What is the recommended management for central post‑stroke neuropathic pain (CPSP) presenting as burning, tingling, or electric‑shock sensations weeks to months after an ischemic stroke?

Management of Central Post-Stroke Neuropathic Pain

Start with amitriptyline 75 mg at bedtime as your first-line pharmacological treatment for central post-stroke pain (CPSP), as it has demonstrated efficacy in lowering daily pain ratings and improving global functioning. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis using established criteria:

• Pain must occur after stroke and be located in an area corresponding to the central nervous system lesion 1, 2
• Exclude nociceptive or peripheral neuropathic causes 1, 2
• Look for characteristic sensory abnormalities: burning sensations, allodynia (pain from light touch), cold-induced pain, and dysesthesia in the affected body region 1
• Expect onset within days to one month post-stroke in most cases, though delayed presentations occur 1, 2
• Monitor treatment response using standardized tools: pain diaries, visual analog scales, or validated pain questionnaires 1, 2

Pharmacological Treatment Algorithm

First-Line Treatment

Amitriptyline 75 mg at bedtime is your primary choice based on the strongest evidence from the American Heart Association guidelines 1, 2:

• Proven to lower daily pain ratings and improve global functioning 1, 2
• Caution: Watch for anticholinergic side effects, particularly in elderly stroke patients (confusion, urinary retention, constipation, falls) 3

Alternative first-line option: If amitriptyline is not tolerated or contraindicated, use gabapentin or pregabalin as recommended by Canadian guidelines 1, 3:

• Pregabalin has mixed results for pain reduction but reliably improves sleep and anxiety 1, 2
• Gabapentin lacks robust CPSP-specific data but is effective in other neuropathic pain conditions 1

Second-Line Treatment

If first-line agents fail or are poorly tolerated:

Lamotrigine can reduce daily pain ratings and cold-induced pain 1, 2:

• Only 44% of patients achieve good clinical response, so set realistic expectations 1, 2
• Can be used as alternative or additive therapy 4

SNRIs, particularly duloxetine, are recommended as second-line alternatives 1, 3

Third-Line Treatment for Refractory Cases

Opioids or tramadol may be considered for treatment-resistant CPSP 1, 3:

• Critical warning: Significant risk of physical dependency; use with extreme caution 1, 3
• Reserve for patients who have failed multiple other agents 1, 3

Essential Non-Pharmacological Components

Combine pharmacotherapy with therapeutic exercise and psychosocial support as recommended by the American Heart Association 1, 2:

• Implement an interdisciplinary team approach with expertise in mental health and central pain management 1, 3
• Address comorbid depression, anxiety, and sleep disturbances, which are common and exacerbate pain 5, 6

Interventional Options for Intractable Pain

Motor cortex stimulation may be reasonable for intractable CPSP unresponsive to pharmacotherapy 1, 2:

• Achieves >50% pain reduction in 50-83% of carefully selected patients 1, 2
• Effects can last up to 2 years 1, 2
• Significant risks: infection, hardware failure, postoperative seizures, and long-term epilepsy 1

Critical Pitfalls to Avoid

Do not use TENS (transcutaneous electrical nerve stimulation) - it has been proven ineffective for CPSP 1, 3:

• Small trials showed no benefit 1

Avoid misdiagnosis delays: CPSP is frequently underdiagnosed or misattributed to musculoskeletal or visceral pain 3, 7:

• Patients may no longer be under stroke care when symptoms emerge weeks to months later 5, 6
• Cognitive and speech limitations post-stroke complicate diagnosis 6

Do not attribute all post-stroke pain to CPSP without excluding other serious causes 3, 7:

• Consider hemiplegic shoulder pain, spasticity-related pain, and other nociceptive sources 1

Treatment Monitoring

Adjust therapy based on specific pain characteristics, comorbidities, and treatment response 2, 3:

• Use serial standardized measurements to objectively track progress 1, 2
• Recognize that CPSP is often treatment-resistant; partial relief may be the realistic goal 4, 8