|
Pain Management in CFS/ME |
|
Pains are common in CFS/ME and are of various types. Fibromyalgic pain is common and this typically causes markedly tender spots (in an accepted distribution). The pain is due to misperception in the brain of incoming non-pain signals from the affected area. I liken it to an old-fashioned telephone switchboard, where someone is randomly connecting the wires to the wrong place. Exercise-induced muscle ache is most likely to be due to failure to clear lactic acid from the muscles, due to impairment of the normal automatic regulation of blood flow through the muscles. This is linked to the problems with the autonomic nervous system. Headaches are common and migraine becomes more frequent and more severe.
Normal pain killers such as codeine and dihydrocodeine do not tend to be helpful in CFS/ME as they increase sleepiness and regular use increases headaches or may be a cause of headaches. This type of drug should be avoided. As there is little in the way of joint or muscle inflammation, drugs such as ibuprofen which act as anti-inflammatories tend not to be very helpful, although are usually recommended for mild fibromyalgia. Paracetamol may be helpful in mild symptoms. More severe pain may be helped by tramadol, which does not have the same effect on headaches as codeine. Where there are localised tender spots particularly over ribs then using local anaesthetic gels may give some relief. Stronger pain killers may be used but only with specialist advice and close monitoring. Most potent pain-killers increase fatigue and sleepiness. Management is therefore about finding the right balance of control and side effects in an individual patient: everyone is different. Fibromylagic pain tends to respond better to drugs which act on the brain. Very low dose amitryptiline at night may relieve night time pain and improve sleep. A few patients are able to tolerate small day-time doses as well. The starting dose should be 10 mg only and increased gradually. Other drugs which tend to be helpful include drugs used for controlling epilepsy such as sodium valproate, gabapentin and pregabalin. The key is always to start with small doses and build up gradually. I tend to start with sodium valproate as it also improves mood. If one drug doesn’t work then it is sensible to try one of the others. Migraine can be troublesome and if frequent, then using preventative drugs is helpful. Propranolol is often used as a preventative drug, but this can make fatigue much worse and should be avoided. Pizotifen which is taken once a day at night is much better and also helps improve sleep. Sodium valproate, gabapentin and pregabalin also have useful anti-migraine activity, which is very helpful where other types of pain are a problem as well There are other newer drugs but review by a migraine specialist is advisable before using them. Chronic pain can cause low mood and anti-depressants can be helpful, although they do not affect the underlying CFS/ME. Duloxetine is often recommended for fibromylagia. Citalopram tends to be better tolerated than fluoxetine and paroxetine. The same rule of starting with a low dose and building up slowly applies. I am very keen that, where anti-depressants are used, there is a clear plan for the duration of therapy agreed before the drug is started. Other approaches include more physical or alternative therapies. TENS machines can provide some relief in some patients, but may be ineffective in others. The effects of acupuncture on pain in CFS/ME are variable, but on the whole it does not seem to benefit large numbers of patients. Any form of massage-based therapy can often provide an important degree of relaxation which will improve pain. It is important for CFS/ME sufferer to discuss their pain symptoms with their GP and/or their therapy team, particularly if they are having difficulty in finding a suitable drug regime. Dr. G.P.Spickett |