make this type of pain bearable. This is why I often use the combination. The latter is not evidence-based. Yes, before you criticise me I do practice non-evidence based medicine when I have back against the wall. At the end of the day MSers with chronic pain are often desperate for some relief so a trial-and-error approach may work. I also spread the hope telling MSers that this drug may not work, but there are others that may. Until we have tried them all we won’t know, which ones work or not.”
“Other strategies that may work are TENS and anti-depressants. People with pain are often depressed and depression makes the handling of pain worse. To break the vicious cycle you need to tackle both the pain and mood.”
“Finally there are surgical and interventions that work for pain, including spinal cord stimulators and functional neurosurgery. The bottom line is that if you have MS and are just living with migraine or neuropathic pain. You shouldn’t be accepting of it; ask your neurologist for help. We have medications and strategies that can take the edge off pain.”
Epub: Moisset et al. Migraine Headaches And Pain With Neuropathic Characteristics: Comorbid Conditions In Patients With Multiple Sclerosis. Pain. 2013 Aug 1. pii: S0304-3959(13)00431-4.
Methods: This group conducted a postal survey to assess the prevalence and characteristics of neuropathic pain and migraine in a cohort of MSers.
Results: Of the 1300 sent questionnaires, 673 could be used for statistical analysis. Among respondents, the overall pain prevalence in the previous month was 79%, with 51% suffering pain with neuropathic characteristics (NC) and 46% migraine. MSers with both migraine and NC pain (32% of the respondents) reported more severe pain and had lower health-related quality of life than MSers with either migraine or NC pain. Pain intensity in MSers with migraine was moderate (6.0±0.1). Migraine was mostly episodic but headaches were occurring on 15 or more days per month in 15% of these migraine sufferers. MSers with migraine were younger and had shorter disease durations than those with NC pain. NC pain was most often located in the extremities, back and head, and was frequently described as tingling and pins-and-needles. The intensity of NC pain was low to moderate (4.9±0.1), but positively correlated with the number of painful body sites. Nonetheless, MSers with NC pain were more disabled (with a higher EDSS and pain interference index) than migraineurs. Migraine, but not NC pain, was associated with age, disease duration, relapsing-remitting course and beta interferon treatment.
Conclusions: These data suggests that NC pain and migraine are mediated by different mechanisms. Therefore, pain mechanisms that specifically operate in MSers need to be characterized to design optimal treatments for these individuals.
Other posts of interest:
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BACKGROUND:Studies investigating a proposed association between multiple sclerosis (MS) and migraine have produced conflicting results and a great range in the prevalence rate of migraine in MS patients.
05 Jun 2012
Results: 102 (49.8 %) MSers were diagnosed as affected by comorbid migraine. About one-third of MSers with comorbid migraine have asked the attending neurologist for a specific anti-migraine treatment. Despite this, only …
07 Aug 2011
Background: The Nurses’ Health Study II (NHS-II), which enrolled over 116,000 female nurses, provides a unique opportunity to investigate whether migraine is associated with MS and to explore the temporal aspects of the …
07 Aug 2011
“Migraine is a big problem in MS’ers; it has always been my impression that migraine is commoner in MS’ers than non-MS’ers. In a large number of my patients in addition to treating their MS, I have to manage their migraine …
07 Jun 2013
Background: Neuropathic pain is a frequent chronic presentation in autoimmune diseases of the nervous system, such as multiple sclerosis (MS) and Guillain-Barre syndrome (GBS), causing significant individual disablement …
08 Aug 2012
Central neuropathic pain in MSers is a common debilitating symptom, which is mostly treated with tricyclic antidepressants or antiepileptics (e.g. gabapentin, carbamazepine, oxcarbamazepine). Unfortunately, the use of these …
31 Jul 2012
In this clinical and neurophysiological study, we examined the clinical characteristics and underlying mechanisms of neuropathic pain related to multiple sclerosis. A total of 302 consecutive patients with multiple sclerosis …
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The new mechanism-based classification proposed here distinguishes nine types of MS-related pain: trigeminal neuralgia and Lhermitte’s phenomenon (paroxysmal neuropathic pain due to ectopic impulse generation along …
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A double-blind, randomized, placebo-controlled, parallel-group study of THC/CBD oromucosal spray in combination with the existing treatment regimen, in the relief of central neuropathic pain in patients with multiple sclerosis …
18 Jan 2013
They quantified prevalence of headache (43%; 95% CI 33-52%), neuropathic extremity pain (26%; 95% CI 7-53%), back pain (20%; 95% CI 13-28%), painful spasms (15%; 95% CI 8.5-23%), Lhermitte’s sign (16%; 95% CI …
20 Feb 2012
Patients with multiple sclerosis, symptoms and signs complying with central neuropathic pain and pain symptoms for more than 6 months, as well as pain intensity of more than 4 on a 0 to 10-point numeric rating scale were …
11 May 2013
Pain is a major problem in MS and this is not adequately controlled. Neuropathic pain is the chronic problem caused by nerve damage within the central nervous system generating aberrant nerve signals that stimulate the …
An excellent post, passed it on to a couple of groups who have members with these issues. An interesting synergy between gabapentin and anti-depressants.Given the variability of MS persons, their symptoms and the differing responses to drugs – it is to your credit that an application of clinical knowledge and observation can lead to a combination that may help. Constant pain is physically limiting and depressing – any reasonable option is to be applauded.
Great posting. I like the way this site contains both individual studies and some meta analysis of studies. That information is difficult to find online. I fall into the group with both types of pain, but due to some freakish medical history i would never rate my pain as seems the norm. Granted, when my migraine headache was bad enough to make me pull over to the side of the road to puke, I rated it as a 6 to my neurologist so I might just be a freak. It's just after being asked to jump in an effort to diagnose testicular torsion as a young teen, I take that as my 10.Personally, I have found nortriptyline and gabapentin keep things tolerable enough to continue working full time. Exercise also helps greatly with the NC pain with aerobic exercise (running is best) helping me more than most . Do you have any idea why this is the case? Thanks for the information.
Thank you for the info. The combination of Lyrica, Gabapentin, Cymbalta and Nortriptyline being used to control nerve pain, or block the brain from interpreting the mis firing of the nerve signals in Multiple Sclerosis is quite intriguing. Perhaps a study showing a percentage in relation to how much of each of these drugs helped control the pain. Know everyone is different, but would be interested in seeing average of relief seen with what combination levels
Re: "Perhaps a study showing a percentage in relation to how much of each of these drugs helped control the pain."This data is not available. It also doesn't work like that with symptomatic treatments. It is essentially a trial and error approach to find out which combination works best for you with the least side effects. Also it is rare for these treatments to make you pain-free they often just take the edge off things.
Thank you. Yes a Trial and Error approach, which takes many months for a "One small change at a time"But how do you keep up when the MS keeps progressing, playing a Cat and Mouse game with these symptomatic drugs?
yes evidence based is what we need my ppainkillers are currently uselw