Understanding neuropathic pain in neurological conditions

Living with a neurological condition such as multiple sclerosis (MS) can involve pain that feels confusing, exhausting and difficult to explain. For many people, this pain is not caused by an injury or inflammation in muscles or joints, but by changes within the nervous system itself. This type of pain is known as neuropathic pain. 

Pain is defined as:

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage.” – International Association for the Study of Pain

This definition is important because it recognises that pain is both physical and emotional. Pain is real to the person experiencing it, even when scans or tests do not show ongoing damage. The brain plays a central role in how pain is experienced. 

People with neurological conditions often experience more than one type of pain at the same time. 

This type of pain comes from damage or strain to body tissues such as muscles, joints, or skin. It is often described as aching, throbbing, sharp or sore. Examples may include, muscle strain, arthritis and pressure areas from reduced mobility.  

Neuropathic pain occurs when there is damage or disease affecting the nervous system itself. Neuropathic pain is often described as burning, shooting, electric shock-like sensations, tingling or ‘pins and needles’ or a stabbing pain.  Some people also notice that their skin feels numb, extremely sensitive, or painful to touch. 

Neuropathic pain is common in neurological conditions such as MS due to damage to nerve fibres and loss of the protective myelin coating around nerves. 

This pain relates to increased sensitivity of the nervous system, sometimes called central sensitisation. Pain may be widespread or disproportionate to any identifiable injury (or no injury seen at all).  

These symptoms can fluctuate and in addition to pain, the person may experience fatigue, sleep disturbances, brain fog and increased sensitivity to touch, sound, light or temperature.  

Neuropathic pain does not have a single cause. It often develops due to several interacting changes, including, demyelination (loss of myelin around nerves), damage to nerve fibres (axonal injury), inflammation within the nervous system, increased sensitivity in the brain and spinal cord and changes in how the brain processes pain signals.

Due to these interacting changes, pain can continue even when medical imaging shows no new disease activity. 

Central sensitisation occurs when the brain and spinal cord become hypersensitive to pain signals. This can mean that pain feels stronger than would normally be expected, gentle touch or clothing can feel painful (also known as allodynia) and pain lasts longer than the original trigger.

Factors that can result in central sensitisation includes, repeated pain signals, ongoing inflammation and reduced ability of the brain to dampen pain messages.

Pain is best understood by looking at three connected areas:

• Biological factors: Nervous system changes, inflammation, muscle spasm or stiffness and disease processes.
• Psychological factors: Emotional wellbeing, stress, anxiety, or low mood, beliefs about pain and coping strategies.
• Social factors: family and carer support, social connection or isolation, work, finances and access to care.  

All three areas overlap and interact. For example, stress and poor sleep can increase pain sensitivity, while strong support and helpful coping strategies can make pain easier to manage and help modulate the nervous system.  

If you’ve ever been asked to rate your pain on a scale from 1 to 10, you know how frustrating it can be. The truth is, assessing pain requires looking at much more than just a number. Some helpful approaches can include observing behaviour and daily function, understanding the person’s normal abilities, involving family and carers and sing validated tools such as the Abbey Pain Scale. 

Most importantly, consistency matters – pain assessments are most reliable when done by the same person/s over time.

Neuropathic pain is usually best managed using a combination of strategies, tailored to the individual.  

Movement and physical therapy can play an important role in pain management. These may include, physiotherapy, gentle strengthening and stretching, aerobic exercise, aquatic (pool‑based) therapies or other modalities

Additionally, you may consider reaching out to an occupational therapist who can help with positioning and body alignment, pressure‑relieving measures, such as cushions or mattresses, fatigue management and pacing of activities and assistive devices to make daily tasks easier. 

Understanding pain can also reduce feelings of fear and improve confidence. Our multidisciplinary team can help you identify pain triggers, pace activities to prevent flare-ups, manage stress and fatigue, challenge unhelpful thoughts about pain and use relaxation and mindfulness techniques.  

Medications used for nerve pain often work gradually and may need careful dose adjustment. Your doctor is your primary person to consult for medication-related advice, followed by your pharmacist. A Neurological Liaison Nurse can liaise with these people and help with some medication queries.

Common options include:

• Antidepressants
• Anticonvulsants
• Muscle relaxants

Topical treatments such as local anaesthetic or capsaicin patches.  

Opioids are not indicated for neuropathic pain and will have minimal effect, though paracetamol or anti-inflammatories can help in some circumstances. Discuss with your doctor, including over-the-counter medications, as they can interact with your regular prescribed medications.

It’s important to note that it can take several weeks to notice benefit, and different people respond differently. 

In some cases, additional treatments may be considered, including nerve blocks for specific pain patterns, referral to a multidisciplinary pain clinic or surgery (rarely, when pain is caused by clear nerve compression). 

If you or a loved one is experiencing pain from a neurological condition, your feelings are real and valid. Pain does not always mean the condition is worsening. However, you do not have to manage the pain alone, we can support you in this manner through movement, education and emotional support to ensure you feel seen and heard.  

Early, integrated pain management can improve comfort, independence and quality of life.