Can multiple sclerosis (MS) cause pain?

Does Multiple Sclerosis Cause Pain?

Yes, multiple sclerosis commonly causes pain, with approximately 50% of MS patients experiencing pain at any given time and up to 75% reporting pain within a one-month period. 1

Pain Prevalence and Impact in MS

Pain is a well-established and frequent symptom of multiple sclerosis that significantly affects quality of life. The point prevalence reaches nearly 50%, with three-quarters of patients experiencing pain within a month of assessment. 1 This pain adversely impacts most aspects of health-related quality of life, including the ability to work and participate in daily activities. 1

Types of MS-Related Pain

MS causes multiple distinct pain syndromes that can be classified into four therapeutically relevant categories: 2

Neuropathic Pain Directly Related to MS

• Painful dysesthesias (burning sensations in extremities) - the most frequent chronic pain syndrome 2
• Trigeminal neuralgia - severe facial pain from nerve root entry zone damage 2, 3
• Lhermitte's sign - electric shock-like sensations down the spine with neck flexion 1, 3
• Painful tonic spasms - sudden muscle contractions causing pain 2, 1

Pain Indirectly Related to MS

• Musculoskeletal pain from spasticity, deconditioning, and malposition 2, 4
• Joint pain secondary to immobility and altered biomechanics 2, 4
• Back pain worsened by disease progression 2

Treatment-Related Pain

• Injection site reactions from interferon-beta or glatiramer acetate 2
• Flu-like symptoms and myalgias from interferon therapy 2
• Treatment-induced headaches 2, 3

Pain Unrelated to MS

• Pre-existing headache or back pain that may worsen with MS 2

Clinical Associations

Pain in MS patients is associated with several factors: 1

• Increased age and longer disease duration
• Greater functional impairment
• Depression and psychological distress
• Fatigue

Pathophysiology

The mechanisms underlying MS-related pain include: 3

• Demyelinating plaques disrupting spinothalamic and quintothalamic sensory pathways
• Abnormal nerve impulses through damaged motor and sensory axons
• Acquired channelopathies in affected nerves
• Glial cell inflammatory mechanisms involving microglial and astrocytic activation

First-Line Treatment Approach

For neuropathic pain in MS, first-line treatment should include tricyclic antidepressants (nortriptyline or desipramine), SSNRIs (duloxetine or venlafaxine), or calcium channel α2-δ ligands (gabapentin or pregabalin). 5

Specific Pain Syndrome Management:

Painful paroxysmal symptoms (trigeminal neuralgia, painful tonic spasms):

• Antiepileptics as first choice: carbamazepine, oxcarbazepine, lamotrigine, gabapentin, or pregabalin 2, 5

Chronic burning dysesthesias:

• TCAs (amitriptyline, nortriptyline, desipramine) or antiepileptics (gabapentin, pregabalin, lamotrigine) 2, 5
• Drug combinations with different mechanisms can reduce adverse effects 2

Spasticity-related pain:

• Physiotherapy as foundation 2
• Antispastic agents: baclofen or tizanidine 2
• For phasic spasticity: gabapentin or levetiracetam 2
• Severe cases: botulinum toxin injections or intrathecal baclofen 2

Musculoskeletal pain:

• Physiotherapy for malposition-induced pain 2
• Acetaminophen or NSAIDs as adjuncts 2

Important Clinical Pitfalls

• Pain is underreported - patients often don't mention pain spontaneously, requiring direct questioning 2
• Multiple pain syndromes coexist - combinations of dysesthesia, headaches, and musculoskeletal pain are frequent, requiring individualized treatment plans for each syndrome 2
• Treatment interactions - pain medications may worsen MS symptoms (e.g., increased fatigue from opioids), while MS treatments may cause pain (e.g., interferon-induced headaches) 4
• Low patient satisfaction - despite pain medications accounting for nearly 30% of all MS symptom treatment, patients report poor satisfaction with pain management 6