What is the relationship between Tramadol (tramadol hydrochloride) and ischemic strokes?

From the Guidelines

Tramadol does not directly cause strokes, but it may slightly increase stroke risk in certain individuals, particularly those with pre-existing cardiovascular conditions, hypertension, or stroke risk factors, as it can potentially raise blood pressure or cause serotonin syndrome when combined with other serotonergic medications 1.

Key Considerations

• Tramadol is an opioid pain medication that works by binding to opioid receptors and inhibiting serotonin and norepinephrine reuptake.
• People with existing cardiovascular conditions, hypertension, or stroke risk factors should use tramadol cautiously.
• The medication can potentially raise blood pressure or cause serotonin syndrome when combined with other serotonergic medications, which might indirectly increase stroke risk.

Recommendations

• If you're taking tramadol and experience sudden symptoms like facial drooping, arm weakness, speech difficulties, severe headache, dizziness, or vision changes, seek emergency medical attention immediately as these could indicate a stroke.
• Always take tramadol exactly as prescribed, typically 50-100 mg every 4-6 hours as needed for pain, not exceeding 400 mg daily (200 mg for elderly patients) 1.
• Discuss your complete medical history and all medications with your healthcare provider before starting tramadol to minimize potential risks.

Management of Stroke Risk

• The management of patients with acute ischemic stroke is multifaceted, and indications for specific therapies vary among patients 1.
• Antihypertensive treatment is recommended for prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke and are beyond the hyperacute period 1.
• Elevated blood pressure can result from the stress of the stroke, a full bladder, pain, preexisting hypertension, a physiological response to hypoxia, or increased intracranial pressure, and should be managed cautiously 1.

From the Research

Tramadol and Stroke

• Tramadol is a pain medication that can be used to treat pain in stroke survivors 2
• The most common locations of pain in stroke survivors are the head, leg, back, and shoulder, and tramadol is one of the most frequently prescribed medications for pain management in this population 2
• However, there is no direct evidence to suggest that tramadol increases the risk of ischemic stroke 3
• In fact, a study found that diclofenac and aceclofenac increase the risk of ischemic stroke, while ibuprofen and naproxen do not, and paracetamol does not increase the risk even in patients with a high background cardiovascular risk 3
• Tramadol has a unique mechanism of action that combines a weak opioid effect with a monoaminergic mode of action, which distinguishes it from other opioids and makes it a useful agent for treating moderate-to-severe pain, including neuropathic pain 4, 5

Management of Stroke

• The management of transient ischemic attack (TIA) and acute ischemic stroke (AIS) involves the use of dual antiplatelet therapy, anticoagulation, and mechanical thrombectomy in select patients 6
• Patients presenting with nondisabling AIS or high-risk TIA should receive dual antiplatelet therapy with aspirin and clopidogrel within 24 hours of presentation, followed by single antiplatelet therapy 6
• Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation 6
• Intravenous alteplase improves the likelihood of minimal or no disability in patients with AIS and disabling deficits interfering with activities of daily living, when administered within 3 hours of presentation 6