Treatment for Central Poststroke Pain Syndrome
The physical anguish brought on by CPSP rarely responds well to common pain-relief medications such as aspirin, ibuprofen or even potent prescription narcotics. To treat CPSP with medication, doctors often turn to other categories of drugs that act on the central nervous system.
Amitriptyline, an antidepressant that belongs to an older class of drugs called tricyclics, is usually the first-line treatment for CPSP. A modest body of research suggests that amitriptyline brings relief to some (but not all) patients, though side effects such as dry mouth and constipation can make it hard to tolerate.
As an alternative, doctors may prescribe newer antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which cause fewer side effects. However, even less research has been done on the use of SSRIs to treat poststroke pain.
Other classes of medications that doctors may prescribe include anticonvulsants (such as gabapentin), anesthetics (such as lidocaine) and drugs administered for controlling spasticity (such as baclofen). Side effects may prohibit use of many medications, particularly in older adults.
Patients who gain inadequate relief from medications or can't tolerate the drugs may be candidates for certain non-drug approaches, called neurostimulation therapy, such as:
- Repetitive transcranial magnetic stimulation (rTMS). rTMS is a noninvasive therapy that sends short pulses of magnetic fields to the brain in rapid succession. It's been approved to treat depression but has been shown in some small studies to relieve neuropathic pain, including CPSP. Pain relief tends to be modest and short lasting, but the therapy appears to be safe and adverse effects rare.
- Deep brain stimulation (DBS). Preliminary research suggests that DBSan invasive procedure that stimulates the brain with mild electrical pulsesappears to dampen pain. While more investigation is needed, small studies have shown that more than half of patients with nerve-related pain (including some with poststroke pain) treated with DBS gain some relief.
- Motor cortex stimulation (MCS). MCS is an invasive procedure that uses electrodes placed in the membranes covering the brain. Electrical pulses stimulate the brain. Two reviews reported a success rate of about 50 percent in relieving pain, but better designed studies are needed to establish the procedure's safety and effectiveness.
Some patients who develop chronic pain following a stroke are fortunate enough to experience spontaneous remissionthat is, their symptoms simply go awaythough no one can say why. But don't wait for that to happen if you've had a stroke and you're struggling with chronic aches and other unpleasant sensations.
Unrelenting painwhether from CPSP or other poststroke paincan prevent a recovery from stroke by interfering with sleep or rehabilitation. See your family doctor or a neurologist if pain persists. If your doctor is unable to provide the pain relief you need, ask for a referral to a pain management clinic that specializes in chronic, difficult-to-treat pain.
Source: Prepared by the Editors of The Johns Hopkins Medical Letter: Health After 50