What is the recommended treatment for chronic post-stroke pain syndrome?

Management of Chronic Post-Stroke Pain Syndrome

First-line treatment for chronic post-stroke pain syndrome should be anticonvulsants such as gabapentin or pregabalin, followed by tricyclic antidepressants or SNRIs as second-line options, and opioids or tramadol for treatment-resistant cases. 1, 2, 3

Understanding Central Post-Stroke Pain (CPSP)

• Central post-stroke pain affects 2-5% of stroke patients, resulting from damage to the spinothalamic tract, causing hypersensitivity to pain and sensory abnormalities 4, 1
• Primary symptoms include pain and loss of sensation in the face, arms, and/or legs, which may worsen with exposure to temperature changes or emotional distress 4
• CPSP significantly impacts activities of daily living, sleep quality, and overall quality of life 1, 2
• Pain typically begins within days to a month after stroke, with most patients becoming symptomatic within the first month 2

Pharmacological Management Algorithm

First-Line Treatment

• Anticonvulsants such as gabapentin or pregabalin are recommended as first-line treatment for CPSP 4, 1, 5
• Gabapentin has shown significant pain reduction and improved function in patients with CPSP 6
• Pregabalin may improve pain-related anxiety and sleep disturbances in addition to pain control 1, 7

Second-Line Treatment

• Tricyclic antidepressants (e.g., amitriptyline 75mg at bedtime) are recommended when first-line treatments are ineffective 4, 1, 3
• SNRIs (particularly duloxetine) are effective alternatives to tricyclic antidepressants 1
• Lamotrigine can reduce daily pain ratings and cold-induced pain, though only 44% of patients have a good clinical response 1, 3

Treatment-Resistant Cases

• Opioids or tramadol may be considered for treatment-resistant cases, though caution is advised due to significant risk of physical dependency 4, 1
• Fluvoxamine may be used adjunctively in some patients 1, 7
• Intravenous infusions of lidocaine, ketamine, or propofol can be considered in intractable cases 5

Non-Pharmacological Interventions

• An individualized patient-centered approach implemented by an interdisciplinary team with expertise in mental health and central pain management is recommended 4, 1
• 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, 2
• Transcranial magnetic stimulation has shown relief in difficult-to-treat patients 5

Common Pitfalls and Caveats

• CPSP is often underdiagnosed or misdiagnosed as musculoskeletal or visceral pain 1, 2
• Avoid attributing all post-stroke pain to CPSP without excluding other serious causes, such as shoulder-hand syndrome (a complex regional pain syndrome) 1, 8
• TENS (transcutaneous electrical nerve stimulation) is not effective for central post-stroke pain and should not be used 1, 3
• Be cautious with anticholinergic side effects of amitriptyline, particularly in elderly patients 1, 9
• Monitor treatment response using standardized serial measurements such as pain diaries, visual analog scales, or pain questionnaires 3

Special Considerations

• Shoulder pain after stroke may be related to glenohumeral subluxation and requires specific management approaches 8
• Headache, leg pain, back pain, and shoulder pain are the most common pain locations in stroke survivors 9
• Pharmacotherapy should be combined with therapeutic exercise and psychosocial support for optimal outcomes 1, 3