Management of Chronic Post-Stroke Pain Syndrome

Understanding Central Post-Stroke Pain (CPSP)

Central post-stroke pain affects 2-5% of stroke patients, resulting from damage to the spinothalamic tract, causing hypersensitivity to pain and sensory abnormalities, with primary symptoms including pain and loss of sensation in the face, arms, and/or legs 2
CPSP significantly impacts activities of daily living, sleep quality, and overall quality of life, typically beginning within days to a month after stroke, with most patients becoming symptomatic within the first month 2

Diagnosis should be based on established criteria: pain occurring after stroke, located in an area corresponding to the central nervous system lesion, and not attributable to nociceptive or peripheral neuropathic causes 3

The American Academy of Neurology recommends anticonvulsants such as gabapentin or pregabalin as first-line treatment, followed by tricyclic antidepressants or SNRIs as second-line options, and opioids or tramadol for treatment-resistant cases 1, 2
The American Academy of Neurology recommends amitriptyline 75 mg at bedtime, which has shown to lower daily pain ratings and improve global functioning 3

An individualized patient-centered approach implemented by an interdisciplinary team with expertise in mental health and central pain management is recommended 1, 2
Motor cortex stimulation might be reasonable for intractable central post-stroke pain not responsive to other treatments, achieving pain reductions >50% in 50-83% of patients for up to 2 years 3

Pharmacotherapy should be combined with therapeutic exercise and psychosocial support, with treatment adjusted based on patient's specific pain characteristics, comorbidities, and response to therapy 3

CPSP is often underdiagnosed or misdiagnosed as musculoskeletal or visceral pain, and attributing all post-stroke pain to CPSP without excluding other serious causes should be avoided 4