From the Guidelines
Neuropathic pain post-stroke should be treated with a choice of amitriptyline, duloxetine, gabapentin, or pregabalin as initial treatment, with consideration of switching to another option if the initial treatment is not effective or tolerated, as recommended by the most recent guidelines 1. The treatment of neuropathic pain post-stroke is crucial to improve the quality of life of stroke survivors.
- First-line medications include:
- Gabapentinoids such as gabapentin (starting at 300mg daily, gradually increasing to 1800-3600mg daily in divided doses)
- Pregabalin (starting at 75mg twice daily, increasing to 300-600mg daily)
- Tricyclic antidepressants like amitriptyline (10-25mg at bedtime, increasing to 25-150mg)
- Duloxetine (30-60mg daily)
- For localized pain, capsaicin cream can be considered for people who wish to avoid or cannot tolerate oral treatments 1.
- Non-pharmacological approaches, including physical therapy, occupational therapy, and cognitive behavioral therapy, should be incorporated into the treatment plan.
- Regular reassessment is essential to monitor efficacy and adjust treatment as needed, with consideration of switching to another option if the initial treatment is not effective or tolerated 1. Key considerations in the treatment of neuropathic pain post-stroke include the individualization of treatment to the patient's needs and response to therapy, as well as the potential side effects of medications 1. The diagnosis of central post-stroke pain should be based on established diagnostic criteria, and the choice of pharmacological agent should be individualized to the patient's needs and response to therapy 1.
From the Research
Neuropathic Pain Post Stroke
- Neuropathic pain is a common sequelae of stroke, with central post-stroke pain (CPSP) being a specific type of neuropathic pain caused by the brain lesion itself 2, 3, 4.
- The prevalence of CPSP is estimated to be between 1-8% of stroke patients, although it can be a major problem due to its persistent and often treatment-resistant nature 2, 3, 4.
- The pathogenesis of CPSP is not yet fully understood, but suggested underlying causes include hyperexcitation in the damaged sensory pathways, damage to the central inhibitory pathways, or a combination of the two 2, 3, 4.
Treatment Options
- Pharmacological treatment options for CPSP include amitriptyline, lamotrigine, and gabapentinoids as first-line therapies 2, 3.
- Other drugs such as fluvoxamine, steroids, and intravenous infusions of lidocaine, ketamine, or propofol can be considered in intractable cases 3.
- Non-pharmacological treatments such as motor cortex stimulation or transcranial magnetic stimulation have also been shown to provide relief in difficult-to-treat patients 2, 3.
- In general, neuropathic pain is best treated with regularly dosed medications, balancing efficacy and tolerability, and may involve a combination of anticonvulsants, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors 5, 6.
Specific Medications
- Amitriptyline is currently the first-line drug for CPSP, although its effect is frequently incomplete and high doses may not be tolerated in stroke patients 2, 4.
- Lamotrigine has been found to be effective in controlled trials and can be used as an alternative or additive therapy 2.
- Gabapentin and pregabalin have emerged as potentially useful therapies for CPSP, and may also improve pain-related anxiety and sleep disturbances 2, 5.