Therapie von Schmerzen bei MS - eine Übersicht mit evidenzbasierten Therapieempfehlungen

Zusammenfassung

Schmerzen sind ein häufiges Problem für Multiple Sklerose-(MS)-Patienten, das oft gezielt erfragt werden muss. Sie lassen sich unter diagnostischen und therapeutischen Gesichtspunkten in 4 Kategorien einteilen: 1. Schmerzen als direkte Folge einer MS: Schmerzhafte paroxysmale Symptome wie die Trigeminusneuralgie oder schmerzhafte tonische Verkrampfungen der Extremitätenmuskulatur werden mit Carbamazepin als Mittel der ersten Wahl behandelt, Alternativen sind Lamotrigin, Gabapentin, Oxcarbazepin und andere Antikonvulsiva oder auch Misoprostol. Schmerzhafte „brennende” Missempfindungen bzw. Dysästhesien als häufigstes chronisches Schmerzsyndrom sprechen vor allem auf trizyklische Antidepressiva wie Amitriptylin an oder auf Carbamazepin. Alternativen sind Gabapentin und Lamotrigin. In der Eskalation kommen auch Opioide zum Einsatz, der Stellenwert der Cannabinoide ist derzeit noch nicht abschließend zu bewerten. 2. Schmerzen als indirekte Folge der MS: Schmerzhaft einschießende Spastik bessert sich oft unter adäquater Lagerung, medikamentös unter klassischen Antispastika wie Baclofen oder Tizanidin. Eine Alternative ist Gabapentin, in der Eskalation lokal Botulinumtoxin bzw. intrathekal Baclofen. Durch Fehlhaltung bedingte Gelenk- und Muskelschmerzen lassen sich durch Krankengymnastik und physikalische Therapie lindern, Druckläsionen durch optimal angepasste Hilfsmittel vermeiden. 3. Schmerzen durch therapeutische Maßnahmen kommen lokal vor allem bei subkutaner Injektion von β-Interferonen oder Glatiramerazetat vor und lassen sich durch optimale Technik bzw. lokale Kühlung positiv beeinflussen. Die systemischen Interferon-Nebenwirkungen wie Myalgien lassen sich durch Paracetamol oder Ibuprofen reduzieren. 4. Primär MS-unabhängige Schmerzen wie Rücken- oder Kopfschmerzen treten häufig auch bei MS-Betroffenen auf, können durch die Erkrankung jedoch beeinflusst werden. Die Therapie folgt den entsprechenden Leitlinien. Insgesamt wird nach genauer Analyse eines Schmerzes und seines Zusammenhangs mit der MS eine spezifische Therapie nach evidenzbasierten Kriterien möglich, die die Lebensqualität vieler Betroffener bessern hilft.

Abstract

While pain is a common problem in multiple sclerosis (MS) patients, it is frequently overlooked and has to be asked for actively. Pain can be classified into 4 diagnostically and therapeutically relevant categories. 1. pain directly related to MS: Painful paroxysmal symptoms like trigeminal neuralgia or painful tonic spasms are treated with carbamazepine as first choice, or lamotrigine, gabapentin, oxcarbazepine and other anticonvulsants. Painful “burning” dysaesthesias, the most frequent chronic pain syndrome, are treated with tricyclic antidepressants or carbamazepine, further options include gabapentin or lamotrigine. While escalation therapy may require opioids, the role of cannabinoids in the treatment of pain still has to be determined. 2. Pain indirectly related to MS: Pain related to spasticity often improves with adaequate physiotherapy. Drug treatment includes antispastic agents like baclofen or tizanidine, alternatively gabapentin. In severe cases botulinum toxin injections or intrathecal baclofen merit consideration. Physiotherapy and physical therapy may ameliorate malposition-induced joint and muscle pain. Moreover, painful pressure lesions should be avoided using optimally adjusted aids. 3. Treatment-related pain can occur with subcutaneous injections of beta interferons or glatiramer acetate and may be reduced by optimizing the injection technique and by local cooling. Systemic side effects of interferons like myalgias can be reduced by paracetamol or ibuprofen. 4. Pain unrelated to MS such as back pain or headache are frequent in MS patients and may be worsened by the disease. Treatment should be follow established guidelines. In summary, a careful analysis of the pain syndrome will allow the design of the appropriate treatment plan using various medical and non-medical options and thus will help to ameliorate the patients' quality of life.

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