What is the optimal management strategy for pain in patients with Normal Pressure Hydrocephalus (NPH)?

The best way to manage pain in normal pressure hydrocephalus (NPH) is to first identify and treat the underlying cause of NPH through surgical intervention, typically with ventriculoperitoneal (VP) shunt placement. For symptomatic pain management before or after shunt placement, acetaminophen (500-1000mg every 6 hours, not exceeding 4000mg daily) is recommended as first-line therapy due to its favorable safety profile. If additional pain control is needed, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-600mg every 6-8 hours) may be used cautiously, especially in elderly patients who commonly have NPH. For more severe pain, low-dose opioids such as tramadol (50-100mg every 6 hours) can be considered for short-term use while monitoring for side effects like constipation and cognitive impairment. Pain in NPH often stems from gait disturbances causing falls or musculoskeletal strain, so physical therapy and assistive devices are important adjunctive treatments. Additionally, treating comorbid conditions like osteoarthritis that may contribute to pain is essential. Regular pain assessments using standardized scales help guide treatment adjustments, particularly important since NPH patients may have cognitive impairments affecting their ability to communicate pain effectively.