Is Pain Normal in Multiple Sclerosis?
Yes, pain is a very common and normal symptom in Multiple Sclerosis, affecting approximately 50% of patients at any given time and up to 75% of patients within a one-month period. 1, 2
Prevalence and Impact
- Pain occurs in approximately 27.5% of MS patients as central neuropathic pain, with an additional 4.9% experiencing trigeminal neuralgia specifically. 3
- Pain adversely affects nearly all aspects of health-related quality of life, including the ability to work and participate in daily activities. 1
- In approximately 5.5% of patients, pain can be a presenting symptom of MS, either alone or combined with other neurological manifestations. 3
- Pain accounts for nearly 30% of all drug use for MS symptom management, though patient satisfaction with pain control remains low. 2
Types of Pain in MS
Pain in MS manifests in several distinct patterns that require different management approaches:
Neuropathic Pain Directly Related to MS:
- Painful "burning" dysesthesias are the most frequent chronic pain syndrome, typically affecting the lower extremities (87%) and upper extremities (31%), usually bilaterally (76%). 4, 3
- Trigeminal neuralgia occurs in approximately 4.9% of MS patients and tends to start later in the disease course. 3
- Lhermitte's sign (electric shock-like sensations down the spine with neck flexion). 1
- Painful tonic spasms (brief, painful muscle contractions). 1, 4
Pain Indirectly Related to MS:
- Musculoskeletal pain from spasticity, deconditioning, and malposition. 4, 5
- Joint pain secondary to altered gait and mobility patterns. 4
Clinical Characteristics
- Most non-trigeminal central pain in MS is constant and daily (88%), rather than paroxysmal (only 2%). 3
- Common pain descriptors include aching, burning, and pricking sensations. 3
- Pain intensity is typically moderate to severe with relatively small spontaneous variation. 3
- Sensory abnormalities are present in 98% of patients with central pain, particularly abnormal responses to painful stimuli and temperature. 3
Evidence-Based Treatment Approach
First-Line Pharmacological Management:
For neuropathic pain (dysesthesias), the American Academy of Neurology recommends starting with: 6
- Tricyclic antidepressants (TCAs) such as nortriptyline or desipramine, OR
- SSNRIs such as duloxetine or venlafaxine, OR
- Calcium channel α2-δ ligands such as gabapentin or pregabalin
For Paroxysmal Pain Syndromes (Trigeminal Neuralgia, Painful Tonic Spasms):
- Antiepileptics are first-choice: carbamazepine, oxcarbazepine, lamotrigine, gabapentin, or pregabalin. 6, 4
For Spasticity-Related Pain:
- Adequate physiotherapy is foundational. 4
- Antispastic agents: baclofen or tizanidine. 4
- For phasic spasticity: gabapentin or levetiracetam. 4
- Severe cases may require botulinum toxin injections or intrathecal baclofen. 4
For Musculoskeletal Pain:
- Physiotherapy to address malposition. 4
- Acetaminophen or NSAIDs as adjunctive therapy. 4
- Optimize assistive devices to prevent pressure-related pain. 4
Important Clinical Considerations
Combination Therapy:
- Combining drugs with different mechanisms of action can reduce adverse effects while improving efficacy. 4
- Patients frequently experience multiple pain syndromes simultaneously, requiring individualized multimodal approaches. 4
Cautions with TCAs:
- Use with caution in patients with cardiac disease or ventricular conduction abnormalities. 6
- Patients over 40 years should have a screening electrocardiogram before starting TCAs. 6
Associated Factors:
- Pain in MS is associated with increased age, longer disease duration, depression, greater functional impairment, and fatigue. 1
- The bidirectional relationship between pain and mood disorders requires attention to both symptoms. 5
Common Pitfall:
- Pain is frequently underreported by patients and requires direct questioning by clinicians. 4
- Despite its high prevalence, pain remains undertreated in MS, with patients reporting low satisfaction with pain management. 2
Non-Pharmacological Approaches: