What are the treatment options for neck pain after a stroke?

Treatment Options for Neck Pain After Stroke

For neck pain after stroke, a multimodal approach including pharmacotherapy with amitriptyline or lamotrigine as first-line treatments, combined with therapeutic exercise and psychosocial support is recommended. 1

Diagnostic Considerations

Before initiating treatment, it's essential to determine the type of neck pain:

1. Central post-stroke pain

   • Burning or aching sensations
   • Often includes allodynia (pain from normally non-painful stimuli)
   • Located in an area corresponding to the brain lesion
   • Occurs in approximately 7-8% of stroke patients 1
   • Typically begins within days to one month after stroke

2. Hemiplegic shoulder/neck pain

   • Often related to subluxation, spasticity, or soft tissue injury
   • May have musculoskeletal and neuropathic components

3. Musculoskeletal neck pain

   • May be related to positioning, weakness, or compensatory movements

Pharmacological Management

First-line treatments:

• Amitriptyline: 75mg at bedtime has shown effectiveness in lowering pain ratings and improving function 1
• Lamotrigine: Effective for reducing daily pain and cold-induced pain (though only 44% of patients have good response) 1

Second-line treatments:

• Pregabalin: Mixed results for pain but improves sleep and anxiety 1
• Gabapentin: Limited studies for post-stroke pain specifically, but effective for neuropathic pain 1
• Carbamazepine or phenytoin: May be considered, though usefulness not well established 1
• Muscle relaxants: Cyclobenzaprine may be beneficial for musculoskeletal components of neck pain 2

Non-pharmacological Approaches

• Therapeutic exercise: Should be combined with pharmacotherapy 1
• Psychosocial support: Important component of comprehensive management 1
• Positioning and supportive devices: Reasonable for pain related to subluxation 1
• Botulinum toxin injections: Useful for severe hypertonicity in neck/shoulder muscles 1
• NMES (Neuromuscular Electrical Stimulation): May be considered for shoulder/neck pain 1

Advanced Interventions for Refractory Pain

• Motor cortex stimulation: Might be reasonable for intractable central post-stroke pain not responsive to other treatments 1, 3

  • Can achieve >50% pain reduction in 50-83% of patients
  • Effective for up to 2 years after implantation
  • Caution: Associated with complications including infection, hardware failure, seizures

• Suprascapular nerve block: May be considered as adjunctive treatment for hemiplegic shoulder/neck pain 1

Monitoring Treatment Response

• Use standardized serial measurements such as:
  • Pain diaries
  • Visual analog scales
  • Pain questionnaires 1

Important Cautions

1. TENS (Transcutaneous Electrical Nerve Stimulation) has not been established as effective for central post-stroke pain 1

2. Deep brain stimulation has conflicting evidence and cannot be recommended 1

3. Vertebral artery dissection should be considered in patients with sudden onset of new and unusual neck pain, especially with accompanying neurological symptoms 4, 5

   • This requires immediate medical attention as it can lead to stroke

4. Overhead pulley exercises are not recommended for shoulder rehabilitation as they may worsen pain 1

5. Cervical manipulation should be approached with extreme caution after stroke due to risk of vertebral artery complications 5

Special Considerations

• Elderly patients may require lower initial doses of medications due to altered pharmacokinetics 6
• Patients with hepatic impairment should start with lower doses and titrate slowly 6
• Cervical proprioception impairment is common in neck pain and may require specific rehabilitation approaches 7

By following this structured approach to diagnosis and treatment, most patients with post-stroke neck pain can achieve significant pain relief and improved quality of life.