Migraine and neuropathic pain in MSers

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."

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.



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