Pain Management in Mitochondrial Disease

admin  ∼  October 2, 2015  ∼  Education Outreach Mitochondrial disease Migraines Muscle Treatment chronic disease Living with chronic pain abdominal neuropathic headache

VMP's Dr Fran Kendall Factoid Friday Blog on Rare Diseases


Unfortunately, chronic pain is a component of many disease processes.

Whether the acute pain from surgical incisions or the burning, searing pain from diabetic peripheral neuropathy, the presence of pain disrupts functioning and leads to a poor quality of life and often depression and hopelessness.

Sadly, mitochondrial disease, a multi system disorder, is often complicated by a variety of different pain issues some acute and others chronic making pain management more complex since chronic pain is often managed less effectively than acute pain.

The main categories of pain in mitochondrial disease include:

  • Abdominal Pain
  • Headaches and Migraines
  • Neuropathic or Nerve Pain
  • Muscle Pain,
  • Generalized Non-Localized Pain.

Abdominal Pain:

To effectively treat and manage pain, one must clarify the etiology of the discomfort as best as possible. Common causes of abdominal pain include gastroesophageal reflux disease, or Gerd, cyclic vomiting and abdominal migraines and dysmotility that can present as constipation or gastroparesis.

As such, effective treatment of certain pain may merely require the identification of the underlying process and subsequent implementation of therapy. For example, Gerd can often be effectively treated utilizing small frequent meals or H2 receptor antagonists or proton pump inhibitors. Other causes of abdominal pain such as gastroparesis can require a more complex approach to remedy discomfort including the use of various medications to help stimulate stomach muscles such as Erythromycin and in some cases Botox.

Headache and Migraine Pain:

Headache and migraine pain may be due to a secondary migraine disorder, autonomic dysfunction or associated with other triggers to include dehydration, intercurrent illness or hormonal fluctuations as can be found during menstrual cycles. As with causes of abdominal pain, the etiology of head pain should be discerned as best as possible given a variety of treatment modalities depending on the cause. 

A migraine disorder is defined as a chronic neurological disorder characterized by moderate to severe headache and nausea. The typical migraine headache is unilateral and pulsating in nature and last from 2 to 72 hours and often includes other symptomatology to include nausea, vomiting, and increased sensitivity to light and sound. Approximately one third of people who suffer from migraine headaches perceive an aura which is a transient Visual, sensory, language, or motor disturbance signaling the migraine will soon occur.

Medications for migraine treatment fall into two broad categories: pain relieving medications and preventative medications. Pain relieving medications are taken during migraine attacks and are designed to stop symptoms that have already begun. Preventative medications are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

There are a broad array of pain relieving medications to include over-the-counter ibuprofen or acetaminophen and some prescription drugs including triptans.

The management of chronic migraines requiring preventative medication can be more complex and the appropriate medication regimen for a given individual will be determined by his or her treating physician. Some categories of medication used as preventative medications include cardiovascular drugs such as beta blockers and antidepressants

Autonomic dysfunction is another cause for chronic headaches in mitochondrial patients. Dysautonomia is a broad term that describes any disease or malfunction of the autonomic nervous system and can be associated with excessive fatigue and thirst, lightheadedness and dizziness, rapid or slow heart rate, orthostatic hypertension and, of course headaches. The treatment of autonomic based migraines may be quite different than that of a chronic idiopathic migraine disorder and typically includes aggressive hydration therapy. In addition, other medications may be required to manage these migraines by stabilizing the autonomic dysfunction.

Neuropathic or Nerve Pain:

Neuropathic or nerve pain results in painful abnormal sensations primarily in the hands feet, arms and legs due to dysfunction of peripheral nerves.

The associated pain may be deep, burning and aching or sudden, sharp and stabbing. It also result in paresthesias that cause tingling, prickling or numbness. There are variety of topical analgesics that can reduce neuropathic pain as well as oral medications, the latter use for persistent problems.

Muscle Pain:

Many mitochondrial patient also struggle with muscle pain described as deep, aching pain in the legs or arms or back or cramping pain in the legs feet arms and hands. Muscle symptoms may be improved by the use of hot baths, supplemental magnesium, potassium, calcium per ticket through the ingestion of several foods rich in these components to include bananas, peaches, and apricots. Exercise and stretching helps some patients with cramping and good hydration is a standard approach to muscle symptomatology. However, persistent pain may require over-the-counter analgesics such as ibuprofen, topical pain medications, or systemic medications.

Generalized Non-Localized Pain:

A number of patients also struggle with generalized non-localized pain of a chronic nature. In general, the best approach to treating chronic pain is to keep it under control at all times.

There are two general groups of medications for chronic pain, non-opiates and opiates. For mild to moderate pain, we typically recommend the use of medications to include NSAIDS. Severe pain is often treated with opiate-based medications. However, mitochondrial patient should be aware that the use of these medications, while helpful for generalized, muscle and nerve pain may exacerbate abdominal pain due to its effect on G.I. functioning. In addition, if these medications are required, the use of longer acting forms of the drugs are preferable for chronic pain management.

As such, other classes of drug's should be considered for chronic pain management to include certain antidepressants and anticonvulsants.

Alternative approaches to chronic pain include massage, acupuncture, yoga, meditation and, cannabis-based products.

Overall, and in summary, pain and it's management are a large component to mitochondrial patient care. Pain may be generalizing or localized or isolated to a specific region of the body. Treatment and approaches to the management of a given patient's pain requires understanding of the etiology of their discomfort and it's pathophysiology so that the most appropriate pain regimen can be developed. With the help of an appropriate specialist, this aspect of mitochondrial disease care can be markedly improved.

Regards,

Dr Fran Kendall

The above blog was funded by a generous donation from the Foot Foundation. More can be learned at www.footfoundation.org.

This post is not meant to be a recommendation or a substitute for professional advice and services rendered by qualified doctors, allied medical personnel, and other professional services. The responsibility for any use of this information, or for proper medical treatment, rests with you.