Is tramadol (tramadol hydrochloride) appropriate for a patient with a history of hemiplegic stroke?

From the Guidelines

Tramadol should only be considered for patients with a history of hemiplegic stroke who are resistant to first and second line treatments for Central Post Stroke Pain (CPSP), and its use should be approached with caution due to the risk of physical dependency and other potential adverse effects. When managing CPSP in patients with a history of hemiplegic stroke, it is essential to follow a stepped approach to treatment, starting with low-dose, centrally acting analgesics, anticonvulsants, or tricyclic antidepressants as first-line treatments 1. Tramadol, being an opioid, is recommended for patients who do not respond to these initial treatments, highlighting the need for careful patient selection and monitoring 1. The use of tramadol in this context is supported by the Canadian Stroke Best Practice Recommendations, which emphasize an individualized patient-centered approach for managing central pain syndromes, including the involvement of an interdisciplinary team with expertise in mental health and central pain management 1. Key considerations in the use of tramadol include:

• Starting with a low dose and carefully titrating based on response and tolerability
• Close monitoring for adverse effects such as respiratory depression, dizziness, and sedation
• Alternative pain medications like acetaminophen may be safer first-line options for these patients
• Consultation with a neurologist or pain specialist may be beneficial to establish the safest regimen.

From the Research

Tramadol for Patients with Hemiplegic Stroke

• Tramadol is a medication that has been used to treat pain in patients with a history of stroke, including those with hemiplegic stroke 2.
• A study published in 2013 found that tramadol/acetaminophen medication was effective in reducing pain in patients with central post-stroke pain (CPSP), a common complication of stroke 3.
• The study found that 77.8% of patients with CPSP experienced a reduction in pain after taking tramadol/acetaminophen, with a mean dose of 121±61.6 mg/day 3.
• Another study published in 2005 found that tramadol was one of the most frequently prescribed pain medications for stroke survivors, along with acetaminophen and other analgesics 2.

Considerations for Tramadol Use

• When considering the use of tramadol for patients with hemiplegic stroke, it is essential to weigh the potential benefits against the potential risks and side effects 3.
• The study published in 2013 found that side effects were observed in six cases, but medication was continued in eight cases, suggesting that the benefits of tramadol/acetaminophen may outweigh the risks for some patients 3.
• Additionally, the choice of medication should be based on the medical condition causing pain, the ability of the patient to comply with administration of the medication, and the cost of the medication 2.

Alternative Treatment Options

• Other treatment options for pain management in patients with hemiplegic stroke include pregabalin, gabapentin, and transcutaneous electrical nerve stimulation (TENS) 4, 5, 6.
• A study published in 2021 found that the combination of pregabalin and TENS was effective in relieving neuropathic pain in a stroke patient after contralateral C7 nerve transfer 4.
• Another study published in 2011 found that pregabalin was effective in reducing pain and improving sleep and anxiety in patients with CPSP 5.