What are the treatment options for post-stroke pain?

Treatment Options for Post-Stroke Pain

Anticonvulsants such as gabapentin or pregabalin should be used as first-line treatment for central post-stroke pain, followed by tricyclic antidepressants or SNRIs as second-line options, and opioids or tramadol for treatment-resistant cases. 1

Types of Post-Stroke Pain

• Central post-stroke pain (CPSP) affects 2-5% of stroke patients, resulting from damage to the spinothalamic tract, causing hypersensitivity to pain and sensory abnormalities in the face, arms, and/or legs 1
• Other common post-stroke pain locations include the head, leg, back, and shoulder 2
• Spasticity-related pain can result in significant functional disturbances and may lead to contractures if untreated 3

Pharmacological Management Algorithm

For Central Post-Stroke Pain:

1. First-line treatment:

   • Anticonvulsants: gabapentin or pregabalin 3, 1
   • These medications have shown efficacy in neuropathic pain conditions with fewer side effects than older medications 4

2. Second-line treatment:

   • Tricyclic antidepressants (e.g., amitriptyline 75mg at bedtime) 3, 5
   • SNRIs (particularly duloxetine) 3
   • Amitriptyline has been shown to lower daily pain ratings and improve global functioning 5

3. Treatment-resistant cases:

   • Opioids or tramadol may be considered, though caution is advised due to significant risk of physical dependency 3, 1
   • Lamotrigine can reduce daily pain ratings and cold-induced pain, though only 44% of patients have a good clinical response 5, 6

For Spasticity-Related Pain:

1. Non-pharmacological approaches:

   • Antispastic positioning, range of motion exercises, stretching, splinting, serial casting 3

2. Pharmacological options:

   • Tizanidine, dantrolene, and oral baclofen for spasticity resulting in pain 3
   • Botulinum toxin or phenol/alcohol injections for selected patients with disabling or painful spasticity 3
   • Intrathecal baclofen for chronic stroke patients with pain-causing spasticity 3

3. Avoid benzodiazepines:

   • Diazepam and other benzodiazepines should be avoided during stroke recovery due to possible deleterious effects on recovery and sedation side effects 3

Advanced Interventions for Refractory Pain

• Motor cortex stimulation might be reasonable for intractable central post-stroke pain not responsive to other treatments, achieving pain reductions >50% in 50-83% of patients for up to 2 years 1, 5
• Consider neurosurgical procedures such as selective dorsal rhizotomy or dorsal root entry zone lesion for spasticity resulting in pain that is unresponsive to other treatments 3
• IV medications such as lidocaine, ketamine, or propofol have shown efficacy for short-term control but are unsuitable for long-term treatment due to application challenges and potential side effects 6

Management Approach

• An individualized patient-centered approach implemented by an interdisciplinary team with expertise in mental health and central pain management is recommended 3, 1
• Pharmacotherapy should be combined with therapeutic exercise and psychosocial support 1, 5
• Treatment should be adjusted based on the patient's specific pain characteristics, comorbidities, and response to therapy 5

Common Pitfalls and Caveats

• CPSP is often underdiagnosed or misdiagnosed as musculoskeletal or visceral pain 1, 7
• Avoid attributing all post-stroke pain to CPSP without excluding other serious causes 1, 7
• TENS (transcutaneous electrical nerve stimulation) is not effective for central post-stroke pain and should not be used 5
• Be cautious with anticholinergic side effects of amitriptyline, particularly in elderly patients 7
• Appropriate and timely treatment of painful conditions is essential to maximize function, maintain quality of life, and prevent complications such as depression and cognitive dysfunction 2, 8