What are the recommended treatments for post-stroke pain?

Treatment of Post-Stroke Pain

For post-stroke pain management, a stepwise pharmacological approach starting with amitriptyline or lamotrigine as first-line treatments, followed by pregabalin or gabapentin as second-line options, and opioids as third-line therapy is recommended, combined with appropriate non-pharmacological interventions. 1

Types of Post-Stroke Pain

• Central Post-Stroke Pain (CPSP):

  • Affects 2-8% of stroke patients
  • Characterized by burning or aching sensations, often with allodynia
  • Located in areas corresponding to brain lesion 2

• Hemiplegic Shoulder/Neck Pain:

  • Related to subluxation, spasticity, or soft tissue injury
  • May have both musculoskeletal and neuropathic components 2

• Musculoskeletal Pain:

  • Often related to spasticity, positioning issues, or compensatory movements 1

Pharmacological Management Algorithm

First-Line Treatments:

• Anticonvulsants: Lamotrigine (effective for reducing daily pain, though only 44% of patients have good response) 1, 2
• Tricyclic Antidepressants: Amitriptyline 75mg at bedtime (shown to lower pain ratings and improve function) 1

Second-Line Treatments:

• Other Anticonvulsants: Pregabalin or gabapentin (effective for neuropathic pain components) 1
• SNRIs: Particularly duloxetine 1

Third-Line Treatments:

• Opioids or tramadol (for resistant cases, with caution due to dependency risk) 1
• Carbamazepine or phenytoin (limited evidence but may be considered) 1

Management of Spasticity-Related Pain

1. Non-pharmacological approaches:

   • Antispastic positioning
   • Range of motion exercises
   • Stretching
   • Splinting or serial casting 1

2. Pharmacological options:

   • Tizanidine (particularly effective in chronic stroke patients)
   • Dantrolene
   • Oral baclofen 1
   • Avoid diazepam or other benzodiazepines during stroke recovery due to possible negative effects on recovery 1

3. Interventional options (for severe cases):

   • Botulinum toxin injections for focal spasticity
   • Phenol/alcohol injections
   • Intrathecal baclofen for chronic cases 1
   • Neurosurgical procedures (selective dorsal rhizotomy or dorsal root entry zone lesion) in refractory cases 1

Advanced Interventions for Refractory Central Pain

• Motor cortex stimulation: May be reasonable for intractable central post-stroke pain, with >50% pain reduction in 50-83% of patients, though associated with complications including infection, hardware failure, and seizures 1, 2
• TENS: Not established as effective for central post-stroke pain 1
• Deep brain stimulation: Not recommended due to conflicting evidence 1, 2

Monitoring Treatment Response

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

Important Clinical Considerations

• Pain after stroke is often undertreated but significantly impacts recovery and quality of life 3
• Gabapentin has shown promise in treating thalamic pain syndrome (a type of CPSP) in recent studies 4
• The choice of medication should consider the patient's comorbidities, potential side effects, and drug interactions 5
• Stroke patients often have multiple pain locations, with head, leg, back, and shoulder being most common 6

By following this structured approach to post-stroke pain management, clinicians can effectively address this challenging complication and improve patients' functional outcomes and quality of life.