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Current Treatment Options in Neurology

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01-12-2019 | Neuropathic Pain | Multiple Sclerosis and Related Disorders (J Graves, Section Editor)

Pain Management in Multiple Sclerosis: a Review of Available Treatment Options

Authors: Talal Aboud, MD, Nathaniel M. Schuster, MD

Published in: Current Treatment Options in Neurology | Issue 12/2019

Abstract

Purpose of review

Multiple Sclerosis (MS) is a chronic autoimmune disease with no curative treatment available. While recent years have ushered in many effective new disease-modifying therapies for MS, they have not obviated the need for symptomatic treatments for MS-related pain. In this review, we discuss available approaches to control pain, which is one of the most common complaints MS patients have.

Recent findings

The most recent research in this topic is directed towards non-pharmacologic interventions including water exercises, yoga and cannabis. More trials are being conducted on neuromodulation for MS-related neuropathic pain, including transcutaneous electrical nerve stimulation (TENS) and transcranial direct current stimulation (tDCS).

Summary

Pain control for MS patients is challenging, considering the progressive and relapsing remitting nature of the disease, however, it is a very important aspect of it’s management, as it improves mobility, exercise tolerance, concomitant depression and overall quality of life. Future research should focus on the use of neuromodulation in controlling MS pain.

Rolak LA. Multiple sclerosis: It’s not the disease you thought it was. Clin Med Res. 2003;1:57–60. https://doi.org/10.3121/cmr.1.1.57.CrossRefPubMedPubMedCentral

2.••

Wallin MT, Culpepper WJ, Campbell JD, Nelson LM, Langer-Gould A, Marrie RA, et al. The prevalence of MS in the United States: A population-based estimate using health claims data. Neurology [Internet]. 2019 Mar 5 [cited 2019 Jul 27];92(10):e1029–40. The most recent published estimate of MS prevalence in the US, signifies how common the disease is, highlighting the importance of continued research targeting its management.

3.••

Solaro C, Trabucco E, Messmer Uccelli M. Pain and multiple sclerosis: pathophysiology and treatment. Current Neurology And Neuroscience Reports [Internet]. 2013 Jan [cited 2019 Apr 9];13(1):320. Highlights the prevalence of pain in MS patients as a relatively common complaint, that may account for a significant portion of the disability frequently found in this patient population.

Solaro C, Brichetto G, Amato M, Cocco E, Colombo B, D’Aleo G, et al. The prevalence of pain in multiple sclerosis - A multicenter cross-sectional study. NEUROLOGY [Internet]. [cited 2019 Apr 9];63(5):919–21.

Treede R-D( 1 ), Jensen TS( 2,11 ), Campbell JN( 3 ), Griffin JW( 4 ), Cruccu G( 5 ), Dostrovsky JO( 6 ), et al. Neuropathic pain: Redefinition and a grading system for clinical and research purposes. Neurology [Internet]. [cited 2019 Apr 9];70(18):1630–5.

Kassirer M. Multiple sclerosis and pain: a medical focus. Int J Mult Scler Care. 2000;2:30–4.

7.•

Ashton JC. Emerging treatment options for spasticity in multiple sclerosis–clinical utility of cannabinoids. Degener Neurol Neuromuscul Dis. 2011; 1:15–23. Discusses Spasticity and highlights it’s major role as a pain generator in MS patients.

Lapeyre E( 1 ), Kuks JBM( 2 ), Meijler WJ( 3 ). Spasticity: Revisiting the role and the individual value of several pharmacological treatments. NeuroRehabilitation [Internet]. [cited 2019 Apr 12];27(2):193–200.

9.•

Truini A, Barbanti P, Pozzilli C, Cruccu G. A mechanism-based classification of pain in multiple sclerosis. Journal Of Neurology [Internet]. 2013 Feb [cited 2019 Apr 12];260(2):351–67. Classifies pain etiologies in MS patients and provides a better understanding of the most important pain generators.

10.

Amatya B( 1 ), Khan F( 1 ), Young J( 2 ). Non-pharmacological interventions for chronic pain in multiple sclerosis. Cochrane Database of Systematic Reviews [Internet]. [cited 2019 Apr 12];2018(12).

11.

Ordia JI, Fischer E, Adamski E, Spatz EL. Chronic intrathecal delivery of baclofen by a programmable pump for the treatment of severe spasticity. Journal Of Neurosurgery [Internet]. 1996 Sep [cited 2019 Apr 12];85(3):452–7.CrossRef

12.•

Demaneuf T, Aitken Z, Karahalios A, Leong TI, De Livera AM, Jelinek GA, et al. Effectiveness of Exercise Interventions for Pain Reduction in People With Multiple Sclerosis: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Archives of Physical Medicine and Rehabilitation [Internet]. 2019 Jan 1 [cited 2019 Aug 7];100(1):128–39. Large scale, well designed meta-analysis that highlights the importance of exercise in MS pain management, the strong evidence behind it, and that it should not be overlooked in favor of emerging medical or interventional treatments, but rather included as first line in every management plan when tolerated.

13.•

Adelaida María Castro-Sánchez, Guillermo A. Matarán-Peñarrocha, Inmaculada Lara-Palomo, Manuel Saavedra-Hernández, Manuel Arroyo-Morales, Carmen Moreno-Lorenzo. Hydrotherapy for the Treatment of Pain in People with Multiple Sclerosis: A Randomized Controlled Trial. Evidence-Based Complementary and Alternative Medicine [Internet]. 2012 [cited 2019 Apr 12]. RIdentifies a feasible alternative to aerobic exercise in disabled MS patients who can not tolerate it, which is commonly seen in advanced and aggressive MS cases.

14.

Doulatabad SN, Nooreyan K, Doulatabad AN, Noubandegani ZM. The effects of pranayama, hatha and raja yoga on physical pain and the quality of life of women with multiple sclerosis. African Journal Of Traditional, Complementary, And Alternative Medicines: AJTCAM [Internet]. 2012 Oct 1 [cited 2019 Apr 12];10(1):49–52.

15.

Salgado BC, Jones M, Ilgun S, McCord G, Loper-Powers M, van Houten P. Effects of a 4-month Ananda Yoga program on physical and mental health outcomes for persons with multiple sclerosis. International Journal Of Yoga Therapy [Internet]. 2013 [cited 2019 Apr 12];(23):27–38.

16.

Velikonja O, Curić K, Ozura A, Jazbec SS. Influence of sports climbing and yoga on spasticity, cognitive function, mood and fatigue in patients with multiple sclerosis. Clinical Neurology And Neurosurgery [Internet]. 2010 Sep [cited 2019 Apr 12];112(7):597–601.CrossRef

17.

Ehde DM, Elzea JL, Verrall AM, Gibbons LE, Smith AE, Amtmann D. Efficacy of a Telephone-Delivered Self-Management Intervention for Persons With Multiple Sclerosis: A Randomized Controlled Trial With a One-Year Follow-Up. Archives Of Physical Medicine And Rehabilitation [Internet]. 2015 Nov [cited 2019 Apr 12];96(11):1945–58.e2.

18.

Thomas PW. Psychological interventions for multiple sclerosis. Hillier C, Galvin K, editors. Cochrane Database of Systematic Reviews [Internet]. [cited 2019 Aug 7];(1).

19.

Rosti-Otajärvi, EM. Neuropsychological rehabilitation for multiple sclerosis. Hämäläinen PI, editor. Cochrane Database of Systematic Reviews [Internet]. [cited 2019 Aug 7];(2).

20.

Amatya B, Khan F, Galea M. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews. The Cochrane Database Of Systematic Reviews [Internet]. 2019 Jan 14 [cited 2019 Aug 7];1:CD012732.

21.

Hosseinzadegan F, Radfar M, Shafiee-Kandjani AR, Sheikh N. Efficacy of Self-Hypnosis in Pain Management in Female Patients with Multiple Sclerosis. The International Journal Of Clinical And Experimental Hypnosis [Internet]. 2017 Jan [cited 2019 Apr 12];65(1):86–97.CrossRef

22.

Hughes CM, Smyth S, Lowe-Strong AS. Reflexology for the treatment of pain in people with multiple sclerosis: a double-blind randomized sham-controlled clinical trial. Multiple Sclerosis (13524585) [Internet]. 2009 Nov [cited 2019 Apr 12];15(11):1329.CrossRef

23.

Musial F. Nazari F, Soheili M, Hosseini SM, Shaygannejad V: A comparison of the effects of reflexology and relaxation on pain in women with multiple sclerosis. J Complement Integr Med 2015;18:26581073. Forschende Komplementarmedizin [Internet]. [cited 2019 Apr 13];23(1):10–1.

24.

Quispe-Cabanillas JG, Damasceno A, von Glehn F, Brandao CO, Damasceno BP, Silveira WD, et al. Impact of electroacupuncture on quality of life for patients with Relapsing-Remitting Multiple Sclerosis under treatment with immunomodulators: A randomized study. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE [Internet]. [cited 2019 Aug 16];12.

25.

Díaz-Toral LG, Banderas-Dorantes TR, Rivas-Vilchis JF. Impact of Electroacupuncture Treatment on Quality of Life and Heart Rate Variability in Fibromyalgia Patients. Journal of Evidence-Based Complementary and Alternative Medicine [Internet]. [cited 2019 Aug 7];22(2):216–22.

26.

Warke K, Al-Smadi J, Baxter D, Walsh DM, Lowe-Strong AS. Efficacy of transcutaneous electrical nerve stimulation (tens) for chronic low-back pain in a multiple sclerosis population: a randomized, placebo-controlled clinical trial. The Clinical Journal Of Pain [Internet]. 2006 Nov [cited 2019 Apr 13];22(9):812–9.CrossRef

27.

Miller L, Mattison P, Paul L, Wood L. The effects of transcutaneous electrical nerve stimulation (TENS) on spasticity in multiple sclerosis. MULTIPLE SCLEROSIS [Internet]. [cited 2019 Aug 7];13(4):527–33.

28.

Shaygannejad V( 1 ), Vaezi A( 1 ), Haghighi S( 1 ), Golabchi K( 1 ), Janghorbani M( 2 ), Heshmatipour M( 3 ). Comparison of the effect of baclofen and transcutaneous electrical nerve stimulation for the treatment of spasticity in multiple sclerosis. Neurological Research [Internet]. [cited 2019 Aug 7];35(6):636–41.

29.

Chitsaz A( 1 ), Shaygannejad V( 1 ), Janghorbani M( 2,5 ), Ashtari F( 2 ), Heshmatipour M( 3 ), Freeman J( 4 ). Sensory complaints of the upper extremities in multiple sclerosis: Relative efficacy of nortriptyline and transcutaneous electrical nerve stimulation. Clinical Journal of Pain [Internet]. [cited 2019 Apr 13];25(4):281–5.CrossRef

30.

Ayache SS, Palm U, Chalah MA, Al-Ani T, Brignol A, Abdellaoui M, et al. Prefrontal tDCS Decreases Pain in Patients with Multiple Sclerosis. Frontiers In Neuroscience [Internet]. 2016 Apr 8 [cited 2019 Apr 13];10:147.

31.

Kumar K, Hunter G, Demeria D. Spinal cord stimulation in treatment of chronic benign pain: Challenges in treatment planning and present status, a 22-year experience. Neurosurgery [Internet]. [cited 2019 Apr 13];58(3):481–94.CrossRef

32.

Brooks JW, Pryce G, Bisogno T, Jaggar SI, Hankey DJR, Brown P, et al. Arvanil-induced inhibition of spasticity and persistent pain: evidence for therapeutic sites of action different from the vanilloid VR1 receptor and cannabinoid CB(1)/CB(2) receptors. European Journal Of Pharmacology [Internet]. 2002 Mar 29 [cited 2019 Apr 13];439(1–3):83–92.CrossRef

33.

Wade DT, Makela P, Robson P, House H, Bateman C. Do cannabis-based medicinal extracts have general or specific effects on symptoms in multiple sclerosis? A double-blind, randomized, placebo-controlled study on 160 patients. Multiple Sclerosis (Houndmills, Basingstoke, England) [Internet]. 2004 Aug [cited 2019 Apr 13];10(4):434–41.

34.

Corey-Bloom J, Wolfson T, Gamst A, Jin S, Marcotte TD, Bentley H, et al. Smoked cannabis for spasticity in multiple sclerosis: a randomized, placebo-controlled trial. CMAJ: Canadian Medical Association Journal [Internet]. 2012 Jul 10 [cited 2019 Apr 13];184(10):1143.

35.

Rog D, Nurmikko T, Friede T, Young C. Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis. NEUROLOGY [Internet]. [cited 2019 Apr 13];65(6):812–9.CrossRef

36.

Mara Turri, Francesco Teatini, Francesco Donato, Giampietro Zanette, Valeria Tugnoli, Luciano Deotto, et al. Pain Modulation after Oromucosal Cannabinoid Spray (SATIVEX®) in Patients with Multiple Sclerosis: A Study with Quantitative Sensory Testing and Laser-Evoked Potentials. Medicines [Internet]. 2018 [cited 2019 Apr 13];(3):59.

37.

Zajicek J( 1,5 ), Fox P( 1 ), Vickery J( 1 ), Sanders H( 2 ), Wright D( 2 ), Nunn A( 3 ), et al. Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): Multicenter randomized placebo-controlled trial. Lancet [Internet]. [cited 2019 Apr 13];362(9395):1517–26.

38.

Nance PW, Sheremata WA, Lynch SG, Vollmer T, Hudson S, Francis GS, et al. Relationship of the antispasticity effect of tizanidine to plasma concentration in patients with multiple sclerosis. Archives Of Neurology [Internet]. 1997 Jun [cited 2019 Apr 13];54(6):731–6.CrossRef

39.

Smith C, Birnbaum G, Carter JL, Greenstein J, Lublin FD. Tizanidine treatment of spasticity caused by multiple sclerosis: results of a double-blind, placebo-controlled trial. US Tizanidine Study Group. Neurology [Internet]. 1994 Nov [cited 2019 Apr 13];44(11 Suppl 9):S34.

40.

A double-blind, placebo-controlled trial of tizanidine in the treatment of spasticity caused by multiple sclerosis. United Kingdom Tizanidine Trial Group. Neurology [Internet]. 1994 Nov [cited 2019 Apr 13];44(11 Suppl 9):S70–8.

41.

Brar SP, Smith MB, Nelson LM, Franklin GM, Cobble ND. Evaluation of treatment protocols on minimal to moderate spasticity in multiple sclerosis. Archives Of Physical Medicine And Rehabilitation [Internet]. 1991 Mar [cited 2019 Apr 13];72(3):186–9.

42.

Sachais BA, Logue JN, Carey MS. Baclofen, a new antispastic drug. A controlled, multicenter trial in patients with multiple sclerosis. Archives Of Neurology [Internet]. 1977 Jul [cited 2019 Apr 13];34(7):422–8.CrossRef

43.

Penn RD, Savoy SM, Corcos D, Latash M, Gottlieb G, Parke B, et al. Intrathecal baclofen for severe spinal spasticity. The New England Journal Of Medicine [Internet]. 1989 Jun 8 [cited 2019 Apr 13];320(23):1517–21.CrossRef

44.

Dario A, Tomei G. Management of spasticity in multiple sclerosis by intrathecal baclofen. Acta Neurochirurgica Supplement [Internet]. 2007 [cited 2019 Apr 13];97(Pt 1):189–92.

45.

Romijn JA, van Lieshout JJ, Velis DN. Reversible coma due to intrathecal baclofen. Lancet (London, England) [Internet]. 1986 Sep 20 [cited 2019 Apr 13];2(8508):696.

46.

Reeves RK, Stolp-Smith KA, Christopherson MW. Hyperthermia, rhabdomyolysis, and disseminated intravascular coagulation associated with baclofen pump catheter failure. Archives Of Physical Medicine And Rehabilitation [Internet]. 1998 Mar [cited 2019 Apr 13];79(3):353–6.CrossRef

47.

Schmidt RT, Lee RH, Spehlmann R. Comparison of dantrolene sodium and diazepam in the treatment of spasticity. Journal of Neurology, Neurosurgery & Psychiatry [Internet]. 1976 Apr [cited 2019 Apr 13];39(4):350.

48.

49.

Cendrowski W, Sobczyk W. Clonazepam, baclofen and placebo in the treatment of spasticity. European Neurology [Internet]. 1977 [cited 2019 Apr 13];16(1–6):257–62.CrossRef

50.

Houtchens MK, Richert JR, Sami A, Rose JW. Open label gabapentin treatment for pain in multiple sclerosis. Multiple Sclerosis (Houndmills, Basingstoke, England) [Internet]. 1997 Aug [cited 2019 Apr 13];3(4):250–3.CrossRef

51.

Johannessen Landmark C( 1 ), Larsson PG( 2,3 ), Rytter E( 2,3 ), Johannessen SI( 2,3,4 ). Antiepileptic drugs in epilepsy and other disorders-A population-based study of prescriptions. Epilepsy Research [Internet]. [cited 2019 Apr 13];87(1):31–9.

52.

Breuer B, Pappagallo M, Knotkova H, Guleyupoglu N, Wallenstein S, Portenoy RK. A randomized, double-blind, placebo-controlled, two-period, crossover, pilot trial of lamotrigine in patients with central pain due to multiple sclerosis. Clinical Therapeutics [Internet]. 2007 Sep [cited 2019 Apr 13];29(9):2022–30.CrossRef

53.

Vollmer TL, Robinson MJ, Risser RC, Malcolm SK. A Randomized, Double-Blind, Placebo-Controlled Trial of Duloxetine for the Treatment of Pain in Patients with Multiple Sclerosis. Pain Practice [Internet]. 2014 Nov [cited 2019 Apr 13];14(8):732.

54.

Brown TR, Slee A. A Randomized Placebo-Controlled Trial of Duloxetine for Central Pain in Multiple Sclerosis. International Journal of MS Care [Internet]. 2015 Mar [cited 2019 Apr 13];17(2):83.CrossRef

55.

Burchiel KJ, Hsu FP. Pain and spasticity after spinal cord injury: mechanisms and treatment. Spine [Internet]. 2001 Dec 15 [cited 2019 Apr 13];26(24 Suppl):S146–60.

56.

Shaikh A, Phadke CP, Ismail F, Boulias C. Relationship Between Botulinum Toxin, Spasticity, and Pain: a Survey of Patient Perception. The Canadian Journal Of Neurological Sciences Le Journal Canadien Des Sciences Neurologiques [Internet]. 2016 Mar [cited 2019 May 24];43(2):311–5.

57.

Rockliff BW( 1 ), Davis EH( 2 ). Controlled Sequential Trials of Carbamazepine in Trigeminal Neuralgia. Archives of Neurology [Internet]. [cited 2019 Aug 7];15(2):129–36.CrossRef

58.

Campbell FG, Graham JG, Zilkha KJ. Clinical trial of carbazepine (tegretol) in trigeminal neuralgia. Journal of Neurology, Neurosurgery & Psychiatry [Internet]. 1966 Jun [cited 2019 Aug 7];29(3):265.

59.

Zakrzewska JM, Wu J, Brathwaite TS-L. A Systematic Review of the Management of Trigeminal Neuralgia in Patients with Multiple Sclerosis. World Neurosurgery [Internet]. 2018 Mar 1 [cited 2019 Aug 7];111:291–306.

60.

Zorro O, Lobato-Polo J, Kano H, Flickinger JC, Lunsford LD, Kondziolka D. Gamma knife radiosurgery for multiple sclerosis-related trigeminal neuralgia. NEUROLOGY [Internet]. [cited 2019 Aug 7];73(14):1149–54.CrossRef

61.

Mathieu D, Effendi K, Blanchard J, Seguin M. Comparative study of Gamma Knife surgery and percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia in patients with multiple sclerosis Clinical article. JOURNAL OF NEUROSURGERY [Internet]. [cited 2019 Aug 7];117:175–80.

62.

Alvarez-Pinzon AM, Wolf AL, Swedberg HN, Barkley KA, Cucalon J, Curia L, et al. Comparison of Percutaneous Retrogasserian Balloon Compression and Gamma Knife Radiosurgery for the Treatment of Trigeminal Neuralgia in Multiple Sclerosis. World Neurosurgery [Internet]. 2017 Jan 1 [cited 2019 Aug 7];97:590–4.

63.

Kanai A, Suzuki A, Kobayashi M, Hoka S. Intranasal lidocaine 8% spray for second-division trigeminal neuralgia. British Journal of Anaesthesia [Internet]. 2006 Oct 1 [cited 2019 Aug 7];97(4):559–63.

64.

Zaghi S, Thiele B, Pimentel D, Pimentel T, Fregni F. Assessment and treatment of pain with non-invasive cortical stimulation. Restorative Neurology And Neuroscience [Internet]. 2011 [cited 2019 Aug 7];29(6):439–51.CrossRef

65.

Hagenacker T, Bude V, Naegel S, Holle D, Katsarava Z, Diener H-C, et al. Patient-conducted anodal transcranial direct current stimulation of the motor cortex alleviates pain in trigeminal neuralgia. JOURNAL OF HEADACHE AND PAIN [Internet]. [cited 2019 Aug 7];15.

66.

Raslan AM, Nasseri M, Bahgat D, Abdu E, Burchiel KJ. Motor Cortex Stimulation for Trigeminal Neuropathic or Deafferentation Pain: An Institutional Case Series Experience. STEREOTACTIC AND FUNCTIONAL NEUROSURGERY [Internet]. 2011 [cited 2019 Aug 7];89(2):83–8.

67.

Cordella R, Franzini A, La Mantia L, Marras C, Erbetta A, Broggi G. Hypothalamic stimulation for trigeminal neuralgia in multiple sclerosis patients: efficacy on the paroxysmal ophthalmic pain. Multiple Sclerosis (Houndmills, Basingstoke, England) [Internet]. 2009 Nov [cited 2019 Aug 7];15(11):1322–8.CrossRef

68.

Tomycz ND, Deibert CP, Moossy JJ. Cervicomedullary Junction Spinal Cord Stimulation for Head and Facial Pain. HEADACHE [Internet]. [cited 2019 Aug 7];51(3):418–25.CrossRef

69.

Shaparin N, Gritsenko K, Garcia-Roves DF, Shah U, Schultz T, DeLeon-Casasola O. Peripheral neuromodulation for the treatment of refractory trigeminal neuralgia. Pain Research & Management [Internet]. 2015 Mar [cited 2019 Aug 7];20(2):63–6.

70.

Singla S, Prabhakar V, Singla RK. Role of transcutaneous electric nerve stimulation in the management of trigeminal neuralgia. Journal of Neurosciences in Rural Practice [Internet]. 2011 Jul [cited 2019 Aug 7];2(2):150–2.CrossRef

Title: Pain Management in Multiple Sclerosis: a Review of Available Treatment Options
Authors: Talal Aboud, MD
Nathaniel M. Schuster, MD
Publication date: 01-12-2019
Publisher: Springer US
Keywords: Neuropathic Pain
Multiple Sclerosis
Trigeminal Neuralgia
Cannabinoid
Pain in MS
Nerve Stimulation
Published in: Current Treatment Options in Neurology / Issue 12/2019
Print ISSN: 1092-8480
Electronic ISSN: 1534-3138
DOI: https://doi.org/10.1007/s11940-019-0601-2

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Pain Management in Multiple Sclerosis: a Review of Available Treatment Options

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