Central post-stroke pain (CPSP) follows stroke in up to 8% of patients. The pain is usually burning in character and is accompanied by a sensory deficit, particularly for nonpainful temperature and for pinprick (sharpness) sensations. About one-half of patients exhibit allodynia. The pain is not experienced until some months after the stroke in two-thirds of patients, so it is frequently the family doctor who is responsible for determining the diagnosis.
Conventional analgesics (including morphine) are largely ineffective, and precious time should not be wasted ‘trying’ them. The most effective treatment is with adrenergically active antidepressants (e.g. amitriptyline, nortriptyline, desipramine and maprotiline), in dosages increasing gradually from 10 or 25 to 50 or 75 mg/day. The sooner such treatment is commenced after pain onset, the better the prognosis.
In patients who do not respond to antidepressants, benefit may be obtained by the addition of mexiletine. Transcutaneous nerve stimulation or surgically implanted stimulators may help in recalcitrant cases.
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