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Pain and Multiple Sclerosis

Many options are available to treat pain in patients with multiple sclerosis.

Anticonvulsant Drugs Offer Relief

For the most part, however, acute MS pain can't be effectively treated with aspirin, ibuprofen, or other common OTC pain reliever medications or treatments. "Since most MS pain originates in the central nervous system, it makes it a lot more difficult to control than joint or muscle pain," says Kathleen Hawker, MD, an assistant professor of neurology in the multiple sclerosis program at the University of Texas Southwestern Medical Center in Dallas (UTSW).

So what's the alternative? In many cases, the treatment of choice is one of a range of anticonvulsant medications, such as Neurontin and Tegretol. "The main thing that links them all up is that we're not quite sure how they work -- either for seizures or for pain," says Hawker. Since the FDA hasn't officially approved these anticonvulsants for the treatment of pain, they're all being used "off-label," but Neurontin, for example, is prescribed five times more often for pain than for seizures, says Hawker.

"In the vast majority of patients, these medications do work," says George Kraft, who directs the Multiple Sclerosis Rehabilitation, Research, and Training Center and the Western Multiple Sclerosis Center at the University of Washington in Seattle. "There's a problem, though, in that most of them can make people sleepy, groggy, or fatigued, and MS patients have a lot of fatigue anyway."

The good news: Most pain in MS can be treated. There are more than half a dozen of these anticonvulsants, and they all have a slightly different mechanism of action and different side effects. The side effects of these drugs can also include low blood pressure, possible seizures, and dry mouth. They can also cause some weight gain.

"Some drugs are so similar to each other that if one drug in the class fails, another is unlikely to work," says Hawker. "That's not the case with these. Which one you use for which patient depends on the side effect profile."

Finding the right anticonvulsant is all about trial and error, says Bethoux. "We'll start them at the lowest possible dose of one medication and increase it until the person feels comfortable or until side effects aren't tolerable. If one medication doesn't work, we'll try another," he says. "It's a process that can take a long time, but it's the only way we have to do this."

New Frontiers in Treatment

Some patients, however, still haven't found the right drug and the right dosage to control their pain. "About 1% to 2% of patients have extremely refractory pain that's very hard to manage," says Kraft. So MS experts are still looking for options to add to their treatment arsenal.

One intriguing possibility: Botox. The anti-wrinkle injections popular with Park Avenue socialites have shown promise in helping to control some types of MS pain. Botox, which acts locally to temporarily paralyze a nerve or muscle, has been used for years at some multiple sclerosis clinics, including Hawker's, to manage spasticity and bladder problems. "Serendipitously, we found that it also seemed to have an effect on pain," she says. "It's far from being a known treatment for pain in MS at this point, but it's an exciting possibility."

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