From the Guidelines
Post-stroke neuropathic pain can be effectively managed with oral medications, with first-line options including amitriptyline, duloxetine, gabapentin, or pregabalin, as recommended by the most recent guidelines 1. When selecting an oral medication for post-stroke neuropathic pain, it is essential to consider the individual patient's needs and response to therapy, as well as potential side effects, as suggested by the American Heart Association/American Stroke Association guidelines 1. The choice of medication should be based on the patient's specific condition, with anticonvulsants like gabapentin (starting at 300mg daily, gradually increasing to 1800-3600mg daily in divided doses) or pregabalin (starting at 75mg twice daily, increasing to 300-600mg daily) being effective options, as well as tricyclic antidepressants like amitriptyline (10-25mg at bedtime, gradually increasing to 75-150mg) 1. Key considerations for treatment include:
- Starting with low doses and titrating up slowly to minimize side effects
- Regular monitoring for efficacy and adverse effects
- Individualizing treatment based on patient response and needs
- Considering alternative options, such as capsaicin cream for localized neuropathic pain, if oral treatments are not effective or tolerated 1. It is crucial to prioritize the patient's quality of life, morbidity, and mortality when selecting a treatment option, and to regularly assess and adjust the treatment plan as needed, in accordance with the most recent and highest-quality guidelines 1.
From the Research
Oral Medication Options for Post-Stroke Neuropathic Pain
The following oral medications have been studied for the treatment of post-stroke neuropathic pain:
- Amitriptyline, an adrenergic antidepressant, is currently considered a first-line drug for central post-stroke pain (CPSP) 2, 3
- Lamotrigine, an antiepileptic, has been found to be effective in a controlled trial and can be used as an alternative or additive therapy 2, 3
- Gabapentin, a GABAergic drug with potential calcium channel-blocking effects, has been reported to control CPSP in a few patients and may be an effective medication for the treatment of central post-stroke pain syndrome 4, 2, 3
- Pregabalin, another GABAergic drug, has demonstrated efficacy in several forms of neuropathic pain and may improve pain-related anxiety and sleep disturbances, although its long-term efficacy in CPSP is unproven 2, 5
- Other medications such as fluvoxamine and mexiletine may be used adjunctively in some patients 2
Key Findings
- A study found that gabapentin may be an effective medication for the treatment of central post-stroke pain syndrome, with significant reduction in average pain and improvement in level of function 4
- A review of the literature found that amitriptyline and lamotrigine are the only oral drugs proven to be effective in the treatment of CPSP in a placebo-controlled study 3
- A study evaluating the efficacy and safety of pregabalin in patients with CPSP found that although pain reductions at endpoint did not differ significantly between pregabalin and placebo, improvements in sleep, anxiety, and clinician global impression of change suggest some utility of pregabalin in the management of CPSP 5