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Stroke and transient ischaemic attack - Management
Pain

  • Neuropathic pain:
    • Five percent to 20% of people experience neuropathic pain after a stroke.
    • It can occur together with spasticity or sensory loss. It is (in principle) separate from musculoskeletal pain.
    • Everyone who has had a stroke should be asked whether they are experiencing pain as a result of the stroke.
    • Neuropathic pain can be treated with one or more of:
      • An antidepressant (e.g. amitriptyline).
      • An anticonvulsant (e.g. carbamazepine, gabapentin).
    • For more information on drug treatments for neuropathic pain, see the CKS topic on Neuropathic pain - drug treatment.
    • People with pain that is poorly controlled within a few weeks should be referred to a specialist in pain management.
  • Shoulder pain and subluxation:
    • People with arm weakness after a stroke should be asked about shoulder pain from time to time.
    • People with shoulder pain and their carers should have advice on position and handling the weak arm — overhead arm slings and shoulder supports should not be used.
    • Offer simple analgesics (e.g. paracetamol, a nonsteroidal anti-inflammatory drug [NSAID] with a proton pump inhibitor [PPI] for gastroprotection) to people with shoulder pain — intra-articular corticosteroids should not be used.
    • Consider referring people with persistent troublesome shoulder pain for specialist treatments such as shoulder strapping, high-intensity transcutaneous nerve stimulation, and functional electrical stimulation.
  • Musculoskeletal pain other than shoulder pain:
    • After a stroke, immobility and abnormal posture can cause pain, especially in people who have osteoarthritis or inflammatory arthritis.
    • Everybody with significant motor loss after a stroke should be asked about musculoskeletal pain.
    • People with musculoskeletal pain should be assessed to determine whether the pain can be reduced by improvements in handling techniques, posture or movement.
    • Offer simple analgesics to be taken regularly:
      • Paracetamol, up to 1 g four times daily.
      • An NSAID — together with a PPI for gastroprotection. The recommendation to routinely use a PPI is in line with NICE guidelines.
      • Codeine or similar morphine derivative.

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