From the Guidelines
Post-stroke pain management should prioritize non-narcotic options, with opioids considered only as a last resort due to the significant risk of physical dependency, as recommended by the Canadian Stroke Best Practice Recommendations 1. The most effective approach to managing post-stroke pain involves an individualized patient-centered plan developed by an interdisciplinary team, including healthcare professionals with expertise in mental health and central pain management 1.
Non-Narcotic Options
Non-narcotic medications such as anticonvulsants (e.g., gabapentin or pregabalin) and tricyclic antidepressants (e.g., amitriptyline) or SNRIs (e.g., duloxetine) are recommended as first-line and second-line treatments, respectively, for central post-stroke pain 1. For instance, amitriptyline has been shown to lower daily pain ratings and improve global functioning 1.
Opioid Consideration
Opioids, including tramadol, may be considered for patients who are resistant to first and second-line treatments, but their use is advised with caution due to the risk of physical dependency 1. However, there is limited evidence on the efficacy of opioids for central post-stroke pain, and their use should be carefully weighed against potential risks 1.
Multidisciplinary Approach
A multidisciplinary approach, including pharmacotherapy, therapeutic exercise, and psychosocial support, is reasonable for managing central post-stroke pain 1. The response to treatment should be assessed with standardized serial measurements such as pain diaries, visual analog scales, or pain questionnaires 1.
Specialist Consultation
Given the complexity of post-stroke pain management, consultation with a neurologist or pain specialist is crucial to develop an appropriate treatment plan tailored to the individual's situation. This approach ensures that the treatment plan is personalized, considering the patient's specific condition, medical history, and needs, and may include a combination of medications, physical therapy, and other interventions 1, 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Post-Stroke Pain Management
The management of post-stroke pain, particularly central post-stroke pain (CPSP), is a complex issue with various treatment options available.
Opioids for Post-Stroke Pain
- Opioids are commonly used for chronic neuropathic pain, but their efficacy in treating central neuropathic pain, particularly CPSP, is not clear 2.
- Tramadol, an opioid analgesic, in combination with acetaminophen, has been shown to be effective in reducing pain in patients with CPSP 2.
- A systematic review and meta-analysis found that seven out of eight included studies showed an overall slight analgesic effect of opioids, with less consistent effects on other pain-related symptoms 3.
Comparison of Opioids
- There is limited evidence to support the efficacy of specific opioids in post-stroke pain management 3.
- Morphine and levorphanol have been evaluated in placebo-controlled studies, but the results are inconclusive due to the small number of studies and patients 3.
Other Treatment Options
- Adrenergic antidepressants, such as amitriptyline, are currently the first-line drugs for CPSP, but their effect is frequently incomplete 4, 5.
- Antiepileptics, such as lamotrigine, and GABAergic drugs, such as gabapentin or pregabalin, have recently emerged as potentially useful therapies for CPSP 4, 5.
- Non-pharmacological treatments, such as motor cortex stimulation or deep brain stimulation, may also be useful in certain patients 4, 5.
Medication Usage
- The most frequently prescribed classifications of pain medications for stroke survivors are other analgesics (acetaminophen and tramadol), followed by narcotic analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, and tricyclic antidepressants 6.
- Medications should be chosen based on the medical condition causing pain, the ability of the stroke survivor to comply with administration of the medication, and the cost of the medication 6.