What are the management options for post-stroke pain syndrome?

Management of Post-Stroke Pain Syndrome

The first-line treatment for post-stroke pain syndrome should be amitriptyline 75 mg at bedtime combined with therapeutic exercise and psychosocial support, as this has been shown to lower daily pain ratings and improve global functioning. 1

Diagnosis and Assessment

• Diagnosis of central post-stroke pain should be based on established criteria: pain occurring after stroke, located in an area corresponding to the central nervous system lesion, and not attributable to nociceptive or peripheral neuropathic causes 1
• The incidence of central post-stroke pain is estimated at 7-8%, typically beginning within a few days after stroke, with most patients becoming symptomatic within the first month 1
• Response to treatment should be monitored using standardized serial measurements such as pain diaries, visual analog scales, or pain questionnaires 1

Pharmacological Management Algorithm

First-Line Treatments:

• Amitriptyline 75 mg at bedtime - shown to lower daily pain ratings and improve global functioning 1, 2
• Lamotrigine - can reduce daily pain ratings and cold-induced pain, though only 44% of patients have a good clinical response 1, 2

Second-Line Treatments (if first-line fails):

• Pregabalin - mixed results for pain but may improve sleep and anxiety 1
• Gabapentin - limited studies for post-stroke pain specifically but effective in other neuropathic pain conditions 1, 3
• Carbamazepine or phenytoin - usefulness not well established but may be considered 1

Non-Pharmacological Options

• Interprofessional pain management in conjunction with pharmacotherapy is recommended 1
• TENS (transcutaneous electrical nerve stimulation) is not effective and should not be used 1
• Motor cortex stimulation might be reasonable for intractable central post-stroke pain not responsive to other treatments in carefully selected patients 1
  • Can achieve pain reductions >50% in 50-83% of patients for up to 2 years 1
  • Associated with complications including infection, hardware failure, postoperative seizures, and long-term epilepsy 1
• Deep brain stimulation has conflicting evidence and cannot be recommended 1

Comprehensive Management Approach

• Pharmacotherapy should be combined with therapeutic exercise and psychosocial support 1
• Treatment should be individualized based on patient's specific pain characteristics, comorbidities, and response to therapy 1
• Recent meta-analysis shows pharmacological therapy has a small effect on mean pain score, while neuromodulation treatments have a moderate effect 4

Pitfalls and Caveats

• Central post-stroke pain is often underdiagnosed or misdiagnosed as musculoskeletal or visceral pain 5, 6
• Be cautious with medication side effects, particularly anticholinergic effects of amitriptyline in elderly patients 5, 3
• Avoid attributing all pain to central post-stroke pain without excluding other serious causes 5, 6
• Pain after stroke is associated with depression, cognitive dysfunction, and impaired quality of life, making effective management crucial for optimal recovery 7, 6