What are the recommended pain management options for stroke patients?

Pain Control in Stroke

For acute stroke pain (headache, agitation), treat symptomatically with standard analgesics while managing blood pressure; for post-stroke pain syndromes, use gabapentin or pregabalin as first-line therapy, followed by amitriptyline or duloxetine as second-line, reserving opioids for treatment-resistant cases. 1

Acute Stroke Phase Pain Management

During the hyperacute and acute stroke period, pain should be addressed as part of blood pressure management, as pain itself can elevate blood pressure and complicate stroke care 2:

• Treat headache, pain, agitation, nausea, and vomiting symptomatically in patients with systolic BP <220 or diastolic <120 mmHg who are not receiving thrombolytic therapy 2
• Pain from a full bladder or other reversible causes should be identified and addressed, as these can contribute to elevated blood pressure 2
• Standard analgesics like acetaminophen are most commonly used during acute rehabilitation, followed by narcotic analgesics and NSAIDs as needed 3

Central Post-Stroke Pain (CPSP)

CPSP affects 2-8% of stroke patients and results from damage to the spinothalamic tract, causing hypersensitivity and sensory abnormalities 1, 4:

First-Line Pharmacological Treatment

Anticonvulsants (gabapentin or pregabalin) are recommended as first-line therapy by the American College of Physicians 1:

• Gabapentin is effective for neuropathic pain conditions, though specific stroke data is limited 4
• Pregabalin has mixed results for pain intensity but may improve sleep quality and anxiety, which are commonly impaired in stroke patients 4
• These medications are better tolerated than tricyclic antidepressants, particularly in elderly stroke patients 5, 6

Second-Line Pharmacological Treatment

Tricyclic antidepressants (amitriptyline 75mg at bedtime) or SNRIs (duloxetine) should be used as second-line options 1, 4:

• Amitriptyline has been shown to lower daily pain ratings and improve global functioning 4
• However, anticholinergic side effects are problematic in elderly patients, limiting tolerability 5
• Duloxetine (an SNRI) provides an alternative with fewer anticholinergic effects 1

Alternative and Adjunctive Options

• Lamotrigine can reduce daily pain ratings and cold-induced pain, though only 44% of patients achieve good clinical response 1, 4
• Fluvoxamine may be used adjunctively in some patients 5, 6

Treatment-Resistant Cases

Opioids or tramadol may be considered for treatment-resistant CPSP, though caution is warranted due to significant risk of physical dependency 1:

• Reserve these medications only after failure of anticonvulsants, antidepressants, and lamotrigine 1
• Tramadol was commonly prescribed in rehabilitation settings and may offer a lower dependency risk than traditional opioids 3

Spasticity-Related Pain

Spasticity causes significant pain and functional disturbances in stroke patients and can lead to contractures if untreated 7:

Non-Pharmacological First-Line Treatment

Begin with antispastic positioning, range of motion exercises, stretching, splinting, and serial casting 7, 1:

• These are recommended as first-line treatments before pharmacological intervention 7

Pharmacological Management

For spasticity causing pain, poor skin hygiene, or decreased function 7:

• Consider tizanidine, dantrolene, or oral baclofen 7
• Avoid diazepam or other benzodiazepines due to possible deleterious effects on stroke recovery and sedation 7
• Baclofen was commonly prescribed in rehabilitation settings for antispasticity-related pain 3

Advanced Interventions

For selected patients with disabling or painful spasticity, consider botulinum toxin or phenol/alcohol injections, intrathecal baclofen, or neurosurgical procedures 7

Musculoskeletal Pain (Including Shoulder Pain)

Shoulder pain is one of the most common pain locations in stroke survivors 3:

• Standard analgesics (acetaminophen, NSAIDs) are appropriate for musculoskeletal pain 3
• Muscle relaxants like cyclobenzaprine may be helpful for muscle-related pain 3
• Address underlying causes such as shoulder subluxation with appropriate positioning and physical therapy 8

Comprehensive Management Approach

An individualized patient-centered approach implemented by an interdisciplinary team with expertise in mental health and central pain management is essential 1, 4:

• Pharmacotherapy must be combined with therapeutic exercise and psychosocial support 7, 1
• Monitor treatment response using standardized serial measurements such as pain diaries, visual analog scales, or pain questionnaires 4
• In about 25% of stroke patients, pain negatively influences rehabilitation progress, making aggressive pain management critical 9

Critical Pitfalls to Avoid

• CPSP is often underdiagnosed or misdiagnosed as musculoskeletal or visceral pain 1
• Do not attribute all post-stroke pain to CPSP without excluding other serious causes 1
• TENS (transcutaneous electrical nerve stimulation) is not effective for central post-stroke pain and should not be used 1, 4
• Pain in about 20% of stroke patients affects attention during rehabilitation sessions, potentially delaying recovery 9
• Patients with hypoesthesia present significantly higher neuropathic pain scores and require more aggressive neuropathic pain management 9

Interventional Options for Refractory Cases

Motor cortex stimulation might be reasonable for intractable central post-stroke pain not responsive to pharmacological treatments, achieving pain reductions >50% in 50-83% of patients for up to 2 years 1, 4