Most of what we have learned about pain in the last few years has helped answer why patients with some pain syndromes, have pain. Fibromyalgia, irritable bowel syndrome, interstitial cystitis, TMJ, chronic low back pain, and tension headaches have associated pain that is difficult to treat with traditional medications. Specific options for treatment of this kind of pain are now available with many more on the horizon.
Think of neuropathic pain as being driven either by the peripheral or central nervous system.
Central neuropathic pain states are conditions such as fibromyalgia, irritable bowel syndrome, TMJ, interstitial cystitis, tension headache, chronic low back pain and even osteoarthritis of the knee. The overwhelming evidence has shown that the pain in these conditions is occurring primarily because of altered pain processing, without there necessarily being any damage or ongoing pain from the periphery. Does that mean “it’s all in your head?” Absolutely not.
There is now overwhelming evidence for a strong biologic reason for these symptoms. Everyone needs to look at the central problem in these patients and guide treatment as such. For example, altered levels of neurotransmitters are found in fibromyalgia patients leading to the change in sensory transmission.
Central pain (as in the above listed conditions) is typically characterized by:
- Multifocal pain (pain in lots of areas.)
What medications don’t work for treatment of these conditions:
- Multiple other symptoms: fatigue, memory difficulties and sleep disturbances.
- A higher level of current and lifetime history of pain.
- A family history of pain (there is evidence of a genetic component in chronic pain.)
- Hyperalgesia: patients have increased pain to normally painful stimuli.
- Allodynia: pain from normally non-painful stimuli.
- On history or on physical exam, these individuals will often have pain just with light brushing of the skin, light pressure or may even report pain from wearing tight-fitting clothes, for example.
- Opioids are not effective in central pain states and have shown no benefit in treatment of fibromyalgia patients.
What medications have been shown to work (Centrally acting analgesics):
- NSAIDS (naproxen, Advil, ibuprofen, Celebrex) and acetaminophen (Tylenol) primarily work peripherally and don’t have much benefit in central pain states.
- Drugs that enhance the effect of the GABA receptors: benzodiazepines (Ativan. Xanax), muscle relaxants like Baclofen or cyclobenzaprine (Flexeril.)
- SNRI’s (serotonin norepinephrine reuptake inhibitors): Cymbalta, Savella.
- Tricyclic antidepressants.
- Alpha-2-delta ligand drugs: Lyrica or Neurontin (gabapentin.)
- Anticonvulsants: like carbamazepine (Tegretol.)
Tell us what your experience has been. The addition of Savella, Lyrica, and Cymbalta, among others, has been encouraging for people suffering with these difficult conditions.
- Dr O.