What is the best management approach for central pain syndrome?

Management of Central Pain Syndrome

For central pain syndrome, initiate amitriptyline 75 mg at bedtime as first-line pharmacotherapy, combined with interprofessional pain management including therapeutic exercise and psychosocial support. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis using established criteria: 1

• Pain must occur after a CNS lesion (stroke, spinal cord injury, or other traumatic injury to brain/spinal cord) 1, 2
• Pain location corresponds to the area of CNS damage 1, 3
• Exclude peripheral nociceptive or neuropathic causes 1
• Typical presentation includes burning or aching pain with allodynia (touch, cold, or movement-induced) 1
• Pain usually begins within days to one month after the CNS injury, with 7-8% incidence in stroke patients 1

First-Line Pharmacological Treatment

Amitriptyline and lamotrigine are the only medications with Class IIa (reasonable) recommendations: 1

• Amitriptyline 75 mg at bedtime lowers daily pain ratings and improves global functioning 1, 2
• Lamotrigine reduces daily pain ratings and cold-induced pain, though only 44% of patients achieve good clinical response 1, 2

The choice between these two should be based on side effect profiles: amitriptyline causes anticholinergic effects (dry mouth, constipation, sedation), while lamotrigine requires slow titration to avoid Stevens-Johnson syndrome. 1

Second-Line Pharmacological Options

If first-line agents fail or are not tolerated, consider: 1

• Pregabalin: Mixed evidence for pain reduction, but improves sleep and anxiety 1
• Gabapentin: Not well-studied specifically for central poststroke pain but effective in other neuropathic pain conditions 1, 2
• Carbamazepine or phenytoin: Usefulness not well established 1

Essential Multimodal Approach

Pharmacotherapy alone is insufficient—combine with: 1

• Interprofessional pain management involving physicians from neurology, pain medicine, and rehabilitation 1
• Therapeutic exercise as part of comprehensive rehabilitation 1
• Psychosocial support including stress management and cognitive-behavioral approaches 1, 4
• Pain neuroscience education to help patients understand central sensitization mechanisms 5, 4

Monitoring Treatment Response

Use standardized serial measurements rather than subjective reports: 1

• Pain diaries 1
• Visual analog scales 1
• Validated pain questionnaires 1

Interventions to Avoid

TENS (transcutaneous electrical nerve stimulation) has been proven ineffective and should not be used. 1

Deep brain stimulation has conflicting evidence and cannot be recommended. 1

Refractory Cases

For intractable central pain unresponsive to all pharmacological and conservative treatments: 1

• Motor cortex stimulation may be considered in carefully selected patients 1
• Achieves >50% pain reduction on visual analog scale in 50-83% of patients in case series 1
• Effectiveness maintained up to 2 years post-implantation 1
• Significant risks include: infection, hardware failure, postoperative seizures, and long-term epilepsy 1

Critical Clinical Pitfalls

• Do not delay treatment: Central pain typically develops within the first month after CNS injury, and early intervention may prevent chronification 1
• Individualize medication selection based on patient response and side effects, as efficacy is unpredictable for any individual 1
• Avoid opioid monotherapy: While opioids show some efficacy in central pain syndromes, they should be part of multimodal treatment given addiction risks 2, 5
• Set realistic expectations: Central pain is often chronic and intractable, requiring long-term management strategies 3, 6
• Address central sensitization mechanisms: Consider that CS involves complex psycho-neuro-immunological interactions requiring multimodal rather than purely pharmacological approaches 5, 4